1-Year Outcomes Following Transfemoral Transseptal Transcatheter Mitral Valve Replacement: The HighLife TSMVR Feasibility Study

BACKGROUND

A significant number of patients with severe mitral regurgitation (MR) are not suitable for either surgical or transcatheter edge-to-edge repair because of high surgical risk or inappropriate mitral valve anatomy.

OBJECTIVES

The aim of this study was to evaluate the HighLife Trans-Septal Mitral Valve Replacement (TSMVR) system in patients with symptomatic MR and high surgical risk.

METHODS

This prospective, multicenter, nonrandomized feasibility study evaluated the safety and performance of the HighLife TSMVR system in patients with moderate to severe or severe symptomatic MR during 1-year follow-up. Echocardiographic data were assessed at an independent core laboratory.

RESULTS

A total of 30 patients (mean age 75.6 years, 27% women, median Society of Thoracic Surgeons score 5.5%) with severe MR (90% with secondary MR, median left ventricular ejection fraction 43%) were treated at 13 sites. In 27 of the 30 patients, the HighLife TSMVR system was implanted successfully (technical success rate 90%). Device success at 30 days was 83%. After 1 year, 5 patients (17%) had died. None of the patients who underwent implantation required mitral valve reintervention. All patients who underwent implantation had no or trace (78%) or mild (22%) MR, the mean gradient of the HighLife valve was 5.1 mm Hg, and there were no signs of left ventricular outflow tract obstruction (mean gradient 2.0 mm Hg).

CONCLUSIONS

The 1-year results from the HighLife TSMVR feasibility study demonstrate a high technical success rate, excellent valve function, no left ventricular outflow tract obstruction, and no need for mitral valve reintervention. Additional patient outcomes and longer follow-up are needed to confirm these findings. (Expanded Study of the HighLife 28mm Trans-Septal Trans-Catheter Mitral Valve in Patients With Moderate-Severe or Severe Mitral Regurgitation and at High Surgical Risk; NCT04029363).

3-Year Outcomes From the Amplatzer Amulet Left Atrial Appendage Occluder Randomized Controlled Trial (Amulet IDE)

BACKGROUND

The Amulet (Abbott) left atrial appendage occluder investigational device exemption trial is the largest randomized trial evaluating the safety and effectiveness of the Amulet left atrial appendage occluder compared with the Watchman 2.5 device (Boston Scientific) through 5 years.

OBJECTIVES

This analysis evaluated the device effect on 3-year outcomes in the Amulet investigational device exemption trial.

METHODS

The medication regimen and key clinical outcomes were reported through 3 years including: 1) the composite of ischemic stroke or systemic embolism (SE); 2) the composite of all strokes, SE, or cardiovascular (CV) death; 3) major bleeding; and 4) all-cause death and CV death.

RESULTS

A total of 1,878 patients at 108 sites were randomized. A significantly higher percentage of patients were free of oral anticoagulation usage at 3 years with Amulet (96.2%) vs Watchman (92.5%) (P < 0.01). Clinical outcomes were comparable for the composite of ischemic stroke or SE (5.0% vs 4.6%; P = 0.69); the composite of all strokes, SE, or CV death (11.1% vs 12.7%; P = 0.31); major bleeding (16.1% vs 14.7%; P = 0.46); all-cause death (14.6% vs 17.9%; P = 0.08); and CV death (6.6% vs 8.5%; P = 0.14) for Amulet and Watchman, respectively. Through 3 years, device factors (device-related thrombus or peridevice leak ≥3 mm) preceded ischemic stroke events and CV deaths more frequently in Watchman compared with Amulet patients.

CONCLUSIONS

The Amulet occluder demonstrated continued safety and effectiveness with over 96% free of oral anticoagulation usage through 3 years in a high-risk population compared to the Watchman device. (AMPLATZER Amulet LAA Occluder Trial [Amulet IDE]; NCT02879448).

Changes in R-wave amplitude at implantation are associated with gender and orientation of insertable cardiac monitor: observations from the confirm Rx™ body posture and physical activity study

Background

Insertable cardiac monitors (ICMs) are small subcutaneously implanted devices that detect changes in R-wave amplitudes (RWAs), effective in arrhythmia-monitoring. Although ICMs have proven to be immensely successful, electrical artefacts are frequent and can lead to misdiagnosis. Thus, there is a growing need to sustain and increase efficacy in detection rates by gaining insight into various patient-specific factors such as body postures and activities.

Methods

RWAs were measured in 15 separate postures, including supine, lying on the right-side (RS) or left-side (LS) and sitting, and two separate ICM orientations, immediately after implantation of Confirm Rx™ ICM in 99 patients.

Results

The patients (53 females and 46 males, mean ages 66.62 ± 14.7 and 66.40 ± 12.25 years, respectively) had attenuated RWAs in RS, LS and sitting by ~ 26.4%, ~ 27.8% and ~ 21.2% respectively, compared to supine. Gender-based analysis indicated RWAs in RS (0.32 mV (0.09–1.03 mV), p < 0.0001) and LS (0.37 mV (0.11–1.03 mV), p = 0.004) to be significantly attenuated compared to supine (0.52 mV (0.20–1.03 mV) for female participants. Similar attenuation was not evident for male participants. Further, parasternally oriented ICMs (n = 44), attenuated RWAs in RS (0.37 mV(0.09–1.03 mV), p = 0.05) and LS (0.34 mV (0.11–1.03 mV), p = 0.02) compared to supine (0.48 mV (0.09–1.03 mV). Similar differences were not observed in participants with ICMs in the 45°-relative-to-sternum (n = 46) orientation. When assessing the combined effect of gender and ICM orientation, female participants demonstrated plausible attenuation in RWAs for RS and LS postures compared to supine, an effect not observed in male participants.

Conclusion

This is the first known study depicting the effects on RWA due to body postures and activities immediately post-implantation with an overt impact by gender and orientation of ICM. Future work assessing the cause of gender-based differences in RWAs may be critical.

Trial registration: Clinical Trials, NCT03803969. Registered 15 January 2019 – Retrospectively registered, https://clinicaltrials.gov/NCT03803969

R-wave amplitude changes with posture and physical activity over time in an insertable cardiac monitor

Background

Insertable cardiac monitors (ICMs) are accepted tools in cardiac arrhythmia management. Consistent R-wave amplitude (RWA) is essential for optimal detection.

Objectives

Assess RWAs with posture/activities at insertion and at 30 days.

Methods

Participants (n = 90) with Confirm Rx™ ICM had RWAs measured in different postures (supine, right-side [RS], left-side [LS], sitting, and standing) and defined physical activities (including isometric push [IPUSH] and pull) at 2 time points. ICMs were inserted in 45° to sternum and parasternal orientations.

Results

There were significant reductions at insertion with RS, LS, sitting, or standing vs supine (reference position) (all P < .05). At 30 days, significant changes only occurred with LS and sitting (P < .05). Sex had an effect on RWAs, with females having significant variability at insertion (supine vs RS, LS, sitting, standing, and IPUSH; all P < .05). Males showed large RWA interpatient variabilities but minimal differences between positions vs supine. At 30 days, RS, LS, and sitting positions remained significant for females (P < .05), while in males RWAs were higher than at insertion for most postures and activities. The orientation 45° to sternum had consistently higher RWAs vs parasternal orientation at both time points (P < .0001). In females, ICM orientation had no significant effect on RWAs; however, in males the 45° to sternum produced higher RWAs. ICM movement from the insertion site showed no correlation with RWA changes.

Conclusion

The mean RWAs were higher at 30 days with less interparticipant and interpostural variability; males had higher RWAs compared to females; 45° to sternum orientation had higher RWAs; and ICM migration from the insertion site did not affect RWAs.

Associations between metabolic syndrome at index PCI and 1-year outcomes

Background

The prevalence of obesity, diabetes and metabolic syndrome is rising, with negative health consequences for the community.

Purpose

We sought to examine the prevalence and impact of metabolic syndrome (MetS) on 1-year outcomes from an Australian cohort of all-comer PCI patients.

Methods

We retrospectively analysed the GenesisCare Outcomes multicentre Registry of prospectively collected data in patients undergoing PCI from 2008–2020. Metabolic syndrome was defined as presence of any 3 features including hypertension, diabetes, obesity with body mass index ≥30 kg/m2 and dyslipidaemia. We examined 1-year outcomes for death and MACE (death, MI or TLR), and the adjusted risk after accounting for each of the defining variables.

Results

During the study period from 2005–2018, 14,405 were included, of which 5480 (38%) had metabolic syndrome. MetS patients were somewhat younger without sex differences (∼76% men). They had greater prevalence of defining characteristics, and smoking and lower prevalence of myocardial infarction presentation compared to non-MetS patients. MetS patients had higher prevalence of B2/C type lesions, restenosis, chronic total occlusions and multivessel disease. At 30-days MetS patients had lower risk of re-infarction (0.1% vs. 0.3%, p=0.011) but from 30-days to 1-year they had greater risk of MI (1.1% vs. 0.5%, p&lt;0.01), TLR (1.5% vs. 1.1%, p=0.03), readmissions (21.8% vs. 19.8%, p=0.008) and MACE (3.6% vs. 2.7%, p=0.03) without differences in mortality (1.3% in both, p=0.88). Unadjusted models showed trend for greater risk of 1-year MACE with MetS, HR 1.15 (95% CI 1.00–1.33), p=0.054. In multivariable models, this risk was lost after adjusting individually for hypertension, dyslipidaemia and insulin-treated diabetes, but not after adjustment for obesity and non-insulin diabetes (See Figure).

Conclusions

Metabolic syndrome was noted in over one-third of all-comer PCI patients, and was associated with greater risk of 1-year MACE. This risk appeared to be related to hypertension, dyslipidaemia and insulin-treated diabetes but not obesity.

Funding Acknowledgement

Type of funding sources: None.

Associations between the PARIS ischaemic and bleeding risk scores and 1-year mortality in an all-comers Australian national PCI cohort

Background

Prediction scores can complement bedside clinical risk assessment in patients undergoing PCI.

Purpose

We sought to validate the PARIS ischaemic and bleeding risk scores in a national cohort of all-comer PCI patients in Australia, and to examine impact on 1-year mortality.

Methods

We retrospectively analysed the GenesisCare Outcomes multicentre Registry of prospectively collected data in patients undergoing PCI from 2008–2020. The ischaemic and bleeding scores were assessed in separate cohorts. Patients were included if all defining variables were available. The ischaemic integer score included diabetes, acute coronary syndrome, current smoking, GFR &lt;60ml/min, prior PCI or CABG, and patients were grouped according as low (0 to 2), intermediate (3 or 4), and high (≥5) thrombotic risk. The bleeding integer score included age, body mass index, current smoking, GFR &lt;60ml/min, anaemia and discharge on triple therapy after PCI, and patients were grouped as low (0 to 3), intermediate (4 to 7) and high (≥8) bleeding risk. One-year ischaemic and in-hospital bleeding endpoints were examined. Adjusted risk of 1-year mortality was assessed accounting for age, sex, family history, smoking, vascular disease, presentation status, hypertension, diabetes, obesity and dyslipidaemia.

Results

A total of 16,961 patients were included in the ischaemic risk cohort and 6431 patients in the bleeding risk cohort. The patient distributions by risk category for both scores are shown in the figure. Increasing ischaemic risk was associated with greater incidence of in-hospital (0.2% vs. 0.5% vs. 0.5%, p=0.01), and 1-year death (0.7% vs. 2.1% vs. 3.1%). Increasing bleeding risk was associated with greater in-hospital death (0.0% vs. 0.3% vs. 0.9%, p&lt;0.01) and bleeding (0.6% vs. 0.9% vs. 3.2%, p&lt;0.01), and greater 1-year death (0.3% vs. 1.4% vs. 2.8%, p&lt;0.01). At 1-year compared to the low bleeding risk group, high risk patients had lower use of aspirin, P2Y12 inhibitors and statins. Similarly, compared to low ischaemic risk group, high-risk patients had lower use of aspirin and statins but higher use of P2Y12 inhibitors. With both risk scores, compared to low-risk patients, high-risk patients had significantly greater adjusted risk of 1-year mortality (See Figure).

Conclusions

The PARIS ischaemic and bleeding risk scores were associated with greater risk of in-hospital and medium-term adverse outcomes after PCI to 1-year. Prospective use of the scores can assist in guiding adherence to secondary prevention and optimal anti-thrombotic strategies to improve overall outcomes.

Funding Acknowledgement

Type of funding sources: None.

Two-year outcomes from the MitrAl ValvE RepaIr Clinical (MAVERIC) trial: a novel percutaneous treatment of functional mitral regurgitation

AIMS

We report the 2-year outcomes of the MitrAl ValvE RepaIr Clinical (MAVERIC) trial. Functional mitral regurgitation (FMR) is associated with poor outcomes for which there remains an unmet clinical need. ARTO is a transcatheter annular reduction device for the treatment of FMR and an emerging alternative for patients at high surgical risk. The MAVERIC trial was designed to evaluate the safety and performance of the ARTO system in FMR and heart failure (HF).

METHODS AND RESULTS

MAVERIC is an international multicentre, prospective, single arm study enrolling patients with FMR grade ≥ 2, New York Heart Association (NYHA) class ≥II symptoms despite maximal medical therapy. Patients were excluded if they had significant structural mitral valve abnormality or life expectancy <1 year. The primary outcome measures were a composite safety outcome and efficacy defined as mitral regurgitation (MR) reduction 30 days post-procedure. Secondary outcome measures included safety, change in MR grade, NYHA class and hospitalization for HF at 2 years. Forty-five patients were enrolled. The composite safety outcome was met (2/45 adverse events at 30 days) and no device-related deaths occurred at 2-year follow-up. A sustained reduction in MR [grade < 2: 21/31 (68%) vs. 31/31(0%); P < 0.0001], left ventricular end-diastolic volume index (90.0 ± 30 vs. 106 ± 26 mL/m² ; P = 0.004) and anteroposterior diameter (35.5 ± 4.7 vs. 41.4 ± 4.6 mm; P < 0.0001) was seen at 2 years compared to baseline. Progressive symptomatic improvement [NYHA class ≤II: 27/34 (80%) vs. 12/34 (36%); P < 0.0001] and a reduction in HF hospitalizations (19.8% 2 years post vs. 52.3% 2 years prior; P < 0.001) were seen at 2 years compared to baseline.

CONCLUSIONS

The ARTO system is a safe and effective treatment for FMR with reductions in left ventricular end-diastolic volumes sustained to 2 years.

Transcatheter reshaping of the mitral annulus in patients with functional mitral regurgitation: one-year outcomes of the MAVERIC trial

AIMS

The aim of this study was to assess the one-year safety and efficacy of the transcatheter ARTO system in the treatment of functional mitral regurgitation (FMR).

METHODS AND RESULTS

MAVERIC is a multicentre, prospective, non-randomised pre-commercial study. Eligible patients were on guideline-recommended therapy for NYHA Class II-IV systolic heart failure and had an FMR grade ≥2+. The ARTO system was implanted in forty-five (100%) patients. The primary safety composite endpoint (death, stroke, myocardial infarction, device-related surgery, cardiac tamponade, renal failure) at 30 days and one year was 4.4% (95% CI: 1.5-16.6) and 17.8% (95% CI: 9.3-32.4), respectively. Periprocedural complications occurred in seven patients (15.5% [95% CI: 6.5-29.5]), and five patients (11.1% [95% CI: 4.9-24.0]) died during one-year follow-up. Paired results for 36 patients demonstrated that 24 (66.7%) had grade 3+/4+ mitral regurgitation at baseline; however, only five (13.9%) and three (8.3%) patients remained at grade 3+/4+ 30 days and one year post procedure (p<0.0001). Echocardiographic parameters such as anteroposterior annulus diameter decreased from 41.4 mm (baseline) to 36.0 and 35.3 mm at 30 days and one year, respectively (p<0.0001). Twenty-five patients (69.4%) had baseline NYHA Class III/IV symptoms decreasing significantly to nine (25.0%) at 30 days and eight (22.2%) at one year post procedure (p<0.0001).

CONCLUSIONS

The ARTO transcatheter mitral valve repair system is both safe and effective in decreasing FMR up to one year post procedure.

2-year real-world outcomes of prasugrel, ticagrelor or clopidogrel therapy following percutaneous coronary intervention from a large multi-centre Australian registry

Background

Real-world data comparing outcomes for prasugrel, ticagrelor or clopidogrel use in patients undergoing percutaneous coronary intervention (PCI) is limited, with only smaller cohorts or 12-month observations available.

Methods

Data was collected prospectively from a total of 14 sites around Australia, from November 2008 until March 2019. The cohort included consecutively enrolled patients presenting electively or following acute coronary syndromes who were prescribed dual antiplatelet therapy following PCI. There were no exclusion criteria. The primary end point was the composite of death, myocardial infarction, or stroke at 1 year and 2 years after PCI. Secondary end points included safety, which was the incidence of major bleeding (BARC 3,4 or 5) at discharge.

Results

A total of 12,940 patients were included over a 11-year period. Patients receiving prasugrel were more likely to be male, younger (mean age 62.3+8.7 years), obese and present with STEMI than those receiving either ticagrelor or clopidogrel (all p&lt;0.001). At 2 years the primary end point occurred in 120 of the 2968 patients (2.8 per 1000pyr) in the ticagrelor group, 446 of 9280 (2.7 per 1000pyr) patients in the clopidogrel group and 21 of 692 (1.8 per 1000pyr) prasugrel group (p=0.03). Major bleeding was observed in 0.2% in the ticagrelor group, 0.4% clopidogrel group and 0.1% in the prasugrel group (p=0.21).

Conclusion

For the first time we have shown in a large cohort of patients treated by PCI for ACS or CAD significantly lower 2-year rates of death, myocardial infarction and stroke amongst patients who received prasugrel than among those who received either clopidogrel or ticagrelor. The incidence of major bleeding did not differ between antiplatelet therapies.

Funding Acknowledgement

Type of funding source: None

Onyx ONE: outcomes in patients with acute coronary syndrome

Background/Introduction

The Onyx ONE Global Study (Onyx ONE), a randomized, single-blind, international trial, demonstrated non-inferiority of a zotarolimus-eluting stent (ZES) to a polymer-free drug-coated stent (DCS) in high-bleeding risk patients treated with 1-month dual antiplatelet therapy (DAPT) followed by single antiplatelet therapy (SAPT). More than half of the Onyx ONE patients presented with an acute coronary syndrome (ACS). The safety and effectiveness of ZES and DCS in ACS patients treated with SAPT after 30 days remains unknown.

Purpose

To evaluate the safety and effectiveness outcomes for ZES and DCS in Onyx ONE patients presenting with ACS.

Methods

The primary outcome of the trial was a composite of cardiac death, myocardial infarction, or stent thrombosis at 1 year. To align with the time that DAPT is interrupted, we also evaluated the primary endpoint between the 2 stent groups in a landmark analysis between 30 days and 1 year. All analyses were performed in ACS patients (includes unstable angina, non ST-elevation myocardial infarction and ST-elevation myocardial infarction).

Results

Among the 1996 patients randomized in Onyx ONE, 982/1902 (51.6%) presented with ACS, of which 511/982 (52.0%) and 471/982 (48.0%) were treated with ZES and DCS respectively. In a pre-defined subgroup analysis in ACS patients, the event rates between the two stent groups regarding the primary outcome at one year were similar (18.5% ZES; 20.8% DCS; HR: 0.91; 95% CI [0.68, 1.22]; p=0.523). In the landmark analysis beyond day 30, the primary outcome rate tended to be lower among those treated with the ZES (8.4%) compared with the DCS (12.1%) [HR: 0.66 (95% CI: 0.43, 1.01), p=0.055] (Figure). This was primarily driven by lower rates of myocardial infarction with ZES (6.5% ZES; 10.2% DCS; [HR: 0.58 (95% CI: 0.36, 0.93); p=0.025], while other components were similar: cardiac death, 2.6% ZES vs. 2.8% DCS [HR: 1.00 (95% CI: 0.44, 2.27); p&gt;0.99) and stent thrombosis, 1.4% ZES vs. 1.4% DCS [HR: 0.93 (95% CI: 0.27, 3.21); p=0.91].

Conclusions

In Onyx ONE, high-bleeding risk patients presenting with ACS had similar safety and efficacy at 1 year in both the ZES and DCS stent groups. However, a trend was present for greater safety with the ZES with SAPT treatment beyond 30 days driven by lower myocardial infarction rates in that time period thus warranting additional confirmatory studies.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Medtronic sponsored the Onyx ONE Global Study

Self-expanding intra-annular versus commercially available transcatheter heart valves in high and extreme risk patients with severe aortic stenosis (PORTICO IDE): a randomised, controlled, non-inferiority trial

BACKGROUND

Randomised trial data assessing the safety and efficacy of the self-expanding intra-annular Portico transcatheter aortic valve system (Abbott Structural Heart, St Paul, MN, USA) compared with any commercially available valves are needed to compare performance among designs.

METHODS

In this prospective, multicentre, non-inferiority, randomised controlled trial (the Portico Re-sheathable Transcatheter Aortic Valve System US Investigational Device Exemption trial [PORTICO IDE]), high and extreme risk patients with severe symptomatic aortic stenosis were recruited from 52 medical centres experienced in performing transcatheter aortic valve replacement in the USA and Australia. Patients were eligible if they were aged 21 years or older, in New York Heart Association functional class II or higher, and had severe native aortic stenosis. Eligible patients were randomly assigned (1:1) using permuted block randomisation (block sizes of 2 and 4) and stratified by clinical investigational site, surgical risk cohort, and vascular access method, to transcatheter aortic valve replacement with the first generation Portico valve and delivery system or a commercially available valve (either an intra-annular balloon-expandable Edwards-SAPIEN, SAPIEN XT, or SAPIEN 3 valve [Edwards LifeSciences, Irvine, CA, USA]; or a supra-annular self-expanding CoreValve, Evolut-R, or Evolut-PRO valve [Medtronic, Minneapolis, MN, USA]). Investigational site staff, implanting physician, and study participant were unmasked to treatment assignment. Core laboratories and clinical event assessors were masked to treatment allocation. The primary safety endpoint was a composite of all-cause mortality, disabling stroke, life-threatening bleeding requiring transfusion, acute kidney injury requiring dialysis, or major vascular complication at 30 days. The primary efficacy endpoint was all-cause mortality or disabling stroke at 1 year. Clinical outcomes and valve performance were assessed up to 2 years after the procedure. Primary analyses were by intention to treat and the Kaplan-Meier method to estimate event rates. The non-inferiority margin was 8·5% for primary safety and 8·0% for primary efficacy endpoints. This study is registered with ClinicalTrials.gov, NCT02000115, and is ongoing.

FINDINGS

Between May 30 and Sept 12, 2014, and between Aug 21, 2015, and Oct 10, 2017, with recruitment paused for 11 months by the funder, we recruited 1034 patients, of whom 750 were eligible and randomly assigned to the Portico valve group (n=381) or commercially available valve group (n=369). Mean age was 83 years (SD 7) and 395 (52·7%) patients were female. For the primary safety endpoint at 30 days, the event rate was higher in the Portico valve group than in the commercial valve group (52 [13·8%] vs 35 [9·6%]; absolute difference 4·2, 95% CI -0·4 to 8·8 [upper confidence bound {UCB} 8·1%]; p_{non-inferiority}=0·034, p_superiority=0·071). At 1 year, the rates of the primary efficacy endpoint were similar between the groups (55 [14·8%] in the Portico group vs 48 [13·4%] in the commercial valve group; difference 1·5%, 95% CI -3·6 to 6·5 [UCB 5·7%]; p_{non-inferiority}=0·0058, p_superiority=0·50). At 2 years, rates of death (80 [22·3%] vs 70 [20·2%]; p=0·40) or disabling stroke (10 [3·1%] vs 16 [5·0%]; p=0·23) were similar between groups.

INTERPRETATION

The Portico valve was associated with similar rates of death or disabling stroke at 2 years compared with commercial valves, but was associated with higher rates of the primary composite safety endpoint including death at 30 days. The first-generation Portico valve and delivery system did not offer advantages over other commercially available valves.

FUNDING

Abbott.

Safety Profile of an Intra-Annular Self-Expanding Transcatheter Aortic Valve and Next-Generation Low-Profile Delivery System

OBJECTIVES

The aim of this study was to characterize the safety profile of an intra-annular self-expanding valve with a next-generation low-profile delivery system (DS).

BACKGROUND

Key design modifications to the FlexNav DS include the addition of a hydrophilic-coated, integrated sheath and stability layer to facilitate gradual, controlled deployment in vessels with diameter ≥5 mm.

METHODS

Patients were pooled from 2 concurrent prospective, multicenter, single-arm studies (FlexNav DS arm of PORTICO IDE [Portico Re-Sheathable Transcatheter Aortic Valve System U.S. IDE Trial] [n = 134] and the FlexNav EU CE Mark Study [n = 46]) for the analysis. The primary endpoint was Valve Academic Research Consortium-2-defined major vascular complications at 30 days. Clinical outcomes and valve performance were assessed through 30 days by an independent clinical events committee and an echocardiography core laboratory, respectively.

RESULTS

One hundred forty high-risk and 40 extreme-risk subjects enrolled between October 15, 2018, and December 10, 2019, from 28 sites in the United States, Australia, and Europe who underwent attempted transfemoral Portico valve implantation were included. The mean age was 85.1 ± 5.6 years, 60% were women, the mean Society of Thoracic Surgeons score was 5.3%, and 96.1% presented with ≥1 frailty factor. Technical device success was 96.7%. At 30 days, the rate of major vascular complications was 5.0%, with 4.4% of complications adjudicated as access site-related (3.3% transcatheter aortic valve replacement DS access site-related). Death (0.6%) and disabling stroke (1.1%) were rare. The rate of new permanent pacemaker implantation was 15.4%. Echocardiography revealed a mean gradient of 7.1 ± 3.2 mm Hg, mean valve area of 1.77 ± 0.41 cm², and a 4.1% rate of moderate paravalvular leak at 30 days.

CONCLUSIONS

Portico valve implantation with the FlexNav DS was associated with an excellent safety profile at 30 days.

1-Year Outcomes of the CENTERA-EU Trial Assessing a Novel Self-Expanding Transcatheter Heart Valve

OBJECTIVES

The purpose of this study is to report the 1-year results of the CENTERA-EU trial.

BACKGROUND

The CENTERA transcatheter heart valve (THV) (Edwards Lifesciences, Irvine, California) is a low-profile (14-F eSheath compatible), self-expanding nitinol valve, with a motorized delivery system allowing for repositionability. The 30-day results of the CENTERA-EU trial demonstrated the short-term safety and effectiveness of the valve.

METHODS

Implantations were completed in 23 centers in Europe, Australia, and New Zealand. Transfemoral access was used in all patients. Echocardiographic outcomes were adjudicated by a core laboratory at baseline, discharge, 30 days, 6 months, and 1 year. Major adverse clinical events were adjudicated by an independent clinical events committee.

RESULTS

Between March 2015 and July 2016, 203 high-risk patients (age 82.7 ± 5.5 years, 67.5% women, 68.0% New York Heart Association functional class III or IV, Society of Thoracic Surgeons score 6.1 ± 4.2%) with severe, symptomatic aortic stenosis underwent transcatheter aortic valve replacement with the CENTERA THV. The primary endpoint of the study was 30-day mortality (1.0%). At 1 year, overall mortality was 9.1%, cardiovascular mortality was 4.6%, disabling stroke was 4.1%, new permanent pacemakers were implanted in 6.5% of patients at risk, and cardiac-related rehospitalization was 6.8%. Hemodynamic parameters were stable at 1 year, with a mean aortic valve gradient of 8.1 ± 4.7 mm Hg, a mean effective orifice area of 1.7 ± 0.42 cm², and no incidences of severe or moderate aortic regurgitation.

CONCLUSIONS

The CENTERA-EU trial demonstrated mid-term safety and effectiveness of the CENTERA THV, with low mortality, sustained improvements in hemodynamic performances, and low incidence of permanent pacemaker implantations in high-risk patients with symptomatic aortic stenosis. (Safety and Performance of the Edwards CENTERA-EU Self-Expanding Transcatheter Heart Valve [CENTERA-2]; NCT02458560).

Performance and Safety of Transfemoral TAVI With SAPIEN XT in Australian Patients With Severe Aortic Stenosis at Intermediate Surgical Risk: SOLACE-AU Trial

BACKGROUND

To determine the safety and performance of the SAPIEN XT transcatheter heart valve (THV) in Australian patients with severe aortic stenosis (AS) and intermediate surgical risk.

METHODS

Eligible patients in this multi-centre, prospective, consecutively enrolled, non-randomised, clinical trial, received transcatheter aortic valve replacement via femoral artery access. Follow-up visits were at discharge, 30 days, and 6, 12, and 24 months. The primary endpoint was Valve Academic Research Consortium-2 composite safety at 30 days: all-cause mortality, all stroke, life-threatening bleeding, acute kidney injury-Stage 3, coronary artery obstruction requiring intervention, major vascular complication, and valve-related dysfunction requiring repeat procedure. Other endpoints were device success (successful vascular access, delivery, and deployment; correct position; intended performance mean aortic valve gradient <20 mmHg, mild or less paravalvular aortic regurgitation [PAR]; and only one valve implanted) and New York Heart Association functional class (NYHA). Kaplan-Meier (KM) estimates were calculated for the primary endpoint.

RESULTS

At baseline, mean patient (N=199) age was 85.5 years, mean Society of Thoracic Surgeon score was 5.9, and 78.4% were in NYHA class III/IV. The primary composite endpoint KM estimate was 12.1%. Device success was 88.8%. SAPIEN XT was implanted in the proper location in 98.5% (n=2: valve-in-valve procedures, n=1: no implant due to left main coronary artery occlusion). No device malfunctions were reported. The post procedure PAR was mild or less in 93.8% of patients. Mean aortic gradient decreased from baseline (50.0 mmHg) to 2 years (10.3 mmHg). Most patients (90.9%) were in NYHA class I/II at 30 days. New permanent pacemaker rate was 8.1%. Stroke at 30 days was 3.5% (1.5% disabling).

CONCLUSION

SAPIEN XT was safe and improved heart failure symptoms and valve haemodynamics in this cohort of Australian patients.

P5491Gender differences in long-term outcomes and predictors of all-cause mortality after percutaneous coronary intervention

Background

Gender disparities have been consistently reported in the nature, presentation, and treatment of coronary artery disease, leading to significant outcome differences. Previous reports have suggested that after adjusting for differing baseline and procedural characteristics female gender was an independent predictor of all-cause mortality after Percutaneous Coronary Intervention (PCI). We examined this issue using data from the Genesis Cardiovascular Outcomes Registry (GCOR).

Methods

We prospectively collected data on 10,989 PCI procedures from January 2009 to January 2018 from 12 Australian Hospitals, and compared the baseline patient and procedural characteristics and 1-year mortality by gender.

Results

Female patients were more likely than males to present with NSTEMI (23.0% vs. 21.1%, p=0.042), however less likely to have prior MI (19.5% vs. 24.2%, p<0.001) or PCI (28.8% vs 33.6%, p<0.001). Procedural success rates were similar between females and males (97.2%). On multivariate logistic regression, female gender had a higher rate of all cause mortality (OR 0.58, 95% CI 0.31 to 1.07; P=0.08) but similar rates of MACE (OR 0.84, 95% CI 0.55 to 1.07, P=0.42). Variables contributing to an increased risk of mortality in female patients, included a history of previous heart failure (OR 2.45, 95% CI 1.15 to 5.22; p=0.02), myocardial infarction (OR 2.06, 95% CI 1.09 to 3.90; p=0.026), and peripheral vascular disease (OR 2.69, 95% CI 1.32 to 5.47; p=0.006). Performing PCI to the LMCA significantly increased the risk of mortality in female patients (OR 3.84, 95% CI 1.14 to 12.9; p=0.029), and the use of BMS vs DES contributed to a worse outcome in women compared to men (OR 0.46, 95% CI 0.25 to 0.84; p=0.012). The presence of hypercholesterolaemia in women significantly increased the risk of mortality (OR 0.44, 95% CI 0.22 to 0.86; p=0.016).

Multivariate logistic regression assessing 1-year outcome by gender for all-cause mortality, MACE, and unplanned admissions Outcome Male (vs female) Odds ratio 95% CI P-value Death (143) 0.58 0.31 to 1.07 0.08 MACE (334) 0.84 0.55 to 1.28 0.42 Unplanned readmission (888) 0.79 0.63 to 0.98 0.04

Conclusion

Women have significant differences in baseline characteristics and increased all-cause mortality at 1 year compared to men, although overall MACE rates are similar. This study increases awareness of women at high risk, highlighting the need to improve the care of women undergoing PCI.

Rationale and design of the Onyx ONE global randomized trial: A randomized controlled trial of high-bleeding risk patients after stent placement with 1 month of dual antiplatelet therapy

BACKGROUND AND RATIONALE

Polymer-free drug-eluting stent (DES) implantation in combination with 1-month dual antiplatelet therapy (DAPT) has shown superior safety and efficacy outcomes compared with bare-metal stents among patients with high-bleeding risk (HBR) treated with 1-month DAPT. The safety and efficacy of the newer-generation durable-polymer DES Resolute Onyx compared with polymer-free DES among HBR patients treated with 1-month DAPT is unknown.

TRIAL DESIGN

The Onyx ONE global randomized trial is an international, prospective, randomized, blinded, controlled study enrolling HBR patients undergoing percutaneous coronary intervention. The trial will randomize up to 2,000 patients in a 1:1 fashion to receive either the durable-polymer Resolute Onyx DES or the polymer-free Biosensors BioFreedom DES. After index procedure, patients in both arms will be treated with 1 month of DAPT (aspirin and oral P2Y12 inhibitor), followed by single antiplatelet therapy thereafter. The primary end point is the composite end point of cardiac death, myocardial infarction, or stent thrombosis at 1-year follow-up. The powered secondary end point is target lesion failure (defined as the composite of cardiac death, target vessel myocardial infarction, or clinically driven target lesion revascularization) at 1 year. Patient follow-up is planned for 1, 2, and 6 months and 1 and 2 years after the procedure.

CONCLUSIONS

The Onyx ONE global randomized trial is the first study to directly compare the safety and efficacy of a durable polymer DES (Resolute Onyx) with a polymer-free DES (BioFreedom) in HBR patients treated with 1 month of DAPT.

Self-Expanding Transcatheter Aortic Valve System for Symptomatic High-Risk Patients With Severe Aortic Stenosis

BACKGROUND

The CENTERA transcatheter heart valve (THV) is a low-profile, self-expanding nitinol valve made from bovine pericardial tissue that is 14-F compatible with a motorized delivery system allowing for repositionability.

OBJECTIVES

The pivotal study evaluated safety and efficacy of this THV in high-surgical-risk study patients with severe symptomatic aortic stenosis.

METHODS

Implantations were completed in 23 centers. Clinical and echocardiographic outcomes were assessed at baseline, discharge, and 30 days. Major events were adjudicated by an independent clinical events committee. Echocardiograms and computed tomography scans were reviewed by core laboratories. The primary endpoint was all-cause mortality at 30 days.

RESULTS

Between March 25, 2015 and July 5, 2016, 203 patients with severe symptomatic aortic stenosis and increased surgical risk, as determined by the heart team, were treated by transfemoral THV implantation (age 82.7 ± 5.5 years, 67.5% female, 68.0% New York Heart Association functional class III/IV). At 30 days, mortality was 1%, disabling stroke occurred in 2.5% of patients, and New York Heart Association functional class I/II was observed in 93.0% of patients. Effective orifice area increased from 0.71 ± 0.20 cm² to 1.88 ± 0.43 cm² (p < 0.001). Mean aortic transvalvular gradient decreased from 40.5 ± 13.2 mm Hg to 7.2 ± 2.8 mm Hg at 30 days post-procedure (p < 0.001). Paravalvular aortic regurgitation at 30 days was moderate or higher in 0.6% of patients. A new permanent pacemaker was implanted in 4.5% of patients receiving the THV (4.9% for patients at risk).

CONCLUSIONS

The herein described THV is safe and effective at 30 days with low mortality, significant improvements in hemodynamic outcomes, and low incidence of adverse events. Of particular interest is the low incidence of permanent pacemaker implantations. (Safety and Performance Study of the Edwards CENTERA-EU Self-Expanding Transcatheter Heart Valve [CENTERA-2]; NCT02458560).

Transcatheter Aortic Valve Replacement With a Repositionable Self-Expanding Prosthesis: The PORTICO-I Trial 1-Year Outcomes

BACKGROUND

The new self-expanding, repositionable transcatheter heart valve (THV) system was designed for treatment of severe, symptomatic aortic stenosis in patients with high surgical risk.

OBJECTIVES

The purpose of this study was to report 1-year outcomes of transcatheter aortic valve replacement with the new THV system.

METHODS

This ongoing, international, multicenter study evaluated patients with severe, symptomatic aortic stenosis implanted with the THV via transfemoral access and follow-up at 30 days, 1 year, and annually through 5 years. The primary endpoint is all-cause mortality at 1 year; secondary endpoints include clinical outcomes and echocardiographic measurements, both adjudicated.

RESULTS

A total of 941 patients (82.4 ± 5.9 years; 65.7% female; Society of Thoracic Surgeons Predicted Risk of Operative Mortality score: 5.8%) were enrolled and underwent an implant at 61 sites in Europe, Australia, and Canada. At 1 year, Kaplan-Meier estimates for all-cause mortality, cardiovascular mortality, disabling stroke rates, and myocardial infarction were 12.1%, 6.6%, 2.2%, and 2.5%, respectively. Mean aortic transvalvular gradient and aortic valve area were 8.66 mm Hg and 1.75 cm², respectively. Paravalvular leakage was moderate or higher in 2.6% of patients with no severe leakage. New pacemaker rates were 18.7% and 21.3% for pacemaker naïve patients at 30 days and 1 year, respectively. Functional class, exercise capacity, and quality of life improved significantly from baseline to 1 year.

CONCLUSIONS

Transcatheter aortic valve replacement with the new THV in patients who are at increased surgical risk is associated with low 1-year mortality and stroke rates. Favorable hemodynamic results at 1 year are observed with low transvalvular pressure gradient and incidence of significant paravalvular leakage. (5 Year Observation of Patients With PORTICO Valves [PORTICO-I]; NCT01802788).

Computed tomography-based oversizing and incidence of paravalvular aortic regurgitation and permanent pacemaker implantation with a new-generation self-expanding transcatheter heart valve

AIMS

We aimed to evaluate the relationship between CT-based annular perimeter oversizing and the incidence of paravalvular aortic regurgitation (PAR) and permanent pacemaker (PPM) implantation in patients treated with the new self-expanding CENTERA transcatheter heart valve (THV) for severe aortic stenosis.

METHODS AND RESULTS

One hundred and ninety-eight patients in the CENTERA-EU trial were stratified a priori into four groups based on the perimeter oversizing (2.5-10%, 10-15%, 15-20% and >20%). PAR at 30 days was moderate or higher in 0.6% of patients. The frequency of PPM implantation was 4.9%. The mean perimeter oversizing was 16.2±5.6%. For patients with a perimeter oversizing >10%, an inverse relationship between oversizing and ≥mild PAR was observed (43.3% for 10-15% oversizing; 37.7%, 15-20%; 33.3%, >20%). No association between oversizing and effective orifice area was observed. The optimal cut-off value of perimeter oversizing for the prediction of ≥mild PAR was 15.9% (AUC 0.718, 95% CI: 0.576, 0.860). No annular ruptures were observed.

CONCLUSIONS

The CENTERA THV appears to have a wide range of sizing tolerance. The degree of oversizing to mitigate PAR is relatively low compared to other self-expanding transcatheter devices. There appears to be no compromise between occurrence of PAR and PPM across this wide range of oversizing.

Matched Comparison of Self-Expanding Transcatheter Heart Valves for the Treatment of Failed Aortic Surgical Bioprosthesis

Background—

Transcatheter valve-in-valve implantation is an established therapy for high-risk patients with failed surgical aortic bioprosthesis. There are limited data comparing outcomes of valve-in-valve implantation using different transcatheter heart valves (THV).

Methods and Results—

Patients included in the Valve-in-Valve International Data registry (VIVID) and treated with self-expanding THV devices were analyzed using centralized core laboratory blinded to clinical events. St. Jude Medical Portico versus Medtronic CoreValve were compared in a 1:2 fashion after propensity score matching. A total of 162 patients, Portico- (n=54) and CoreValve- (n=108) based valve-in-valve procedures comprised the study population with no significant difference in baseline characteristics (age, 79±8.2 years; 60% women; mean STS [Society of Thoracic Surgery] score 8.1±5.5%). Postimplantation, CoreValve was associated with a larger effective orifice area (1.67 versus 1.31 cm 2 ; P =0.001), lower mean gradient (14±7.5 versus 17±7.5 mm Hg; P =0.02), and lower core laboratory–adjudicated moderate-to-severe aortic insufficiency (4.2% versus 13.7%; P =0.04), compared with Portico. Procedural complications including THV malpositioning, second THV requirement, or coronary obstruction were not significantly different between the 2 groups. Survival and stroke rates at 30 days were similar, but overall mortality at 1 year was higher among patients treated with Portico compared with CoreValve (22.6% versus 9.1%; P =0.03).

Conclusions—

In this first matched comparison of THVs for valve-in-valve implantations, Portico and CoreValve demonstrated differences in postprocedural hemodynamics and long-term clinical outcomes. Although this could be related to THV design characteristics, the impact of other procedural factors cannot be excluded and require further evaluation.