P326 SURGICAL VERSUS TRANSCATHETER AORTIC VALVE REPLACEMENT WITH NEWER GENERATION DEVICES IN REAL–WORLD PRACTICE: ONE–YEAR OUTCOMES FROM THE ITALIAN OBSERVANT STUDIES

Objective

To compare the early and 1–year outcomes after transcatheter aortic valve replacement (TAVR) with new–generation devices over surgical replacement (SAVR) among patients with severe aortic stenosis (AS).

Background

TAVR is gaining acceptance for the treatment of lower risk patients with AS after several randomized and observational studies confirmed comparable early results to SAVR. On the other hand, clinical studies have shown that SAVR is still widely used in intermediate and high risk patients. There is need of data from large clinical registries to demonstrate the efficacy and safety of TAVR in the real–world setting, particularly after the introduction of new TAVR technology.

Methods

A total of 5706 AS patients who underwent SAVR and 2989 AS patients who underwent TAVR enrolled in the national, prospective OBSERVANT and OBSERVANT II studies, respectively in 2010–2012 and 2016–2018, were analyzed. Outcomes were adjusted using the propensity score matching. The primary outcomes of interest were all–cause mortality, major adverse cardiac and cerebrovascular events (MACCEs) and hospital readmission due to heart failure at 1–year. Secondary outcomes were major adverse events occurring during the index hospitalization.

Results

Among 1008 propensity score matched pairs, TAVR was associated with significantly lower 30–day mortality (1.8 vs. 3.5%, p = 0.020), stroke (0.8 vs. 2.3%, p = 0.005), acute kidney injury (0.6 vs. 8.2%, p < 0.001), infectious complications (3.8 vs. 6.5%, p = 0.006) and cardiogenic shock (1.4 vs. 5.1%, p < 0.001) compared to SAVR. Moderate–to–severe paravalvular regurgitation (5.9 vs. 2.0%, p < 0.001), major vascular complications requiring invasive treatment (2.2 vs. 0.1%, p < 0.001) and permanent pacemaker implantation (during the index hospitalization, 13.8 vs. 3.3%, p < 0.001) were more frequent after TAVR. At 1–year, TAVR was associated with lower risk of all–cause death (7.9 vs. 11.5%, p = 0.006), MACCE (12.0 vs. 15.8%, p = 0.011), readmission due to heart failure (10.8 vs. 15.9%, p < 0.001) and stroke (3.2 vs. 5.1%, p = 0.033) compared to SAVR.

Conclusions

In a real–world setting, patients with intermediate operative risk treated with newer generation TAVR devices had a low risk of major adverse events during the index–hospitalization and at 1–year follow–up. TAVR could become the treatment of choice for AS in the elderly provided that its durability is proved by long–term follow–up studies.

C28 THE FINANCIAL BURDEN OF NEWER GENERATION TAVI DEVICES: RESULTS FROM THE ITALIAN OBSERVANT STUDIES

Objectives

To estimate the financial burden of using newer generation transcatheter aortic valve implantation (TAVI) devices compared with older generation devices.

Background

TAVI is becoming the standard treatment for severe aortic stenosis in symptomatic elderly patients and is increasingly offered also to younger and lower risk patients. Resource utilization in performing TAVI has become an important focus due to the high likelihood of hospital readmissions, but it is unclear whether readmissions after TAVI contribute to a significant proportion of overall costs of TAVI to the healthcare system at mid–term follow up.

Methods

A probabilistic Markov model was developed in order to estimate the cost consequence of introducing newer generation TAVI devices were calculated as the absolute deterministic difference between a cohort of 6,000 patients treated with the newer TAVI devices (TAVI–new scenario) and the same cohort treated with old TAVI devices (TAVI–old scenario). Transition probability and hospitalization costs were retrieved among patients enrolled in the OBSERVANT I and OBSERVANT II studies; 1898 patients treated with older generation TAVI devices and 1417 patients treated with new generation TAVI devices were compared. Outcomes were adjusted using propensity score matching.

Results

Propensity score matching resulted in 853 pairs, whose baseline risk factors were well balanced. The mean EuroSCORE II (6.6 vs. 6.8; p = 0.76) and the mean age (82.0 vs 82.1; p = 0.62) of older generation TAVI patients and newer generation TAVI patients were similar. The use of newer generation TAVI devices determined a significant reduction of re–hospitalizations (–30.5% re–intervention, –25.2% major re–hospitalization and –30.8% minor re–hospitalization) and mortality (–20%). These reductions were associated with significant cost savings over a 1–year period (−€4.1 million in terms of direct costs and −€19.7 million considering the additional cost of the devices). The main cost–reduction was estimated for re–hospitalization that cover 79% of the overall cost reduction in the economic analysis without the costs of the devices.

Conclusions

After adjusting for baseline characteristics, patients undergoing TAVI with newer generation devices had lower risk of all–cause death and re–hospitalization. These reductions are leading to significant cost savings at 1 year, mainly due to the reduction in re–hospitalization costs.

Characterization of actionable bleeding and thrombotic risk trade-offs in patients undergoing percutaneous coronary intervention

Background

Patients undergoing percutaneous coronary intervention (PCI) are at risk of developing bleeding and/or thrombotic complications. Bleeding and thrombotic risk characteristics may overlap in some patients, which makes decision-making for dual antiplatelet therapy duration a clinical challenge. The actual proportion of PCI patients who have an increased bleeding risk and/or an increased thrombotic risk is unclear.

Purpose

Aim of this study is to identify sizeable and actionable proportions of patients at high bleeding risk (HBR) and/or at high thrombotic risk (HTR) in a contemporary cohort of PCI patients.

Methods

We retrospectively included all patients undergoing PCI at our Institution from November 2019 to April 2020 and identified those at HBR or HTR based on criteria from the Academic Research Consortium for High Bleeding Risk (ARC-HBR) or criteria from Giustino and colleagues, respectively. Since belonging to the HBR and HTR groups was non-mutually exclusive, patients were further stratified into 4 mutually exclusive subgroups: 1) HBR/HTR; 2) HBR, non-HTR; 3) non-HBR, HTR; and 4) non-HBR, non-HTR. In addition, the new ARC-HBR trade-off model (integrating patients' characteristics to define the individual risks of bleeding and thrombotic events) was applied to rank patients based on their computed risk scores for bleeding and thrombosis. Patients were categorized based on the ratio between the ARC-HBR thrombotic and the bleeding risk scores (i.e., high [1.5], intermediate [0.75–1.5], low [<0.75]).

Results

A total of 312 patients were included, of which 93 (30%) presented with HBR and 116 (37%) with HTR. Among patients with HBR, 41% presented with HTR. Among patients with HTR, 33% presented with HBR. Overall, 12.2% of patients had HBR/HTR, 17.6% had HBR, non-HTR, 25.0% had non-HBR, HTR, and 45.2% had non-HBR, non-HTR. Based on the ARC-HBR trade off score, 16.3% of patients had a higher risk of thrombosis than the risk of bleeding, 45.9% had similar risks, and 37.8% had a higher risk of bleeding than the risk of thrombosis. Among patients who had HBR/HTR, the trade-off model identified 8% as having a higher risk of thrombosis than the risk of bleeding and 18.4% as having a higher risk of bleeding than the risk of thrombosis.

Conclusions

Characterizing the risk of bleeding and thrombotic complications is an important prerequisite for tailoring strategies to individual patients, hence minimizing the risks and improving the outcome of PCI. More than half of patients undergoing PCI presented with HBR, HTR, or both. About 40% of patients presented with characteristics of high risk, which make them actionable (e.g., by using shorter durations of dual antiplatelet therapy in patients at HBR and non-HTR or using longer durations in patients at non-HBR and HTR). The ARC-HBR trade off model score is an additional useful tool that may be used to identify an additional quarter of actionable patients in the HBR/HTR category.

Funding Acknowledgement

Type of funding sources: None.

Clinical impact and evolution of mitral regurgitation after TAVI using the new generation self-expandable valves

BACKGROUND

Concomitant mitral regurgitation (MR) impaired prognosis in patients undergoing transcatheter aortic valve implantation (TAVI). It has been suggested that the use of first generation self-expandable valve in patients with significant MR is associated with worse outcome as compared with balloon expandable valve. However, the impact of newer generation transcatheter devices on MR has not been investigated so far. We aim to assess the prognostic impact of MR in patients undergoing TAVI with the first-generation vs. the latest generation of self-expandable valves.

METHODS

We analyzed 2964 consecutive patients who underwent TAVI. Patients were classified into 4 groups according to the degree of baseline MR and the generation of self expandable valve implanted.

RESULTS

Of 1234 patients with moderate or severe MR, 817 were treated with first generation and 417 patients with second generation valves. Whereas, of 1730 patients with no or mild MR, 1130 were treated with first generation and 600 patients with second generation valves. Although, concomitant moderate-severe MR was found to be an independent predictor of mortality after TAVI, the use of newer generation self expandable valves was associated with higher survival rate at 1 year irrespective of the degree of preprocedural MR. At multivariable analysis the use of newer generation valve was associated with MR improvement throughout 1 year follow-up.

CONCLUSION

Baseline moderate-severe MR is associated with an increase in mortality after TAVI. However, the degree of preprocedural MR doesn't impact survival when a second generation self expandable valve is used.

Residual mitral regurgitation impact on outcomes after mitraclip therapy: five-year follow-up from the GRASP registry

Funding Acknowledgements

Type of funding sources: None.

Background – Although percutaneous mitral valve repair is an attractive alternative treatment option for patients with severe mitral regurgitation (MR) at high surgical risk, residual MR is commonly observed after the procedure and little is known about its impact on outcomes after MitraClip therapy, expecially in patients with severe left ventricular (LV) impairment.

Purpose – The aim of this prospective, observational study was to evaluate the impact of residual MR (MR ≤1+ vs. MR >1+) on long-term outcomes of mitral valve repair with the MitraClip System in high surgical risk patients presenting with moderate-to-severe or severe MR and with severe reduction of LV ejection fraction (EF).

Methods – Patients enrolled in the prospective Getting Reduction of Mitral Insufficiency by Percutaneous Clip Implantation (GRASP) with functional MR and EF ≤30% who were eligible at almost five-year follow-up were included in the present analysis.  The primary endpoint was death at 5-year follow-up.  Also echocardiographic parameters at baseline and 5-year follow-up and rehospitalization rates were assessed.

Results – A total of 139 patients were included: 92 (66.2%) with post-procedural residual MR ≤1+ and 47 (33.8%) with residual MR > 1+ (41 patients with residual MR 2+, 5 with residual MR 3+, 1 with residual MR 4+).  Comparable clinical and echocardiographic baseline characteristics were observed between the two groups except for NYHA functional class IV and implanted pace-maker (more frequent in patients with residual MR >1+) and previous myocardial infarction (more frequent  in patients with residual MR ≤1+). At 5-year follow-up, no significant differences were reported in the primary endpoint (49.6% in patients with residual MR ≤ 1+ vs. 65.3% in patients with residual MR > 1+, p 0.203) and in cardiac death (37.8% in patients with residual MR ≤ 1+ vs. 42.6% in patients with residual MR > 1+, p 0.921). Cox regression analysis identified residual MR > 1+ as an independent predictor of re-hospitalization (HR 0.51, 95% CI 0.28-0.92, p =0.026). At 5-year follow-up,  a significant reduction in left ventricular end-systolic volume was  observed in patients with residual MR ≤ 1+.

Conclusions – At 5-year follow no significant differences in survival emerged in patients with severe  LV dysfunction undergoing MitraClip therapy regardless residual MR. Nevertheless residual MR > 1+ emerged as an indipendent predictor of re-hospitalization.

4289Clinical outcomes of percutaneous mitral valve repair in secondary mitral regurgitation: a systematic review and meta-analysis

Background

The benefit of percutaneous mitral valve repair with mitraclip (PMVR) in patients with secondary mitral regurgitation (MR) is still debated.

Methods

In order to compare the outcome of PMVR with optimal medical therapy (OMT) versus OMT alone in patients with secondary MR, we performed a systematic review and meta-analysis of 2 randomized clinical trials (RCT) and 7 non-randomized observational studies (nROS). Hazard ratios (HR) and 95% confidence intervals (CI) were pooled through inverse variance random-effect model to compute the summary effect size for all-cause mortality, cardiovascular death and cardiac-related hospitalization. Subgroup and meta-regression analysis were also performed.

Results

An overall population of 3,118 individuals (67% men; mean age, 73 years) was included: 1,775 PMVR+OMT and 1,343 OMT patients, with mean follow-up of 24±15 months. PMVR+OMT was associated with a lower risk of all-cause death (HR: 0.77; 95% CI: 0.68–0.87), cardiovascular death (HR: 0.55; 95% CI: 0.34–0.89) and cardiac-related hospitalization (HR: 0.77; 95% CI: 0.64–0.92). Meta-regression analysis showed that larger left ventricular end-diastolic volume index (LVEDVI) portends higher mortality after PMVR (p<0.001).

Conclusions

This study-level meta-analysis shows that PMVR+OMT is associated with reduced all-cause death, cardiovascular death and cardiac-related hospitalization when compared with OMT alone in secondary MR. LVEDVI is a predictive marker of efficacy, as patients with smaller LVEDVI derive the largest benefit from PMVR.

Transcatheter Aortic Valve Implantation Experience with SAPIEN 3

Based on randomized trials with first generation devices, transcatheter aortic valve replacement (TAVI) has been included into the treatment strategy for high-risk and inoperable patients with severe aortic stenosis. Procedural complications remain a concern with TAVI, including stroke, vascular complications, paravalvular leak (PVL) and conduction disturbances. Addressing these limitations will support TAVI use in lower risk populations. This review discussed features and most recent clinical evidence of the new balloon-expandable THV (SAPIEN 3, Edwards Lifescience, Irvine, CA, USA).

The Ultimaster® coronary stent system: state of the art

Percutaneous coronary intervention (PCI) has been a mainstay in the management of coronary artery disease since its introduction in the late 1970s. Bare-metal stent (BMS) and then first- and second-generation drug-eluting stents (DES) have enhanced the results of PCI by improving early results and reducing the risk of restenosis and stent thrombosis (ST). The delay of re-endothelialization and recovery of endothelial function after stenting as well as inhibition of vascular repair after DES implantation, in part related to permanent polymers, are consider important part of ST pathophysiology mechanism. Several progresses have been made to overcome this issue, among them the development of new more biocompatible - first - and completely biodegradable - then - polymer coatings. A third-generation DES using a biodegradable polymer and eluting sirolimus (Ultimaster®, Terumo Corporation, Tokyo, Japan) has been recently introduced to overcome the long-term adverse vascular reactions. Thanks to the polymer coating applied to the outside surface only (abluminal side), the total drug dose applied on the stent platform has been reduced, leaving the luminal side of the stent free from drug and polymer to enhance endothelial coverage. Indeed, 3-4 months after implantation, the Ultimaster® DES has lost most of its coating, acquiring a profile similar to conventional BMS. This article reviews the recent publications investigating the safety and effectiveness of the bioresorbable polymer sirolimus-eluting Ultimaster® stent (BP-SES), for the treatment of coronary artery lesions.

Histopathology of thalassemic heart disease: an endomyocardial biopsy study

Right ventricle endomyocardial biopsies were obtained from 13 thalassemic patients. Clinical profiles were investigated, and serum ferritin tests were assessed using diagnostic kits. Histochemical iron detection (Perls method) and immunohistochemical stain for ferritin were performed in the endomyocardial samples. Histologic iron overload was observed in eight patients, and variable iron deposits were recognized by a semiquantitative method. There was a statistically evident correlation between serum ferritin and myocardial iron storage. Marked iron deposition was associated with higher immunohistologic ferritin concentration. Iron-negative tissue samples showed bland immunohistochemical positivity. Myocardial interstitial fibrosis was observed in 12 cases; diffuse perimyocytic or perivascular fibrosis and endocardium thickening were the main histologic patterns identified. One biopsy was characterized by marked fibrolipomatous infiltration. Myocyte hypertrophy, myocytolysis, and severe capillary congestion also were observed.

Treatment of coronary bifurcation lesions with bioresorbable vascular scaffolds

AIM

Aim of the study was to report on the feasibility and early safety and efficacy of Absorb everolimus-eluting bioresorbable vascular scaffold (BVS) for coronary artery bifurcations (CABs) treatment at a single high-volume center.

METHODS

All patients treated with Absorb implantation at our institution from March 2013 to March 2014 were enrolled in the prospective, single-center, ongoing, all-comers registry, which has the main purpose of evaluating the safety and efficacy of Absorb implantation in unselected patients treated in daily practice. In-hospital and at follow-up clinical outcomes of 46 patients undergoing treatment with Absorb in 46 CAB lesions were reported in the present study.

RESULTS

Treated CAB lesions involved the left main in 13.0% of cases, the left anterior descending artery in 65.0%, the left circumflex in 19.6%, and the right coronary artery in 2.2%. Bifurcations were classified as true (47.8%) and non-true (52.2%) according to the Medina classification. The provisional and the two-BVS techniques were used in 78.3% and 21.7%, respectively. Two-BVS techniques included: mini-crush 13.0%; reverse culotte 2.2%; T-stenting 2.2%; and V-stenting 4.3%. No in-hospital adverse events occurred. At 6 months no adverse events occurred. Only one case of target lesion revascularization was observed at day 227. No stent thrombosis occurred during follow-up.

CONCLUSION

Our preliminary experience suggested that CABs treatment with Absorb is feasible and associated with promising immediate and short-term clinical outcomes. However, larger studies with long-term follow-up are needed to adequately address the safety and efficacy of BVS use in CABs.

Self-apposing STENTYS® stent in acute myocardial infarction

Balloon-expandable stents are currently used with satisfactory results in percutaneous coronary interventions. Unfortunately, in challenging anatomical patterns such as high thrombotic burden lesions, outcomes are often impaired. The STENTYS® stent (STENTYS, Paris, France), with its self-expandable capacity and peculiar Z-shape design, has been recently introduced in the clinical arena as an alternative to balloon-expandable stents for challenging lesion subsets. This article provides an overview of clinical trials, completed and currently on-going, on this self-apposing technology.

Safety and efficacy of protease-activated receptor-1 antagonists in patients with coronary artery disease: a meta-analysis of randomized clinical trials

BACKGROUND

Thrombin receptor antagonists blocking protease-activated receptor-1 (PAR-1) on platelets represent a new class of oral antiplatelet agents for patients with atherothrombotic disease manifestations.

OBJECTIVES

We investigated the safety and efficacy of PAR-1 antagonists in patients with coronary artery disease (CAD).

PATIENTS/METHODS

Randomized, placebo-controlled trials of the PAR-1 antagonists atopaxar or vorapaxar in CAD patients were identified. The primary safety endpoint was the composite of Thrombolysis In Myocardial Infarction (TIMI) clinically significant bleeding. The primary efficacy endpoint was the composite of death, myocardial infarction (MI) or stroke.

RESULTS

A total of 41 647 patients from eight trials were included. PAR-1 antagonists were associated with higher risks of TIMI clinically significant (odds ratio [OR] 1.48, 95% confidence interval [CI] 1.39-1.57, P < 0.001), major (OR 1.46, 95% CI 1.28-1.67, P < 0.001) and minor (OR 1.67, 95% CI 1.40-2.00, P < 0.001) bleeding than placebo in the fixed-effects model. PAR-1 antagonists reduced the composite of death, MI or stroke as compared with placebo (OR 0.87, 95% CI 0.81-0.92, P < 0.001), driven by a lower risk of MI (OR 0.85, 95% CI 0.78-0.92, P < 0.001). Conversely, PAR-1 antagonists and placebo did not differ in terms of risk of death (OR 0.99, 95% CI 0.90-1.09, P = 0.81) or stroke (OR 0.96, 95% CI 0.84-1.10, P = 0.59).

CONCLUSIONS

PAR-1 antagonists decrease ischemic events in patients with CAD as compared with placebo, mainly driven by a reduction in MI, at the cost of an increased risk of clinically significant bleeding.

Update on percutaneous mitral valve therapy: clinical results and real life experience

Mitral regurgitation (MR) is a common valvulopathy worldwide increasing in prevalence. Cardiac surgical intervention, preferable repair, is the standard of care, but a relevant number of patients with severe MR do not undergo surgery because of high peri-operative risk. Percutaneous mitral valve repair with the MitraClip System has evolved as a new tool for the treatment of severe MR. The procedure simulates the surgical edge-to-edge technique, developed by Alfieri in 1991, creating a double orifice valve by a permanent approximation of the two mitral valve leaflets. Several preclinical studies, registries and Food and Drug Administration approved clinical trials (EVEREST, ACCESS-EU) are currently available. The percutaneous approach has been recently studied in a randomized controlled trial, concluding that the device is less effective at reducing MR, when compared with surgery, by associated with a lower adverse event rate. The patients enrolled in this trial had a normal surgical risk and mainly degenerative MR with preserved left ventricular function. On the other hand, results derived from the clinical "real life" experience, show that patients actually treated in Europe present a higher surgical risk profile, more complex mitral valve anatomy and functional MR in the most of cases. Thus these data suggest that MitraClip procedure is feasible and safe in this subgroup of patients that should be excluded from the EVEREST trial due to rigid exclusion criteria. Despite the promising results clinical experience is still small, and no data related the durability are currently available. Therefore, MitraClip device should be reserved now to high risk or inoperable patients.