The long-term clinical course of moderate tricuspid regurgitation

Background

Moderate TR is a frequent condition, worsening mid and long-term survival, particularly in patients >75 years old, and in those suffering from left ventricular systolic dysfunction. As TR is often clinically unsuspected until an advanced stage of congestive heart failure (HF), there is a great need of early diagnosis and long-term appropriate follow-up. However, data focusing on the clinical and echocardiographic course of a cohort of patients with moderate TR is lacking, and the most appropriate type and time of management of these patients is still heavily debated.

Purpose

To evaluate the evolution and the long-term clinical outcome of a cohort of patients suffering from moderate and moderate to severe TR, regardless of its etiology.

Methods

Clinical outcome and echocardiographic follow-up were assessed in 212 patients diagnosed with moderate and moderate to severe TR in our centre between January 2014 and December 2019. TR progression at follow-up was defined as TR grade increase to at least severe. The primary endpoint was all-cause death; secondary endpoints were cardiovascular (CV) death and HF hospitalization.

Results

After a median follow-up of 4.2 years, TR progression occurred in 76 patients (36%): patients with TR progression presented with more history of coronary artery disease (p=0.042), atrial fibrillation (AF, p=0.007) and chronic kidney disease (CKD, p=0.007) and with baseline larger right ventricle end-diastolic diameter (RVEDD, p<0.001) and worse left ventricular ejection fraction (LVEF, p=0.048). After univariate and multivariate analyses, a history of AF (HR 2.3, CI 1.2–4.5, p=0.011) and RVEDD (HR 2.4, CI 1.3–4.4, p=0.003) were independent predictors of TR progression. The primary endpoint occurred in 57 patients (27%) and was significantly more frequent (p=0.015) in the group of patients with TR progression compared to those without TR progression; multivariate analyses showed TR grade progression (HR 4.3, CI 2.1–9.1, p<0.001), CKD (HR 3.2, CI 1.5–7.1, p=0.002) and LVEF (HR 0.9, CI 0.93–0.99, p=0.007) as being independently associated with the primary outcome. Moreover, both CV death (p=0.003) and HF hospitalization (p=0.0139) were significantly more frequent in patients with TR progression.

Conclusions

Our results showed that moderate TR, by progressing in a relevant proportion of patients over a long-term follow-up, significantly increases the risk of mortality and HF hospitalization. We identified specific risk factors associated with TR progression, which could help to identify patients at risk before an advanced stage of this disease. We believe that this cohort of patients should be appropriately managed and closely followed-up to avoid adverse clinical events related to the natural course of this valvulopathy.

Funding Acknowledgement

Type of funding sources: None.

Right ventricular-arterial coupling in severe tricuspid regurgitation: prognostic relevance of longitudinal strain

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND. Right ventricular-to-pulmonary artery (RV-PA) coupling integrates RV systolic function at a given afterload and has been shown to have a prognostic impact in different clinical settings. In the context of severe functional TR, it reflects RV adaptation to both volume and pressure overload. However, its prognostic relevance has not been extensively  examined in patients suffering from severe TR, and available data evaluated RV-PA coupling using the TAPSE/PASP ratio, with its intrinsic limitation especially in the setting of concomitant severe TR. In patients with severe TR, right ventricular free-wall longitudinal strain (RVFWLS) has been demonstrated to be more senstie in evaluation of subtle RV systolic dysfunction and to reclassify patients with impaired RV systolic function although conventional echocardiographic parameters within normal limits.

PURPOSE.  To analyze whether the noninvasive evaluation of RV-PA coupling with the use of the RVFWLS/PASP ratio could improve risk stratification in patients with severe TR.

METHODS. Baseline clinical and echcardiographic parameters and correlation with long-term outcome were assessed in 250 consecutive patients with severe TR referred at our center from December 2015 to December 2018.

RESULTS. Patients were predominantly female, with severe cardiovascular risk factors and major comorbidities, history of heart failure (HF) and atrial fibrillation.

RVFWLS/PASP ratio ≤ 0.32 (AUC 0.72, p < 0.001, sensitivity 70%, specificity 67%) marginally predicted the presence of baseline clinical RV HF (p = 0.05). After univariate and multivariate analyses, RV-PA coupling as assessed by RVFWLS/PASP ratio, but not by TAPSE/PASP, was independently associated with all-cause mortality (OR 0.007, p = 0.03) and, at follow-up, "RV-PA coupled patients", defined by RVFWLS/PASP ratio >0.26 (AUC 0.74, p < 0.001, sensitivity 77%, specificity 52%) showed higher surival rates (p = 0.02).

CONCLUSIONS. RVFWLS/PASP ratio was systematically measured to possibly evaluate RV-PA coupling as a novel echocardiographic parameter in the context of patients with severe TR: it is independently associated with poor long-term prognosis and different values seem to improve irsk stratification in this cohort of patients.

Accuracy and reliability of left atrial appendage morphology assessment by new 3D transesophageal echocardiographic rendering modalities: a comparative study with computed tomography

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction. Left atrial appendage (LAA) morphology assessed by contrast-enhanced computed tomography (CT) has been associated to the risk of cardioembolic stroke in non-valvular atrial fibrillation. Subsequent studies with the traditional LAA classification system (CS) into 4 morphologies (Chicken wing, Cauliflower, Cactus and Windsock) yielded mixed results in terms of reliability and stroke risk association. Recently, a simple LAA morphology CS (new-LAAcs) based on the LAA bend angle measurement has been suggested. Three-dimensional transesophageal echocardiography (3D TOE) quality imaging has been improved and new volume rendering modalities developed.

Purpose. Aim of this study was to evaluate the accuracy and reliability of 2D and new 3D TOE rendering modalities compared to CT in assessing LAA morphology. We used and validated a new simple LAA morphology classification system (new-LAAcs) based on the LAA bend angle in contrast to the traditional CS.

Methods. 50 consecutive patients who underwent both cardiac CT and TOE were enrolled. LAA morphology was assessed by three different TEE modalities: (1) 2D TOE inspective evaluation (2D TOE), (2) 3D TOE multiplanar reconstruction (3D TOE MPR) and (3) 3D TOE Philips TrueVue Glass rendering (3D TOE GLASS). We assessed TOE accuracy compared to CT by sensitivity, specificity, accuracy, and Cohen’s kappa. Two trained readers independently adjudicated LAA morphologies in the new-LAAcs and the inter-rater reliability was obtained by percentage agreement and Cohen’s kappa. The reliability of the new- vs. traditional-LAAcs was assessed by CT in terms of reliability rates and influence on LAA morphology prevalence.

Results. CT and TOE imaging analyses were feasible in all patients. 2D TOE was fairly accurate in identifying LAA morphology (κ 0.38, p = 0.022) and had only moderate inter-rater (κ 0.46, p = 0.027) and substantial intra-rater (κ 0.62, p = 0.003) reliability rates. 3D TOE showed high validity: 3D TOE MPR had an almost perfect accuracy (κ 0.84, p < 0.001) and substantial (κ 0.77, p < 0.001) inter-rater reliability; 3D TOE GLASS substantial accuracy (κ 0.67, p < 0.001) and almost perfect (κ 0.82, p < 0.001) inter-rater reliability. Intra-rater agreement was almost perfect for both 3D TOE modalities (κ 0.84, p < 0.001). In the comparison among CS the traditional-LAAcs inter-rater reliability was moderate (κ 0.47, p < 0.001) and the intra-rater reliability substantial (κ 0.68, p < 0.001) while the new-LAAcs yielded an almost perfect reliability level (inter-rater κ 0.84, p < 0.001 and intra-rater κ 0.93, p < 0.001). With the traditional-LAAcs, the prevalence of CW LAA was 30 (60%), while with the new-LAAcs the prevalence of low-risk-LAA was 13 (26%), leading to classify 17 (57%) CW morphologies as high-risk-LAA.

Conclusions. 3D TOE is an accurate, reliable, and feasible alternative to CT in assessing LAA morphology with the new-LAAcs. The new-LAAcs shows higher reliability rates than the traditional one. Abstract Figure.  Abstract Figure.

Multiparametric assessment of the intraprocedural result after transcatheter mitral valve edge-to-edge repair proceduret

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Research grant

OnBehalf

n/a

Background. Quantification of residual mitral regurgitation (MR) after transcatheter edge-to-edge mitral valve repair (TMVr) is challenging.

Objectives.  To evaluate the feasibility and the performance of an intraprocedural multiparametric approach based on echocardiographic and invasive hemodynamic parameters and to develop a multiparametric scoring system for MR grading after TMVr, and to compare this approach against currently recommended methods. 

Methods. Ninety-three consecutive patients treated with MitraClip (April 2019-July 2020) were enrolled. The protocol of MR evaluation included: 2D and 3D color-Doppler (3D-vena contracta area- 3D-VCA), pulsed-wave Doppler (pulmonary vein- PV flow, stroke volume), continuous-wave Doppler (jet density), morphological parameters (spontaneous echocontrast) and invasive hemodynamic (mean left atrial pressure-LAP, V-wave) at baseline and after clip implantation. A multiparametric score (M-score) was calculated by including the significant predictors (3D-VCA, dense jet on CWD, final LAP, final V wave) of primary endpoint (CV death or HF related hospitalization) at one year follow-up, weighted according to the corresponding odds ratio, to predict the clinical outcome at one-month and one-year follow-up. 

Results. The final study population included 86 pts (mean age 78.3 +8.9yrs, 54.6% primary MR). Procedural success was achieved in 78 pts (90.7%). 3D-VCA (AUC 0.808) and current method for MR grading (AUC 0.801) were comparable predictors of lack of symptom improvement (<5 point change in KCCQ-OS score) at one-month (p = 0.398, DeLong’s test). The M-score performed similarly as predictor of one-month follow-up but was a better predictor of primary endpoint at 1-year (AUC 0.919) compared to single parameters (p = 0.005 vs 3D-VCA DeLong"s test) and currently recommended methods for MR grading (p = 0.006 DeLong"s test). The optimal cut-off was 2 points with 86.7% sensitivity and 83.1% specificity.

Conclusion. We evaluated intraprocedural TMVr result in a multiparametric approach showing that 3D-VCA alone is comparable to current recommended method for MR grading. However, the integration of echocardiographic and invasive hemodynamic parameters into a multiparametric score provided a further added value for predicting clinical outcome  at one-year compared to currently recommended methods for MR grading and to 3D-VCA.

Impact on outcome of different etiologies, baseline degree and improvement of mitral regurgitation in patients with aortic stenosis who underwent transcatheter aortic valve replacement

Funding Acknowledgements

Type of funding sources: None.

Background -  Mitral regurgitation (MR) is a frequent finding in patients with aortic stenosis (AS). Moderate or severe MR is present in up to one-third of pts undergoing TAVR and it is a negative prognostic factor as well as the presence of residual MR after TAVR. However, whether different etiologies/mechanisms of MR have different effects on outcome and MR degree changes after TAVR is yet unknown.

Aim – The aim of the study is to evaluate the prognostic impact of baseline MR degree and its changes after TAVR procedures according to different etiologies of MR in patients who underwent TAVR.

Methods - We performed a retrospective observational study on a cohort of patients who underwent TAVR between January 2015 and December 2019. During the index period 947 pts underwent TAVR. To better characterize the mechanism of MR only pts with pre-procedural 3D transesophageal echocardiographic and at least one follow-up available study were included. The final study population consisted of 224 pts. MR severity was evaluated by multiparametric approach and classified in 4 degrees.

The study population was further divided in 4 groups: Group I: fibro-calcific degeneration of the leaflets (78.6% pts); 2. Group II: prolapse or flail (4.4% pts); Group III: functional MR (FMR) due to leaflets tethering (5.6% pts); Group IV: FMR due to annular dysfunction or dilatation (11.3% pts). Primary outcome was all-cause of death.

Results and Discussion – MR was absent in 15 pts (6.7%), mild in 79 pts (35.7%), mild-to-moderate in 109 in pts (49.3%), moderate-to-severe in 7 pts (3.1%) and severe in 11 pts (4.9%). Patients with > moderate MR degree at baseline had a worse outcome than patients with < moderate MR degree (p log rank = 0.029). FMR (groups III and IV) was associated with better outcome than organic MR (groups I and II) (p log rank = 0.035). Moreover, group IV showed a better outcome compared groups I (p log rank = 0.047) and II (p log rank = 0.038). Patients who showed improvement of MR of at least 1 degree post TAVR showed better outcome compared to patients without improvement (p log rank = 0.04). At multivariate analysis, including pre procedural MR > 2+, pre procedural TR > 2+, organic vs functional etiology and MR improvement after TAVR as covariates, only baseline MR > moderate was an independent predictor of mortality (HR 6.3; 95% CI 1.4 -27.0; p < 0.001).

Conclusion - This study confirms the prognostic role of the baseline degree of MR in patients with AS undergoing TAVR. Moreover, this is the first study demonstrating that FMR due to annular dilatation but not due to leaflet tethering is associated with better outcome compared to organic etiologies.

Use of MitraClip system for severe mitral regurgitation in cardiogenic shock: results from a multicentre observational Italian experience (the MITRA-SHOCK study)

Background/Introduction

Cardiogenic shock (CS) is a medical emergency and a frequent cause of death. CS can be complicated by mitral regurgitation (MR). The presence of at least moderate MR in the setting of shock was associated with about three-times higher odds of 1-year mortality. In the setting of refractory CS, percutaneous mitral valve repair (PMVR) can be a potential therapeutic option.

Purpose

The aim of the study was to evaluate the efficacy of percutaneous approach of severe MR in patients with CS assessing short-term clinical outcomes.

Methods

In this study we retrospectively included patients with CS and concomitant severe MR treated with Mitraclip system. We enrolled 28 patients from 5 Italian centers between 2012 and 2019. MitraClip implantation was performed according to each hospital standard care. CS was defined utilizing the Diagnostic Criteria of Cardiogenic Shock used in the SHOCK trial. Procedural success was defined as the presence of moderate or less MR after MitraClip implantation.

Results

All patients presented at least severe MR. All treated patients were at high surgical risk (STS mortality score 36.4±11.7%). Procedural success was obtained in 24 patients (86%). A mean of 1.71±0.76 clips per patients were implanted. In-hospital complications occurred in 13 patients (46%): 7 minor bleedings (25% of patients), 7 major bleedings (25%), 8 acute kidney injuries (28%). In-hospital mortality was 25% and the reported causes of death were cardiovascular in all patients. At Cox multivariate analysis procedural success was a strong predictor of in-hospital survival (HR 0.11, CI 95% 0.02–0.67, p=0.017).

Conclusions

PMVR with Mitraclip system in patients with CS and concomitant MR demonstrated high procedural success and acceptable safety. It can be considered a bailout option in this setting of patients with high short-term mortality. Larger prospective studies are needed.

In-hospital mortality predictors

Funding Acknowledgement

Type of funding source: None

1183 Three-dimensional echocardiographic paramenters for mitral valve quantification: a feasibility and validation study

Introduction

Mitral regurgitation (MR) severity affects prognosis and a correct quantification is key for surgical indication. A multiparametric approach (MPA) is recommended, as singular parameters suffer pitfalls. Recently suggested three-dimensional echocardiographic (3DE) parameters lack clear reference values. No studies have assessed the feasibility of regurgitant volume (RV) and fraction (RF) using the 3D planimetric area of the mitral annulus (MAA) and of the left ventricular outflow tract (LVOTA).

Purpose

To assess the feasibility and reliability of 3DE, RV and RF obtained by doppler volumetric method using MAA and LVOTA, compare results with 2DE and 3D vena contracta area (VCA) and propose cut-offs for these parameters using MPA as gold standard.

Methods

Patients referred to our Department for MR assessment were enrolled from September 2018 to February 2019 without more than mild aortic regurgitation or severe stenosis, mitral stenosis and previous valvular surgery. Transthoracic 2DE was used to calculate a multiparametric index of MR severity including: jet area/left atrium (LA) area, CW characteristics, 2D vena contracta, PISA, pulmonary vein flow, LA volume and systolic pulmonary artery pressure. Transoesophageal 3DE was used to assess MAA and LVOTA from a 3D dataset. RV and RF were calculated by Doppler volumetric method using the planimetric areas instead of diameters. VCA 3D was calculated from a 3D color dataset as the cross-sectional area of the regurgitant jet. We compared the results between 2DE and 3DE and between functional and organic MR. ROC curves were analyzed to assess diagnostic performance and identify cut-offs for severity prediction. Intraclass correlation coefficient was calculated to assess variability in measurements.

Results

Population was composed by 87 patients (56 male, 65 ± 13 years), 72% organic MR. MAA was larger in 2DE (10.4 ± 3.2 vs 9.8 ± 2.9 cm2,) as was the RV (76.6 ± 36.1 vs 66.4 ± 31.9 ml) and RF (55.4 ± 12.4 vs 50.4 vs 10.9%, all p < 0.0001), while LVOTA was smaller (3.9 ± 0.98 vs 4.1 ± 1.0 cm2, p < 0.0001). RV 2D and RF 2D were larger in the organic MR group (p < 0.0001), meanwhile VCA 3D, RV 3D and RF 3D did not show a significant difference (all p > 0.1). VCA 3D had a good correlation with RV 3D (r = 0.593, p < 0.0001) and RF 3D (r = 0.576, p < 0.0001).

We proposed a cut-off value of 41.5 mm2 for VCA 3D (94% sens, 96% spec, AUC 0.978), 52 ml for RV 3D (84% sens, 78% spec, AUC 0.901) and 47.6% for RF 3D (91% sens, 90% spec, AUC 0.966) to predict MR severity as assessed by MPA.

Intraclass correlation coefficient was 0.980 for MAA and 0.985 for LVOTA for intra-observer variability, while for inter-observer variability it was 0.951 for MAA and 0.962 for LVOTA.

Conclusion

2DE overestimates MA dimensions and underestimates LVOT dimensions thus overestimating RV and RF. 3DE measures are relatively simple and reproducible. Proposed cut-offs for RV, RF and VCA 3D have a good diagnostic power.

P218 Accuracy and reproducibility of aortic root assessment by eSie Valves in patients candidate to transcatheter aortic valve implantation: a comparative study with computed tomography

Background

Accurate imaging assessment of the aortic root (AR) is critical for prosthesis sizing in transcatheter aortic valve implantation. Multislice computed tomography (MSCT) is the gold standard for this purpose. 3D transesophageal (3D-TOE) reconstruction tools have recently been introduced, which automatically configures a geometric model of AR from 3D-TOE dataset and perform quantitative analyses of the AR.

Purpose

The aim of the study was to compare semi-automated measurements of AR obtained by eSie Valves (EV) (Siemens Medical Solution, California, USA) tool with MSCT.

Methods

We prospectively enrolled 26 consecutive patients (mean age 79.5 ± 7.5 years; 38% men) with severe symptomatic aortic stenosis (mean gradient 48.8± 13.6 mmHg) who underwent both 3D-TOE and MSCT as part of TAVI evaluation protocol. Volumetric datasets of the AR, acquired with 3D-TOE in mid-esophageal view, were analyzed with EV tool. EV tool automatically detected AR landmarks and, after user validation, created 3D model of AR providing values of area, perimeter, diameters of aortic annulus (AA) and coronary ostia heights (Fig 1).

Results

EV tool analysis on 3D-TOE volumetric data sets was feasible in all patients.

Strong correlation between EV tool and MSCT assessment for AA major diameter (r = 0.79), AA minor diameter (r = 0.81), AA perimeter (r = 0.89) and AA area (r = 0.89) (all p< 0.0001) was found. On average EV tool underestimated MSCT measurements of AA major diameter (1.2 mm, 4.5%), AA minor diameter (2.6 mm, 11.3%), AA perimeter (4 mm, 5.2%) and AA area (65.3 mmq, 13.6%).

Moderate correlation between the two methods, already in this initial sample, for right coronary artery ostium height (r = 0.53, p = 0.007) was discovered. Finally, weak correlation for left coronary artery ostium height (r = 0.33, p = 0.1) was revealed.

EV tool measurements from two different volumetric datasets of the same patient showed an excellent reproducibility

intraclass correlation coefficient (ICC) for AA area 0.94 and ICC for right coronary height 0.98.

Conclusion

With these initial results EV tool could be used in clinical practice for quick and reliable assessment of AA area, perimeter and diameters. A larger group of patients will be needed to assess the consistency of coronary ostia height evaluation by EV tool.

Abstract P218 Figure. eSie Valve landmarks and 3D model of AR

P300 Reappraisal of aortic stenosis severity grading inconsistencies using 3D aortic valve area

Funding Acknowledgements

no fundings

Background

Different 3D imaging modalities have been proposed to overcome the limitations in aortic stenosis (AS) grading derived from underestimation of left ventricular outflow tract (LVOT) area by 2D transthoracic echocardiography (2D-TTE). Transesophageal echocardiography manual and software measurements (3D-TEEm and 3D-TEEs) and multidetector computed tomography (MDCT) have been recently been shown as valuable tools for AS grading using a combined approach incorporating 3D LVOT measurements and 2D Doppler parameters in the continuity equation (CE). This approach results particularly useful in cases of 2D-TTE grading inconsistence. As all these 3D imaging modalities provide larger AVA compared to 2D-TTE, we have recently proposed a 1.2 cm2 AVA cut-off could to define AS severity with 3D-TEE and MDCT.

Purpose

To compare AVA measurements with 3D-TEEm and 3D-TEEs using MDCT as gold standard in order to assess inconsistencies and evaluate the impact of a 1.2 cm2 AVA cut-off on AS severity grading.

Methods

288 patients (80 ± 11 years, 52.4% male) with symptomatic AS underwent 2D-TTE, 3D-TTEm, 3D-TEEs and MDCT within the same hospitalization. 3D-TEE LVOT reconstruction was performed manually and with semi-automated software (EchoPAC version 201). 3D-TEEm, 3D-TEEs and MDCT LVOT areas were combined with 2D-TTE Doppler parameters to calculate AVA by CE. The grading of AS was reassessed in patients with low flow-low gradient AS using a 1.2 cm2 cut-off for severity.

Results

Patients were classified according to flow state (stroke volume index ≥35 ml/m2 or <35 ml/m2) and mean pressure gradient (MPG ≥40 mmHg or <40 mmHg) into 4 groups: normal flow-high gradient (NF-HG; n 173, 60%), normal flow-low gradient (NF-LG; n 45, 15.5%), low flow-high gradient (LF-HG; n 39, 13.5%), and low flow-low gradient (LF-LG; n 31, 11%) AS. Among patients classified as LF-LG AS, 95%, 55%, 29% and 55% of cases were classified as severe by 2D-TTE, 3D-TEEm, 3D-TEEs and MDCT respectively using a 1.0 cm2 AVA cut-off. When the proposed severity AVA cut-off of 1.2 cm2 was applied using 3D imaging modalities, the proportion of severe AS significantly increased to 84% (p = 0.012) (3D-TEEm), 52% (p = 0.046) (3D-TEEs) and 71% (p < 0.001) (MDCT) respectively.

Conclusion

The use of a 1.2 cm2 AVA cut-off for 3D-TEE and MDCT significantly reduces the number of cases of inconsistently graded AS, increasing the proportion of patients with severe AS.

P1251 Percutaneous closure of two mitral perivalvular leaks: when the imaging guides the hands during threatening complications

With the contemporary development of structural interventional cardiology the prevalence of perivalvular leaks (PVL) is expected to grow. Advanced multimodality imaging is necessary for the guidance of transcatheter closure of PVL. We describe the case of a 57 year-old woman who underwent transcatheter mitral PVL closure. Past clinical history included a lymphoma treated with chemio and radiotherapy. Six months before she underwent a surgical replacement of the aortic and mitral valves with two mechanical prosthesis for severe aortic and mitral stenosis. Because of the calcium burden in both the annuluses, undersized mitral valve prosthesis was implanted leading to the presence of two moderate mitral PVL. The patient subsequently required hospitalization for acute HF and hemolytic anemia and received multiple blood transfusions. TEE confirmed the presence of a large antero-lateral PVL and a small medial PVL (3D VCA 0,32 cm2 and 0,2 cm2 respectively, associated with reverse flow in the pulmonary veins) with an extension of 33% of the circumference of the prosthesis. The regurgitation was considered severe and a percutaneous closure was planned with 3D-TEE and fluoroscopy image fusion guidance. Under general anesthesia a transeptal puncture was performed and the medial leak was closed with two vascular plugs (6mm each). During the deployment of the plugs an intermittent blockage of the medial disk of the prosthesis was noticed, which resolved completely after the removal of the wires previously positioned for the engagement of the leak. The lateral leak was then engaged and a second plug (10mm) was advanced causing a discontinuous interference with the two disks. The direct interference with the lateral disk caused a blockage in the closing position (leading to moderate stenosis, medium gradient 7mmHg) and in the opening position (leading to a massive regurgitation). The medial disk was intermittently blocked in the closing position due to the bulky effect of the devices provoking a traction and displacement of the prosthesis towards the medial region of the valve. To avoid this interference the plug was released with a marked atrial protrusion. Notably, after the removal of the wires no malfunctioning of the disks was noticed and the mild residual shunts appeared further decreased. The procedure was considered successful and at follow-up no residual leak was found. The percutaneous closure of PVL is a safe and effective intervention. Multimodality imaging is essential for the diagnosis, planning and procedural guidance. The knowledge of possible complications is warranted for the achievement of an optimal result. This case clearly show the possibility of interference with the prosthesis and overestimation of residual leaks.

Abstract P1251 Figure. PVL closure:procedure and complications

P3472Modifications of renal function in atrial fibrillation patients treated with different oral anticoagulants: a multicentre cohort study

Background

A decline of estimated glomerular filtration rate (eGFR) has been described in atrial fibrillation (AF) patients on Vitamin K antagonists (VKAs). Few real-world data on the modifications of eGFR in AF patients treated with non-vitamin K antagonist oral anticoagulants (NOACs) do exist.

Purpose

To evaluate changes of renal function in AF patients treated with VKAs or NOACs.

Methods

Multicentre prospective cohort study including 1,667 patients with non-valvular AF from 5 clinical centres of Internal Medicine and Cardiology in Italy.

Renal endpoints were: 1) median annual decline of eGFR; 2) transition to eGFR <50 ml/min/1.73 m2; 3) eGFR class worsening according to KDIGO 2012 classification. The eGFR was assessed by the CKD-EPI formula at baseline and during follow-up.

Results

Median age was 73.7±9.1 years and 43.3% were women. 743 patients were on VKAs and 924 on NOACs (Dabigatran, Rivaroxaban e Apixaban). Median annual eGFR decline was −2,11 (Interquartile Range [IQR] −5,68/−0,62] in patients on VKAs, −0,27 [IQR −9,00/4,54] with Dabigatran (p<0.001 vs. VKAs), −1,21 [IQR −9,98/4,02] with Rivaroxaban (p=0.004 vs. VKAs) and −1,32 [IQR −8,7/3,99] with Apixaban (p=0.003, vs. VKAs). Use of Dabigatran and Apixaban was associated to a lower transition to eGFR <50 mL/min/1.73 m2, compared to VKAs: adjusted Odds Ratio (aOR) 0.492, 95% Confidence Interval (CI) 0.298–0.813, p=0.006 for Dabigatran; aOR 0.449, 95% CI 0.276–0.728, p=0.001 for Apixaban). Regarding the eGFR class worsening, Dabigatran (aOR 0.70, 95% CI 0.503–0.975, p=0.035), Rivaroxaban (aOR 0.591, 95% CI 0.423–0.825, p=0.002), and Apixaban (aOR 0.591, 95% CI 0.429–0.815, p=0.001) were all associated to a lower rate of eGFR class worsening compared to VKAs.

Forest plot

Conclusions

In this prospective multicentre cohort study, NOACs use was associated with a lower decline of renal function compared to VKAs. Patients on Dabigatran showed the lowest annual rate of eGFR decline and those on Apixaban and Rivaroxaban a lower eGFR class worsening.

Acknowledgement/Funding

None

Intra-procedural monitoring protocol using routine transthoracic echocardiography with backup trans-oesophageal probe in transcatheter aortic valve replacement: a single centre experience

Aim

The aim of this study is to describe our 9-year experience in transcatheter aortic valve replacement (TAVR) using transthoracic echocardiography (TTE) as a routine intra-procedural imaging modality with trans-oesophageal echocardiography (TEE) as a backup.

Methods and results

From January 2008 to December 2017, 1218 patients underwent transfemoral TAVR at our Institution. Except the first 20 cases, all procedures have been performed under conscious sedation, with fluoroscopic guidance and TTE imaging monitoring. Once the TTE resulted suboptimal for final result assessment or a complication was either suspected or identified on TTE, TEE evaluation was promptly performed under general anaesthesia. Only 24 (1.9%) cases required a switch to TEE: 6 cases for suboptimal TTE prosthetic valve leak (PVL) quantification; 12 cases for haemodynamic instability; 2 cases for pericardial effusion without haemodynamic instability; 4 cases for urgent TAVR. The 30-days and 1-year all-cause mortality were 2.1% and 10.2%, respectively. Cardiac mortality at 30-days and 1-year follow-up were 0.6% and 4.1%, respectively. Intra-procedural and pre-discharge TT evaluation showed good agreement for PVL quantification (k agreement: 0.827, P = 0.005).

Conclusion

TTE monitoring seems a reasonable imaging tool for TAVR intra-procedural monitoring without delay in diagnosis of complications and a reliable paravalvular leak assessment. However, TEE is undoubtedly essential in identifying the exact mechanism in most of the complications.