Retrofitting the Heart: Explaining the Enigmatic Septal Thickening in Hypertrophic Cardiomyopathy

Hypertrophic cardiomyopathy is the most common genetic cardiac disease and is characterized by left ventricular hypertrophy. Although this hypertrophy often associates with sarcomeric gene mutations, nongenetic factors also contribute to the disease, leading to diastolic dysfunction. Notably, this dysfunction manifests before hypertrophy and is linked to hypercontractility, as well as nonuniform contraction and relaxation (myofibril asynchrony) of the myocardium. Although the distribution of hypertrophy in hypertrophic cardiomyopathy can vary both between and within individuals, in most cases, it is primarily confined to the interventricular septum. The reasons for septal thickening remain largely unknown. In this article, we propose that alterations in muscle fiber geometry, present from birth, dictate the septal shape. When combined with hypercontractility and exacerbated by left ventricular outflow tract obstruction, these factors predispose the septum to an isometric type of contraction during systole, consequently constraining its mobility. This contraction, or more accurately, this focal increase in biomechanical stress, prompts the septum to adapt and undergo remodeling. Drawing a parallel, this is reminiscent of how earthquake-resistant buildings are retrofitted with vibration dampers to absorb the majority of the shock motion and load. Similarly, the heart adapts by synthesizing viscoelastic elements such as microtubules, titin, desmin, collagen, and intercalated disc components. This pronounced remodeling in the cytoskeletal structure leads to noticeable septal hypertrophy. This structural adaptation acts as a protective measure against damage by attenuating myofibril shortening while reducing cavity tension according to Laplace Law. By examining these events, we provide a coherent explanation for the septum's predisposition toward hypertrophy.

Infective endocarditis after isolated aortic valve replacement: comparison between catheter-interventional and surgical valve replacement

BACKGROUND AND AIMS

Prosthetic valve endocarditis (PVE) is the prognostically most unfavourable complication after aortic valve replacement. This study aims to contribute to a better understanding of the different pathological and therapeutical aspects between PVE following surgical (SAVR) and transcatheter aortic valve replacement (TAVI).

METHODS

All patients who had undergone primary isolated SAVR (n = 3447) or TAVI (n = 2269) at our Centre between 01/2012 and 12/2018 were analysed. Diagnosis of PVE was based on Duke criteria modified in 2015. Incidence, risk factors, pathogens, impact of complications or therapy on mortality were analysed and compared between SAVR- and TAVI-PVE.

RESULTS

PVE incidence did not differ significantly after SAVR with 4.9/100 patient-years and TAVI with 2.4/100 patient-years (p = 0.49), although TAVI patients were older (mean 80 vs. 67 years) and had more comorbidities (STS score mean 5.9 vs. 1.6) (p < 0.001). TAVI prostheses with polymer showed a 4.3-fold higher risk to develop PVE than without polymer (HR 4.3; p = 0.004). Most common pathogens were staphylococci and enterococci (p > 0.05). Propensity-score matching analysis showed that the type of aortic valve replacement had no effect on the development of post-procedural PVE (p = 0.997). One-year survival was higher in TAVI-PVE patients treated with antibiotics only compared to additional surgical therapy (90.9% vs. 33.3%; p = 0.005). In SAVR-PVE patients, both therapies were comparable in terms of survival (p = 0.861). However, SAVR-PVE patients who were not operated, despite ESC-guideline recommendation, had significantly poorer one-year survival (p = 0.004).

CONCLUSION

TAVI patients did not have a significantly higher risk to develop PVE. Our data suggest that TAVI-PVE patients in contrast to SAVR-PVE patients can more often be treated with antibiotics only, presumably due to the lack of a polymeric suture ring.

First transaortic transcatheter aortic valve implantation with Acurate Neo: case report and technical recommendations

Background

In more than 90%, transcatheter aortic valve implantation (TAVI) is performed via transfemoral access. Alternative access routes are necessary for patients with unfavourable femoral arteries.

Case summary

We report of a 68-year-old female with symptomatic severe aortic stenosis in whom surgical aortic valve replacement was prohibited due to her severe co-morbidities. Both femoral arteries and both subclavian arteries were unsuitable for TAVI access. Surgical aortic valve replacement and transapical TAVI were deferred due to extremely high operative risk and very low originating left coronary artery of 7 mm from the annulus. Hence, we decided to implant a self-expanding TAVI device with a low risk of coronary obstruction (Acurate Neo 2 prosthesis) via transaortic approach, which to our knowledge is the first case worldwide.

Conclusion

The present case demonstrates the feasibility of implanting the Acurate Neo 2 system via transaortic approach when certain key points are respected. Transaortic TAVI with the Acurate Neo 2 offers a minimally invasive treatment of high operative risk patients with low originating coronary arteries.

Impact of left ventricular end-diastolic pressure as a marker for diastolic dysfunction on long-term outcomes in patients undergoing transcatheter aortic valve replacement

OBJECTIVE

The aim of this study was to investigate the proportion of elevated left ventricular end-diastolic pressure (LVEDP) as an indicator of diastolic function after transcatheter aortic valve replacement (TAVR) and its implication in predicting long-term mortality.

METHODS

We analyzed retrospectively collected data on 3328 patients with severe aortic stenosis undergoing TAVR in our institution between July 2009 and June 2021. Patients were stratified into two groups based on invasive post-procedural LVEDP measurements: normal (<15 mmHg) vs. elevated (≥15 mmHg) LVEDP.

RESULTS

Mean age of the patients was 81.6 years, and 53.3% were female. Elevated post-procedural LVEDP was identified in 2408 (72.3%) patients. The 5-year mortality rates were higher in the group with elevated LVEDP compared with the group with normal LVEDP (27.4% vs. 8.3%, p = 0.01; hazard ratio [HR] 1.22, 95% CI 1.05-1.41). A multivariate model revealed the following independent predictors of mortality after TAVR: post-procedural elevated LVEDP (HR 1.24, 95% CI 1.01-1.53), pre-procedural significant tricuspid regurgitation (HR 1.24, 95% CI 1.02-1.52) and pulmonary hypertension (PH) (HR 1.53, 95% CI 1.26-1.86). In the present study, a significant paravalvular leak after TAVR was not associated with higher mortality (HR 1.45, 95% CI-0.95-2.19, p = 0.75).

CONCLUSION

Elevated post-procedural LVEDP in patients who undergo TAVR is an independent predictor of all-cause mortality. Furthermore, PH and tricuspid regurgitation were also identified as predictors of mortality. These data confirm that diastolic dysfunction is an important predictor of mortality in TAVR and should be considered to guide procedure timing, favoring an early interventional approach and management in aortic stenosis patients.

Alcohol Septal Ablation or Mavacamten for Obstructive Hypertrophic Cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is a genetic disease characterized by an increased left ventricular wall thickness in the absence of increased afterload conditions. In addition to diastolic dysfunction, obstruction of the left ventricular outflow tract is common in HCM and has an important influence on symptoms and outcome. Over the last five decades or two decades, respectively, surgical myectomy and alcohol septal ablation were the only therapeutic options if standard medical care was not sufficient. Recently, a new option has become available that has the potential to revolutionize the therapeutic strategies for patients with HCM. Mavacamten is a myosin inhibitor that belongs to a completely new drug class and targets the excessive actin-myosin cross-bridging that is the underlying pathology of HCM. By reducing the actin-myosin interactions, mavacamten not only reduces the left ventricular outflow tract (LVOT) obstruction but also seems to have positive effects on the diastolic function, microcirculation, and cardiac structure. This article summarizes the current evidence on alcohol septal ablation and reviews the preclinical and clinical data on mavacamten for the treatment of patients with obstructive HCM.

Permanent pacemaker implantation and left bundle branch block with self-expanding valves - a SCOPE 2 subanalysis

BACKGROUND

No detailed data on left bundle branch block (LBBB) and permanent pacemaker implantation (PPI) exist from randomised clinical trials comparing the ACURATE neo and CoreValve Evolut devices.

AIMS

Our aim was to assess the incidence and impact of new LBBB and PPI with self-expanding prostheses from a powered randomised comparison.

METHODS

From the SCOPE 2 trial, 648 patients with no previous pacemaker were analysed for PPI at 30 days, and 426 patients without previous LBBB were adopted for analysis of LBBB at 30 days.  Results: At 30 days, 16.5% of patients required PPI; rates were higher in CoreValve Evolut compared to ACURATE neo recipients (21.0% vs 12.3%; p=0.004). Previous right bundle branch block (odds ratio [OR] 6.11, 95% confidence interval [CI]: 3.19-11.73; p<0.001) was associated with an increased risk of PPI at 30 days, whereas the use of the ACURATE neo (OR 0.50, 95% CI: 0.31-0.81; p=0.005) was associated with a decreased risk. One-year mortality was similar in patients with and without new PPI. A total of 9.4% of patients developed persistent LBBB at 30 days, with higher incidences in CoreValve Evolut recipients (13.4% vs 5.5%; p=0.007). New LBBB at 30 days was associated with lower ejection fraction at 1 year (65.7%±11.0 vs 69.1%±7.6; p=0.041).

CONCLUSIONS

New LBBB and PPI rates were lower in ACURATE neo compared to CoreValve Evolut recipients. The ACURATE neo valve was associated with a lower risk of PPI at 30 days. No effect on 1-year mortality was determined for PPI at 30 days, while LBBB at 30 days was associated with reduced ejection fraction at 1 year.

Clinically atypical abdominal manifestation of the lipoma localized in the right atrium: "Invagination hypothesis" revisited

Cardiac lipomas are the second most common cardiac tumors. They are usually asymptomatic and diagnosed as incidental findings. We describe a 71-year-old patient with a tumor in the right atrium. In echocardiography and MRI scan, the diagnosis of a cardiac lipoma was suspected. Moreover, MRI demonstrated continuity of pericardial fat and the tumor in the right atrium by infolding of the atrial wall and epicardial adipose tissue in the space between the atrial walls, which might be a hint for the Waterstone groove hypothesis. An operative resection was performed which confirmed the suspected diagnosis.

Female patients with coronary artery disease and aortic stenosis undergoing a surgical or interventional treatment in terms of revascularization and valve replacement

Background

Coronary artery disease (CAD) in female patients undergoing a Transcatheter Aortic Valve Implantation (TAVI) is accompanied with a worse outcome compared to those without CAD. Nevertheless, it is still unclear whether a complete revascularization and outcome are achieved similarly in women treated with an interventional (PCI plus TAVI) or surgical (CABG plus SAVR) treatment strategy.

Purpose

This study aims to compare the completeness of revascularization in terms of residual SyntaxScore and to evaluate the differences in 30-days (short-term), one-year and three-years (intermediate term) mortality in women with CAD and AS undergoing a surgical or catheter-based treatment.

Methods

Patients were recruited at one tertiary center in Germany between 2016 and 2019. Initially the surgical group contained 932 patients and the interventional cohort 360 patients as a result of setting a maximum time interval of 3 months between PCI and TAVI.

The surgical group (CABG+SAVR) and the interventional group (PCI+TAVI) were compared by using a propensity score analysis. Age, left ventricular function, EuroSCORE II and degree of CAD served as matching parameters so that the matched female cohort finally consisted of 114 patients (57 patients treated interventionally, 57 treated surgically). Syntax Score was measured before and after revascularization. As a primary endpoint all-cause mortality was analyzed at 30 days, one and three years after the procedure.

Results

Median age was 80 years both in the interventional and surgical cohort (p=0.298). Both groups represented a moderate to high-risk population (EuroScore II in PCI+TAVI: 4.39 [2.83–8.82] vs 6.18 [3.43–8.6] in CABG+SAVR (p=0.279) and showed no significant difference in median pre-interventional/preoperative SyntaxScore I (PCI+TAVI: 16.00 [9–26.5] vs CABG+SAVR: 18 [9.5–25.5]; p=0.719). In the interventional group coronary physiology was measured more frequently (6.8% vs 1.8%, p=0.024). There was no significant difference in the presence of an aortoostial lesion, heavy calcification and a length of the lesion &gt;20mm between PCI+TAVI and CABG+SAVR before therapy (PCI+TAVI vs CABG+SAVR: 11.1% vs 13.0%, p=0.581; 60.5% vs 55.1%, p=0.289; 20.4% vs 25.1%, p=0.316). The main stem as target lesion was present in both groups with no significant difference (PCI+TAVI vs CABG+SAVR: 8.8% vs 19.3%, p=0.106).

Median residual SyntaxScore I was significantly higher in PCI+TAVI than in CABG+SAVR (5.0 [0.0–13.0] vs 0.0 [0.0–8.5], p=0.03).

No significant difference in 30-days, 1-year and 3-years mortality was observed between the interventional and surgical group (PCI+TAVI vs CABG+SAVR: 3.5% vs 8.8%, p=0.242; 10.5% vs 14%, p=0.568; 22.8% vs 15.8%, p=0.342).

Conclusion

Female patients with AS and CAD with low SyntaxScore undergoing CABG+SAVR reach a more complete revascularization than those treated interventionally. Nevertheless, this fact seems to have no influence on short and intermediate term mortality.

Funding Acknowledgement

Type of funding sources: None.

Bleeding risk differences after TAVR according to the ARC-HBR criteria: insights from SCOPE 2

BACKGROUND

The Academic Research Consortium - High Bleeding Risk (ARC-HBR) initiative defined conditions associated with percutaneous coronary intervention (PCI)-related bleeding.

AIMS

We sought to further explore these HBR conditions in the setting of transcatheter aortic valve replacement (TAVR).

METHODS

Patients from the SCOPE 2 trial were stratified by their bleeding risk status based on the ARC-HBR definitions. Baseline and procedural characteristics, as well as key clinical outcomes including Bleeding Academic Research Consortium (BARC) 3-5 bleeding, were compared in ARC-HBR positive (HBR+) and ARC-HBR negative (HBR-) patients.

RESULTS

Of 787 patients randomised in SCOPE 2 and included in this study, 633 were HBR+ (80.4%). Compared with HBR- patients, those HBR+ were older and more frequently presented with diabetes, a history of coronary artery disease, atrial fibrillation, prior cerebrovascular accident, and a Society of Thoracic Surgeons predicted risk of 30-day mortality (STS-PROM) (4.9±2.9% vs 3.3%±2.1%; p<0.0001). In addition, HBR+ patients were more frequently on oral anticoagulation therapy. At 1 year, HBR+ patients had higher rates of all-cause death (12.4% vs 4.3%, respectively, risk difference 8.09%; 95% confidence interval [CI]: 3.76-12.41; p=0.0002); the rates of BARC 3-5 type bleeding were relatively high but not statistically different compared with HBR- patients (7.7% vs 6.1%, risk difference 1.67%; 95% CI: -2.72 to 6.06; p=0.46). Subgroup analyses for bleeding events showed no significant interaction in terms of STS-PROM score, age, or medications.

CONCLUSIONS

The ARC-HBR criteria failed to isolate a subgroup of patients at higher bleeding risk in TAVR patients from a randomised trial. These findings have potential implications, especially for the selection of post-TAVR antithrombotic regimens based on individual bleeding-risk profiles. Specific HBR criteria should be defined for TAVR patients.

Impact of impaired renal function on kinetics of high-sensitive troponin I (hs-cTnI) following cardiac surgery

Background

Renal insufficiency might result in increased levels of cardiac troponin due to decreased elimination. Hence, the diagnostic utility of hs-cTnI might be lower in patients with impaired renal function. There is only scarce data on kinetics of high-sensitivity cardiac troponin I (hs-cTnI) following cardiac surgery with regard to renal function.

Purpose

The aim of this study was to assess the impact of impaired renal function on the kinetics of hs-cTnI following cardiac surgery differentiating between patients with and without postoperative myocardial infarction (PMI) and to analyze the prognostic value of hs-cTnI elevations in patients with impaired renal function.

Methods

We performed a retrospective analysis of all adult patients (&gt;18 years) who underwent cardiac surgery at our hospital between Jan, 1st 2013 and May, 1st 2019.

Serial measurements of high-sensitive cardiac troponin I (hs-cTnI) were assessed from baseline up to 48 hours after surgery. Renal function was assessed based on estimated glomerular filtration rate (GFR) using the Modification of Diet in Renal Disease (MDRD) formula with impaired renal function defined by GFR &lt;60 ml/min. Postoperative myocardial infarction was defined by new vessel occlusion on angiography. Predictors of long-term all-cause mortality were assessed by cox regression analysis.

Results

A total of 14,465 patients were included (51.4% underwent coronary artery bypass grafting (CABG), 39.4% had valvular procedures and 9.2% thoracic aortic procedures).

Levels of hs-cTnI were higher in patients with impaired renal function in the overall collective (figure 1). However, in patients with postoperative myocardial infarction levels of hs-cTnI did not differ with regard to renal function (figure 2).

Cox regression analysis showed postoperative elevation of hs-cTnI to be a significant predictor of long-term all-cause mortality over a median follow-up of 3.0 years regardless of baseline kidney function (Hazards ratio 1.67, 95% Confidence interval [1.46–1.91], p&lt;0.001).

Conclusion

Renal function had an impact on postoperative hs-cTnI kinetics only in patients with an uneventful postoperative course. In patients with postoperative myocardial infarction kinetics of hs-cTnI were not affected by baseline renal function. Moreover, elevated hs-cTnI levels were a significant predictor of all-cause mortality regardless of baseline renal function.

Funding Acknowledgement

Type of funding sources: None.

Short- and intermediate-term mortality in women and men after surgical versus interventional revascularization and aortic valve replacement

Background

Patients with isolated aortic valve stenosis (AS) at intermediate and even low-risk benefit from an interventional treatment with TAVI as compared to surgical aortic valve replacement. Whether patients with concomitant coronary artery disease have a better outcome with an interventional (PCI plus TAVI) or surgical (CABG plus SAVR) treatment strategy is still unclear.

Purpose

To evaluate the differences in 30-days (short-term) and one-year (intermediate term) mortality in women and men with CAD and AS undergoing a surgical or catheter-based treatment.

Methods

All patients were treated in Heart and Diabetes Center Bad Oeynhausen during 2016–2019. The surgical group contained 932 patients, the interventional cohort 360 patients as a result of setting a maximum time interval of 3 months between PCI and TAVR.

CABG+SAVR and PCI+TAVR cohorts were compared by using a propensity score analysis including age, left ventricular function, EuroSCORE II and degree of CAD as matching parameters. After matching the total cohort, 406 patients could be obtained. The matched female cohort consisted of 114 patients, the matched male cohort of 284 patients. As a primary endpoint all-cause mortality was analyzed at 30 days and one year after the procedure. Furthermore, procedural and post-procedural outcome were analyzed.

Results

The studied TAVI cohort was a low to intermediate risk population (EuroScore II of the total cohort: 3.82 [2.49–6.64] in CABG+SAVR vs 4.36 [2.59–7.12] in PCI+TAVR, p=0.38; women: 6.18 [3.43–8.6], p=0.279; men: 4.39 [2.83–8.82], p=0.279). There was no significant difference in 30-days mortality between the surgical and interventional group, regarding the total cohort (3.9% vs 2.5%; p=0.398). Whereas in the male cohort 30-days mortality was comparable between interventional and surgical treatment (2.1% vs 2.1%; p=1), in the female group the surgical treatment showed a trend towards higher mortality without reaching statistical significance (8.8% vs 3.5%; p=0.242). Additionally, one-year mortality did not differ in the three cohorts between CABG+SAVR and PCI+TAVR (total cohort: 11.3% vs 12.8%; p=0.648 women: 14% vs 10.5%; p=0.568; men: 11.3% vs 14.8%; p=0.378). The number of postprocedural permanent pacemaker implantations was statistically higher after TAVR plus PCI (total cohort: 7.4% vs 15.3%; p=0.012; women: 7% vs 19.3%; p=0.052; men: 8.5% vs 19%; p=0.01). Furthermore, a significantly longer length of hospital stay was reported for the surgical cohort (total cohort: 13 [11–17] vs 11 [9–15]; p=0; women: 14 [12–18] vs 12 [10.5–15.5]; p=0.019; men: 13 [11–15] vs 11 [9–15]; p=0).

Conclusion

In patients with AS and CAD there is no significant difference in short and intermediate term mortality when comparing surgical or interventional treatment.

Subsequently, an interventional approach might be a legitimate alternative to CABG+SAVR in these patients.

Funding Acknowledgement

Type of funding sources: None.

Comparison of Self-Expanding Bioprostheses for Transcatheter Aortic Valve Replacement in Patients With Symptomatic Severe Aortic Stenosis

Background:

Few randomized trials have compared bioprostheses for transcatheter aortic valve replacement, and no trials have compared bioprostheses with supra-annular design. The SCOPE 2 trial (Safety and Efficacy Comparison of Two TAVI Systems in a Prospective Randomized Evaluation 2) was designed to compare the clinical outcomes of the ACURATE neo and CoreValve Evolut bioprostheses for transcatheter aortic valve replacement.

Methods:

SCOPE 2 was a randomized trial performed at 23 centers in 6 countries between April 2017 and April 2019. Patients ≥75 years old with an indication for transfemoral transcatheter aortic valve replacement as agreed by the heart team were randomly assigned to receive treatment with either the ACURATE neo (n=398) or the CoreValve Evolut bioprostheses (n=398). The primary end point, powered for noninferiority of the ACURATE neo bioprosthesis, was all-cause death or stroke at 1 year. The key secondary end point, powered for superiority of the ACURATE neo bioprosthesis, was new permanent pacemaker implantation at 30 days.

Results:

Among 796 randomized patients (mean age, 83.2±4.3 years; mean Society of Thoracic Surgeons Predicted Risk of Mortality score, 4.6±2.9%), clinical follow-up information was available for 778 (98%) patients. Within 1 year, the primary end point occurred in 15.8% of patients in the ACURATE neo group and in 13.9% of patients in the CoreValve Evolut group (absolute risk difference, 1.8%, upper 1-sided 95% confidence limit, 6.1%; P =0.0549 for noninferiority). The 30-day rates of new permanent pacemaker implantation were 10.5% in the ACURATE neo group and 18.0% in the CoreValve Evolut group (absolute risk difference, –7.5% [95% CI, –12.4 to –2.60]; P =0.0027). No significant differences were observed in the components of the primary end point. Cardiac death at 30 days (2.8% versus 0.8%; P =0.03) and 1 year (8.4% versus 3.9%; P =0.01), and moderate or severe aortic regurgitation at 30 days (10% versus 3%; P =0.002) were significantly increased in the ACURATE neo group.

Conclusions:

Transfemoral transcatheter aortic valve replacement with the self-expanding ACURATE neo did not meet noninferiority compared with the self-expanding CoreValve Evolut in terms of all-cause death or stroke at 1 year, and it was associated with a lower incidence of new permanent pacemaker implantation. In secondary analyses, the ACURATE neo was associated with more moderate or severe aortic regurgitation at 30 days and cardiac death at 30 days and 1 year.

Registration:

URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03192813.

Impact of device landing zone calcification patterns on paravalvular regurgitation after transcatheter aortic valve replacement with different next-generation devices

OBJECTIVE

Residual paravalvular regurgitation (PVR) has been associated to adverse outcomes after transcatheter aortic valve replacement (TAVR). This study sought to evaluate the impact of device landing zone (DLZ) calcification on residual PVR after TAVR with different next-generation transcatheter heart valves.

METHODS

642 patients underwent TAVR with a SAPIEN 3 (S3; n=292), ACURATE neo (NEO; n=166), Evolut R (ER; n=132) or Lotus (n=52). Extent, location and asymmetry of DLZ calcification were assessed from contrast-enhanced CT imaging and correlated to PVR at discharge.

RESULTS

PVR was ≥moderate in 0.7% of S3 patients, 9.6% of NEO patients, 9.8% of ER patients and 0% of Lotus patients (p<0.001), and these differences remained after matching for total DLZ calcium volume. The amount of DLZ calcium was significantly related to the degree of PVR in patients treated with S3 (p=0.045), NEO (p=0.004) and ER (p<0.001), but not in Lotus patients (p=0.698). The incidence of PVR ≥moderate increased significantly over the tertiles of DLZ calcium volume (p=0.046). On multivariable analysis, calcification of the aortic valve cusps, LVOT calcification and the use of self-expanding transcatheter aortic valve implantation (TAVI) prostheses emerged as predictors of PVR.

CONCLUSIONS

The susceptibility to PVR depending on the amount of calcium was mainly observed in self-expanding TAVI prostheses. Thus, DLZ calcification is an important factor to be considered in prosthesis selection for each individual patient, keeping in mind the trade-off between PVR reduction, risk of new pacemaker implantation and unfavourable valve ha emodynamics.

What happens &gt;10 years after percutaneous septal ablation for hypertrophic obstructive cardiomyopathy? Ultra long-term follow-up of 120 patients

Introduction and methods

Recent registry analyses including the European multicenter registry (Euro-ASA) documented a favourable long-term outcome of septal ablation (ASA/PTSMA) competitive to surgical myectomy. There is no information about the period beyond 10 years. We therefore analyzed the outcome in 120 HOCM patients (pts., mean age @ index intervention: 62±13 years) treated with ASA who survived &gt;10 years.

Results

Mean CK rise during the index intervention was 537±258 U/l (reference: &lt;80). A DDD-pacemaker (DDD-PM) had to be implanted in 26 pts. (22%) for procedure-related AV conduction problems. A re-intervention for residual or recurrent outflow obstruction (LVOTO) had to be performed in 12 pts. (10%; re-PTSMA: 10 pts.; myectomy: 2 pts). These cases included, at their last follow-up visit 107 pts. (89%) were in functional class I or II. During follow-up (159±33 [range: 122–264] months), 12 pts. (8%) died, of these 6 (4%) from non-cardiac, and 6 (4%) from cardiovascular causes including one sudden death. Furthermore, 4 (3%) ICDs were implanted (1 for secondary, 3 for primary prevention of sudden cardiac death). The most frequent clinical problem was atrial fibrillation which occurred in 27 pts. (23%), and which was refractory to rhythm control attempts in 21 pts. (18%).

Conclusions

The procedure-related DDD-PM rate in this septal ablation cohort including the early learning curve more than doubled the current one. Nevertheless, during ultra long-term follow up a durable clinical improvement was observed with mortality rates around 1%/year, nearly equivalent to that of 0.8% observed in normal populations. Atrial fibrillation is a frequent problem in this elderly, formerly obstructive HCM population.

Funding Acknowledgement

Type of funding source: None

Tracking physical activity using smart phone apps: assessing the ability of a current app and systematically collecting patient recommendations for future development

Background

Within the United Kingdom’s National Health System (NHS), patients suffering from obesity may be provided with bariatric surgery. After receiving surgery many of these patients require further support to continue to lose more weight or to maintain a healthy weight. Remotely monitoring such patients’ physical activity and other health-related variables could provide healthworkers with a more ‘ecologically valid’ picture of these patients’ behaviours to then provide more personalised support. The current study assesses the feasibility of two smartphone apps to do so. In addition, the study looks at the barriers and facilitators patients experience to using these apps effectively.

Methods

Participants with a BMI > 35 kg/m² being considered for and who had previously undergone bariatric surgery were recruited. Participants were asked to install two mobile phone apps. The ‘Moves’ app automatically tracked participants’ physical activity and the ‘WLCompanion’ app prompted participants to set goals and input other health-related information. Then, to learn about participants’ facilitators and barriers to using the apps, some participants were asked to complete a survey informed by the Theoretical Domains Framework. The data were analysed using regressions and descriptive statistics.

Results

Of the 494 participants originally enrolled, 274 participants data were included in the analyses about their activity pre- and/or post-bariatric surgery (ages 18–65, M = 44.02, SD ± 11.29). Further analyses were performed on those 36 participants whose activity was tracked both pre- and post-surgery. Participants’ activity levels pre- and post-surgery did not differ. In addition, 54 participants’ survey responses suggested that the main facilitator to their continued use of the Moves app was its automatic nature, and the main barrier was its battery drain.

Conclusions

The current study tracked physical activity in patients considered for and who had previously undergone bariatric surgery. The results should be interpreted with caution because of the small number of participants whose data meet the inclusion criteria and the barriers participants encountered to using the apps. Future studies should take note of the barriers to develop more user-friendly apps.

Trial registration

ClinicalTrials.gov- NCT01365416 on the 3rd of June 2011.

P5528Extremely elevated lipoprotein (a) as an independent risk factor for coronary heart disease in large patient cohort

Background

Elevated lipoprotein (a) [LP (a)] levels are an independent risk factor for coronary heart disease (CHD) and associated with myocardial infarction (MI). CHD took a devastating toll in Europe and in the United States in the 20th century, killing more people than any other disease. It remains the leading cause of death in most countries worldwide. CHD shares risk factors with atherosclerosis. It has been shown that elevated LP (a) levels are associated with an increased risk for CHD across various ethnic groups. LP (a) is genetically determined, stable throughout life and yet refractory to drug therapy. While 30 mg/dl is considered the upper normal value for LP (a) in central Europe, extremely high LP (a) levels (>150mg/dl) are rare in the general population.

The aim of our study was to analyse the correlation between lipoprotein (a) [LP (a)] levels and an incidence of coronary heart disease (CHD) in high-risk patients.

Patients and methods

We reviewed the LP (a) concentrations of 52.898 consecutive patients admitted to our cardiovascular center between January 2004 and December 2014. Of these, 579 patients had LP (a) levels above 150 mg/dl (mean 181.45±33.1mg/dl). In the control collective LP (a) was <30mg/dl (n=350). Other atherogenic risk factors in this group were HbA1c 6.58±1.65%, low density lipoprotein (LDL) 141.99±43.76 mg/dl, and body mass index 27.81±5.61. 54.40% were male, 26.07% were smokers, 93.2% had hypertension, and 24% had a family history of cardiovascular diseases. More than 82.6% were under statins. The mean glomerular filtration rate (GFR) was 69.13±24.8 ml/min [MDRD (Modification of Diet in Renal Disease)].

Results

64.98% (n=373) of the patients with LP (a) >150mg/dl had CHD. The prevalence of CHD in patients with LP (a) <30mg/dl in our control collective was 37.14%. (P- Value 0.0001). Patients with LP (a) >150mg/dl had a significantly increased risk for CHD (Odds ratio 5.98). 12.72% (n=73) of these patients suffered from CHD with single-vessel disease (VD), 14.63% (n=84) from CHD with 2VD and 37.63% (n=216) from CHD with 3VD. 47.92% of patients were re-vascularized by percutaneous coronary angioplasty (PTCA) and 37.06% of patients had to undergo coronary artery bypass grafting (CABG). 19.13% of patients had both, PTCA and CABG. Mean LP (a) level in patients with 1-vessel CHD was 181.5±29.98, in patients with 2-vessel CHD 178.94±34.26 and in patients with 3-vessel CHD 180.97±32.38 mg/dl.

Conclusion

Elevated LP (a) levels above 150 mg/dl are associated with a significantly increased risk of CHD in our collective and it confirms our hypothesis. Most of these patients had severe CHD with 3-vessel disease (VD) requiring coronary revascularization therapy. We need more prospective studies to confirm our findings.

Transcatheter Aortic Valve Implantation in Patients With Pre-Existing Mechanical Mitral Valve Prostheses

OBJECTIVES

Transcatheter aortic valve implantation (TAVI) has become standard therapy for aortic stenosis patients with intermediate or high operative risk. Treatment of patients with pre-existing mechanical mitral valve replacement (MVR) is challenging due to possible interference between the TAVI prosthesis and MVR. We present our single-center experience with this special patient cohort.

METHODS

A total of 1960 patients underwent TAVI at our institution between 2009 and March 2018; of these, 16 patients had pre-existing mechanical MVR. Device success and adverse events were analyzed according to the Valve Academic Research Consortium (VARC)-2 criteria. Patients were followed for at least 12 months.

RESULTS

Mean patient age was 81.5 ± 4.4 years. The patients had a mean logistic EuroScore of 37.1 ± 13.5% and STS score of 7.1 ± 3.2%. Successful valve deployment was achieved in all patients, peri-interventional stroke rate was 0.0%, and permanent pacemaker was implanted in 2 patients (12.5%). Two patients experienced major complications, with blockage of the MVR disc in 1 patient and annulus rupture in 1 patient. Hence, 30-day mortality was 12.5% and 1-year mortality was 25.0%.

CONCLUSION

TAVI in patients with mechanical MVR is challenging and requires careful preparation and choice of TAVI device. Repositionable and retrievable devices seem to be a safer option.

Incidence and outcome of peri-procedural transcatheter heart valve embolization and migration: the TRAVEL registry (TranscatheteR HeArt Valve EmboLization and Migration)

Aims

Peri-procedural transcatheter valve embolization and migration (TVEM) is a rare but potentially devastating complication of transcatheter aortic valve implantation (TAVI). We sought to assess the incidence, causes, and outcome of TVEM in a large multicentre cohort.

Methods and results

We recorded cases of peri-procedural TVEM in patients undergoing TAVI between January 2010 and December 2017 from 26 international sites. Peri-procedural TVEM occurred in 273/29 636 (0.92%) TAVI cases (age 80.8 ± 7.3 years; 53.8% female), of which 217 were to the ascending aorta and 56 to the left ventricle. The use of self-expanding or first-generation prostheses and presence of a bicuspid aortic valve were independent predictors of TVEM. Bail-out measures included repositioning attempts using snares or miscellaneous tools (41.0%), multiple valve implantations (83.2%), and conversion to surgery (19.0%). Using 1:4-propensity matching, we identified a cohort of 235 patients with TVEM (TVEMPS) and 932 patients without TVEM (non-TVEMPS). In the matched cohort, all-cause mortality was higher in TVEMPS than in non-TVEMPS at 30 days (18.6% vs. 4.9%; P < 0.001) and after 1 year (30.5% vs. 16.6%; P < 0.001). Major stroke was more frequent in TVEMPS at 30 days (10.6% vs. 2.8%; P < 0.001), but not at 1 year (4.6% vs. 1.9%; P = 0.17). The need for emergent cardiopulmonary support, major stroke at 30 days, and acute kidney injury Stages 2 and 3 increased the risk of 1-year mortality, whereas a better renal function at baseline was protective.

Conclusion

Transcatheter valve embolization and migration occurred in approximately 1% and was associated with increased morbidity and mortality.

Minimally invasive versus transapical versus transfemoral aortic valve implantation: A one-to-one-to-one propensity score-matched analysis

OBJECTIVES

Although transcatheter aortic valve implantation was the treatment of choice in inoperable and high-risk patients, the effect of transcatheter aortic valve implantation relative to conventional aortic valve replacement via ministernotomy in patients with moderate surgical risk remains unclear.

METHODS

We consecutively enrolled patients who underwent minimally invasive aortic valve replacements via ministernotomy (n = 1929), transapical (n = 607), and transfemoral (n = 1273) aortic valve implantations from a single center during the period from July 2009 to July 2017. Of those, we conducted a 1:1:1 propensity score matching according to 23 preoperative risk factors.

RESULTS

We were able to find 177 triplets (n = 531). The median European System for Cardiac Operative Risk Evaluation II was 3.0% versus 3.4% versus 2.9%, and Society of Thoracic Surgeons Predicted Risk of Mortality was 3.2% versus 3.6% versus 3.4%, respectively. According to the Valve Academic Research Consortium 2 criteria, there were no significant periprocedural differences regarding 30-day mortality (2.3% minimally invasive aortic valve replacement vs 4.5% transapical transcatheter aortic valve implantation vs 1.7% transfemoral transcatheter aortic valve implantation, P = .34), stroke (1.1% minimally invasive aortic valve replacement vs 0.6% transapical transcatheter aortic valve implantation vs 1.7% transfemoral transcatheter aortic valve implantation, P = .84), or myocardial infarction (0.6% minimally invasive aortic valve replacement vs 0.0% transapical transcatheter aortic valve implantation vs 0.0% transfemoral transcatheter aortic valve implantation, P = .83). Both intensive care and hospitalization times were significantly longer in the transapical group. Regarding midterm survival, transapical transcatheter aortic valve implantation was associated with a tendency toward a less favorable outcome (hazard ratio, 1.48; 95% confidence interval, 0.95-2.31; P = .17) compared with minimally invasive aortic valve replacement.

CONCLUSIONS

In this real-world propensity score-matched minimally invasive aortic valve replacement, transapical transcatheter aortic valve implantation, transfemoral transcatheter aortic valve implantation cohort of intermediate-risk patients, early mortality was not significantly different, whereas the rates of periprocedural complications were different depending on the approach. During follow-up, there was a tendency in the transapical transcatheter aortic valve implantation group toward a less favorable survival outcome, although there was no significant difference among the 3 groups.

Valve-in-valve transcatheter aortic valve implantation with CoreValve/Evolut R© for degenerated small versus bigger bioprostheses

OBJECTIVES

We present our single center experience with Medtronic CoreValve and Evolut R regarding procedural outcome and 3 years follow-up in patients with degenerated bioprostheses.

METHODS

From 1645 patients who underwent transfemoral TAVI at our institution between February 2009 and December 2016, 37 patients with degenerated bioprosthesis were treated with Medtronic CoreValve/Evolut R. All data concerning baseline characteristic, procedural outcomes and follow-up were entered into a dedicated database.

RESULTS

Mean age was 83.9 ± 4.4 years and patients showed an average logistic EuroSCORE of 33.2 ± 16.7%. Successful ViV deployment was achieved in all cases, a permanent pacemaker was implanted in 16.2%, no periinterventional stroke and no coronary obstruction occurred. Mortality at 30 days was 2.7%, at 1-year follow-up 5.7% and at three years 13.5%. Depending on bioprosthesis size <23 mm versus ≥23 mm echocardiographic mean gradients post implantation were significantly higher in the smaller bioprostheses, 22.8 mmHg ± 9.4 mmHg versus 15.1 ± 7.1, P = 0.013.

CONCLUSION

ViV-TAVI with CoreValve/R is demonstrated to be safe and effective in terms of no coronary obstruction and very low mortality up to 3 years despite slightly higher mean transprosthetic gradients especially in very small bioprostheses.

Impact of procedure-related conduction disturbances after transcatheter aortic valve implantation on myocardial performance and survival evaluated by conventional and speckle tracking echocardiography

OBJECTIVES

Although procedure-related new cardiac conduction disturbances (CCDs) remain an important issue in transcatheter aortic valve implantation (TAVI), their effect on myocardial function and overall patient outcome remains unclear. The goal of this study was to analyze the influence of procedure-related CCDs on systolic and diastolic LV performance and on patient survival after TAVI.

METHODS AND RESULTS

Ninety-five patients who underwent TAVI for severe symptomatic aortic stenosis (AS) and had a complete follow-up were evaluated with respect to procedure-related CCDs. Left ventricular (LV) performance was measured using standard echocardiographic parameters and speckle tracking analysis. Survival was assessed during longer-term follow-up (mean: 29.1 ± 16.9 months). After TAVI, the improvement of global LV function expressed as ejection fraction (LVEF; from 45.5 ± 10.0 to 47.8 ± 13.9%, P = .13) was not significant. New CCDs were found in 35.7% of TAVI recipients. A comparison between patients with and without new CCDs showed that LV systolic function improved in those without CCDs, while it tended to deteriorate in patients with CCDs (change in LVEF: 5.5 ± 12.3% vs -4.9% ± 11.5%, P = .001; change in global longitudinal strain (GLS): -1.1 ± 4.6% vs 1.2 ± 4.5%, P = .01). Changes in diastolic function did not differ significantly between the groups (changes in transmitral E/A-ratio: -0.3 ± 0.6 vs -0.5 ± 0.5, P = .1). Kaplan-Meier survival analysis revealed no significant differences between the two cohorts (P = .795).

CONCLUSION

Procedure-related conduction abnormalities after TAVI lead to an LBBB-related dyssynchrony with impairment of LV performance but not of overall survival.

Impact of sheath diameter of different sheath types on vascular complications and mortality in transfemoral TAVI approaches using the Proglide closure device

OBJECTIVE

Evaluation of the impact of the sheath diameter on vascular complications and mortality in transfemoral aortic valve implantation.

METHOD

Between 2012 and 2014, 183 patients underwent the procedure using a sheath diameter of 18-24 F. This collective was divided into two groups: group 1, with a sheath diameter of 18F (G1, n = 94), consisted of patients with 18F Medtronic Sentrant and 18 F Direct Flow sheaths, and group 2 with a sheath diameter of 19-24 F (G2, n = 89) consisted of patients with Edwards expandable e-sheath and Solopath sheaths. Perclose-Proglide® was used as a closure device in all patients.

RESULTS

G1 had significantly more female patients (64.9% vs. 46.1% in G2, p = 0.01) and the average BMI was lower (26 ± 4.5% vs. 27.4 ± 4.7%, p = 0.03). There was no significant difference in the incidence of major and minor vascular complications (G1: 12.8% vs. G2: 12.4%, p = 0.9). 30-day mortality was similar in both groups (G1: 6.4 ± 2.5% [95% CI: 0.88-0.98], G2: 3.7 ± 1.9% [95% CI: 0.92-0.99]. The Kaplan Meier analysis of survival revealed no significant differences either.

CONCLUSION

The difference in sheath diameter had no effect on either incidence or severity of vascular complications. There was no impact on mortality either.

A multicentre European registry to evaluate the Direct Flow Medical transcatheter aortic valve system for the treatment of patients with severe aortic stenosis

AIMS

Our aim was to assess the clinical outcomes of the Direct Flow Medical Transcatheter Aortic Valve System (DFM-TAVS), when used in routine clinical practice.

METHODS AND RESULTS

This is a prospective, open-label, multicentre, post-market registry of patients treated with DFM-TAVS according to approved commercial indications. Echocardiographic and angiographic data were evaluated by an independent core laboratory and adverse events were adjudicated and classified according to VARC-2 criteria by an independent clinical events committee. The primary endpoint was freedom from all-cause mortality at 30 days post procedure. Secondary endpoints included procedural, early safety and efficacy endpoints at 30 days. Two hundred and fifty patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI) with the DFM-TAVS were enrolled in 21 European centres. The primary endpoint, freedom from all-cause mortality at 30 days, was met in 98% (245/250) of patients. Device success was 83.8%. Moderate or severe aortic regurgitation was reported in 3% of patients, and none/trace regurgitation in 73% of patients. Post-procedural permanent pacemaker implantation was performed in 30 patients (12.0%).

CONCLUSIONS

The DFM-TAVS was associated with good short-term outcomes in this real-world registry. The low pacemaker and aortic regurgitation rates confirm the advantages of this next-generation transcatheter heart valve (THV).

Valve-in-valve using an Edwards Sapien XT into a JenaValve in a patient with a low originating left coronary artery and a heavily calcified aorta

Coronary obstruction during transcatheter aortic valve implantation is a potentially life-threatening complication. Most of the widely used transcatheter heart valves require a certain distance between the basal aortic annular plane and the origins of the coronary arteries. We report the case of a successful valve-in-valve procedure with an Edwards SAPIEN XT valve into a JenaValve as a bail-out procedure in a patient with a low originating left coronary artery and a heavily calcified aorta.

First Explantation of Direct Flow Medical Transcatheter Valve

Next-generation transcatheter heart valves are designed to overcome procedure-related adverse events such as vascular complications and annulus rupture, and to minimize paravalvular regurgitation. The Direct Flow Medical valve is fully repositionable and shows promising results. The case is presented of Direct Flow Medical valve implantation in a patient with a functional bicuspid aortic valve. Multiple repositioning maneuvers failed to overcome the anatomic difficulties, and this resulted in a moderately high persisting gradient and moderate paravalvular leakage. Surgical valve explantation was necessary which, to the present authors' knowledge, is the first such case of Direct Flow Medical valve explantation to be performed.

Development of an algorithm to plan and simulate a new interventional procedure

OBJECTIVES

The number of implanted biological valves for treatment of valvular heart disease is growing and a percentage of these patients will eventually undergo a transcatheter valve-in-valve (ViV) procedure. Some of these patients will represent challenging cases. The aim of this study was to develop a feasible algorithm to plan and in vitro simulate a new interventional procedure to improve patient outcome.

METHODS

In addition to standard diagnostic routine, our algorithm includes 3D printing of the annulus, hydrodynamic measurements and high-speed analysis of leaflet kinematics after simulation of the procedure in different prosthesis positions as well as X-ray imaging of the most suitable valve position to create a 'blueprint' for the patient procedure.

RESULTS

This algorithm was developed for a patient with a degenerated Perceval aortic sutureless prosthesis requiring a ViV procedure. Different ViV procedures were assessed in the algorithm and based on these results the best option for the patient was chosen. The actual procedure went exactly as planned with help of this algorithm.

CONCLUSIONS

Here we have developed a new technically feasible algorithm simulating important aspects of a novel interventional procedure prior to the actual procedure. This algorithm can be applied to virtually all patients requiring a novel interventional procedure to help identify risks and find optimal parameters for prosthesis selection and placement in order to maximize safety for the patient.

Psychological characteristics, eating behavior, and quality of life assessment of obese patients undergoing weight loss interventions

BACKGROUND AND AIMS

Bariatric surgery is the most effective treatment for obesity. However, not all patients have similar weight loss following surgery and many researchers have attributed this to different pre-operative psychological, eating behavior, or quality-of-life factors. The aim of this study was to determine whether there are any differences in these factors between patients electing to have bariatric surgery compared to less invasive non-surgical weight loss treatments, between patients choosing a particular bariatric surgery procedure, and to identify whether these factors predict weight loss after bariatric surgery.

MATERIAL AND METHODS

This was a prospective study of 90 patients undergoing gastric bypass, vertical sleeve gastrectomy, or adjustable gastric banding and 36 patients undergoing pharmacotherapy or lifestyle interventions. All patients completed seven multi-factorial psychological, eating behavior, and quality-of-life questionnaires prior to choosing their weight loss treatment. Questionnaire scores, baseline body mass index, and percent weight loss at 1 year after surgical interventions were recorded.

RESULTS AND CONCLUSIONS

Surgical patients were younger, had a higher body mass index, and obesity had a higher impact on their quality of life than on non-surgical patients, but they did not differ in the majority of eating behavior and psychological parameters studied. Patients opting for adjustable gastric banding surgery were more anxious, depressed, and had more problems with energy levels than those choosing vertical sleeve gastrectomy, and more work problems compared to those undergoing gastric bypass. Weight loss after bariatric surgery was predicted by pre-operative scores of dietary restraint, disinhibition, and pre-surgery energy levels. The results of this study generate a number of hypotheses that can be explored in future studies and accelerate the development of personalized weight loss treatments.

[Combined intravitreal therapy for age-related macular disease]

Since the introduction of anti-VEGF drugs for the treatmet of CNV in age-related macular degeneration (AMD), visual acuity can be stabilised or improved in a significant number of patients. There is an ongoing debate on the safety, efficiency and economic aspects related to current intravitreal therapeutic concepts. Twenty-four to 36 hours after 80 % low-fluence verteporfin photodynamic therapy (PDT) a combined phrarmacosurgical intravitreal therapy for 52 patients with wet AMD was conducted (multiple therapy). By performing a 23-gauge core vitrectomy with the Intrector, an intravitreal substitution with BSS, dexamethasone and bevacizumab was achieved via a self-adapting two-channel cannula for aspiration and injection in one probe tip. After 14 months the mean gain in visual acuity (VA) was 0.18 Snellen lines, with VA stabilisation in 14 / 52 (27 %) and VA gain in 38 / 52 (73 %) of the patients. This safe pharmacosurgical regimen indicated a low intravitreal retreatment rate of (13 / 52) 25 %.

B- and T-cell-specific alloantigens in man

Screening for B-cell-specific antibodies in unabsorbed pregnancy sera preselected for weak reactivity in regular HLA-A, -B, and -C screening yielded a relatively high proportion (35/81) of B-cell-specific antibodies. Most B-cell-specific antibodies react broadly, showing inclusion phenomena suggesting 'cross-reactivity' analogous to that observed in HLA-A and -B serology. In control experiments with T-cell-enriched suspensions three antisera reacted with T cells and not with B cells. These antisera are highly associated with HLA-A2 in the unrelated population and segregate with HLA haplotypes in families and with HLA-A in a family with HLA-A, B recombination, Thus it appears that the human equivalents of Ia antigens may include--in analogy to the murine Ia antigens--B cell- as well as T-cell-specific alloantigens.