Contemporary outcomes of surgical aortic valve replacement in patients referred for a transcatheter approach

OBJECTIVES

The purpose of this study is to examine which patients referred to our structural valve clinic for potential transcatheter aortic valve replacement (TAVR) are receiving surgical aortic valve replacement (SAVR) whether due to unsuitable anatomy for TAVR versus other reasons.

METHODS

Individuals referred for TAVR from January 2019 to March 2022, who ultimately underwent SAVR were examined, retrospectively. Patients were divided into 2 surgical groups: TAVR was technically unsuitable (SAVR-TU) and those in which TAVR was technically feasible (SAVR-TF).

RESULTS

215 patients referred for TAVR underwent SAVR with 61 (28.4%) patients in the SAVR-TU group and 154 (71.6%) in the SAVR-TF group. The SAVR-TU group were more commonly female (52.5% vs 23.4%, p < 0.0001), had a higher incidence of stroke at baseline (9.8% vs 2.0%, p = 0.017) were frailer (5-m gait 5.2 s vs 4.7 s, p = 0.0035), and had a higher Society of Thoracic Surgery risk score (2.2 vs 1.7, p = 0.04). In the SAVR-TU group, unsuitability for TAVR was due to inadequate aortic root anatomy (86.9%), and poor peripheral access (6.6%). In the SAVR-TF group, the most common reasons for SAVR referral were concomitant coronary artery disease (42.9%), bicuspid aortic valve disease (16.9%), and concomitant aortic aneurysm (10.4%). Overall, in-hospital mortality was 1.4% with no difference between both groups. One-year survival was 96.7%.

CONCLUSION

Despite a higher trend of aortic stenosis being treated with TAVR, higher risk patients unsuitable for TAVR can have SAVR with excellent outcomes. Moreover, patients with AS and concomitant other pathology should be evaluated for cardiac surgery.

Evaluation of Left Ventricular Function in Patients With Severe Aortic Stenosis Utilizing Automated Cardiac Motion Quantitation Techniques

OBJECTIVE

The objective of this study is to explore the patterns of alteration in left ventricular systolic function among patients with severe aortic stenosis (SAS) through the application of automatic myocardial motion quantification (aCMQ) techniques. Furthermore, we seek to ascertain dependable quantitative markers for the assessment of impaired left ventricular function in patients with SAS and an ejection fraction (EF) ≥ 60%.

METHODS

Seventy patients who underwent echocardiography and received a diagnosis of severe aortic stenosis (SAS) in the hospital from November 2021 to August 2022 were selected for the SAS group and categorized into three subgroups based on ejection fraction (EF)-SAS group with EF ≥ 60%, SAS group with EF ranging from 50% to 59%, and SAS group with EF < 50%. Concurrently, 30 healthy individuals were recruited at the hospital during the same timeframe to serve as the control group. Participants from both groups underwent standard transthoracic echocardiography to assess conventional echocardiographic parameters. Dynamic images were examined using automatic myocardial motion quantification (aCMQ) software to derive longitudinal peak strain (LPS) parameters, which were then subjected to statistical analysis.

RESULTS

In comparison to the control group participants, the measurements of ascending aorta diameter (AoD), left atrium diameter (LAD), interventricular septal end diastolic thickness (IVSd), left ventricular posterior wall end diastolic thickness (LVPWd), peak systolic velocity (Vmax), and mean pressure gradient (MPG) were significantly higher in the SAS groups (p < 0.05). When compared to participants in the SAS group with an EF ≥ 60%, the values of IVSd, LVPWd, Vmax, and MPG in the SAS group with EF ranging from 50% to 59% were significantly elevated (p < 0.05). Similarly, left ventricular end-diastolic diameter (LVEDD), the ratio of early diastolic mitral inflow velocity to early diastolic mitral annular velocity (E/e'), and the ratio of early to late diastolic mitral inflow velocities (E/A) in the SAS group with EF < 50% were significantly elevated (p < 0.05). The absolute values of longitudinal peak strain (LPS) in the SAS groups were significantly lower in comparison to those in the control group (p < 0.05). Furthermore, all measurements of left ventricular global longitudinal systolic peak strain (GLPS) showed a positive correlation with MPG, a moderate negative correlation with aortic valve area index (AVAI), and a moderate positive correlation with E/A.

CONCLUSIONS

Patients with SAS and an EF < 50% exhibited the most profound impairment in left ventricular myocardial function. Utilizing the aCMQ technique enables the precise and quantitative evaluation of the severity of impaired left ventricular systolic function in patients within the SAS group with an EF ≥ 60%.

Clinical efficacy of tolvaptan in acute decompensated heart failure patients with severe aortic stenosis and atrial fibrillation: a sub-analysis from the LOHAS registry

BACKGROUND

Severe aortic valve stenosis (AS) and atrial fibrillation (AF) are risk factors of hemodynamic instability in heart failure (HF) management due to low cardiac output, respectively. Therefore, the treatment of HF due to severe AS complicated with AF is anticipated to be difficult. Tolvaptan, a vasopressin V2 receptor inhibitor, is effective in controlling acute decompensated heart failure (ADHF) with hemodynamic stability. However, its clinical efficacy against ADHF caused by AS with AF remains to be determined.

METHODS

Clinical information (from September 2014 to December 2017) of 59 patients diagnosed with ADHF due to severe AS (20 patients with AF; 39 patients with sinus rhythm [SR]) was obtained from the LOHAS registry. The registry collected data from seven hospitals and assessed the short-term effects of tolvaptan in patients hospitalized for ADHF with severe AS. We attempted to identify clinical differences from baseline up to 4 days, comparing patients with AF (AF group) versus those with SR (SR group).

RESULTS

There were no significant differences between the groups in age (83.7 ± 4.5 vs. 85.8 ± 6.9 years, respectively; p = 0.11) and aortic valve area (0.60 [0.46-0.73] vs. 0.56 [0.37-0.70] cm2, respectively; p = 0.50). However, left atrial volume was larger (104 [85-126] vs. 87 [64-103] mL, respectively; p < 0.01), whereas stroke volume was lower (51.6 ± 14.8 vs. 59.0 ± 18.7 mL, respectively; p = 0.08) in the AF group versus the SR group. Body weight decreased daily from baseline up to day 4 in both groups (from 55.4 to 53.2 kg [p < 0.01] and from 53.5 to 51.0 kg [p < 0.01], respectively) without change in heart rate. Notably, the systolic blood pressure decreased slightly in the AF group after 2 days of treatment with tolvaptan.

CONCLUSIONS

Short-term treatment with tolvaptan improved HF in patients hospitalized for severe AS, regardless of the presence of AF or SR. After achieving sufficient diuresis, a slight decrease in blood pressure was observed in the AF group, suggesting an appropriate timeframe for safe and effective use of tolvaptan.

Acute Heart Valve Emergencies

Within the cardiac intensive care unit, prompt recognition of severe acute valvular lesions is essential because hemodynamic collapse can occur rapidly, especially when cardiac chambers have not had time for compensatory remodeling. Within this context, optimal medical management, considerations for temporary mechanical circulatory support and decisive treatments strategies are addressed. Fundamental concepts include an appreciation for how sudden changes in flow and pressure gradients between cardiac chambers can impact hemodynamic and echocardiographic findings differently compared to similarly severe chronic lesions, as well as understanding the main causes for decompensated heart failure and cardiogenic shock for each valvular abnormality.

Feasibility and technicality of aortic valve lithotripsy-facilitate balloon valvuloplasty in patients with severe aortic stenosis unsuitable for immediate valvular replacement

BACKGROUND

Aortic valve lithotripsy can fragment aortic valve calcium deposits and potentially restore leaflet pliability in animal model and ex-vivo, but clinical data is limited. Transcatheter aortic valve implantation (TAVR) might not be feasible as an urgent procedure in critically ill patients. Balloon valvuloplasty has the major limitation of valve recoil and inducing aortic regurgitation.

AIMS

To determine the clinical feasibility of aortic valve lithotripsy-facilitated balloon valvuloplasty in patients with severe aortic stenosis unsuitable for valvular replacement.

METHODS

We performed lithotripsy as adjunctive therapy to balloon aortic valvuloplasty in ten consecutive patients, most of whom were deemed unfit for TAVR. Lithotripsy of the aortic valve was performed with simultaneous inflation of one to three peripheral lithotripsy balloons to deliver ultrasound pulses. Rapid pacing was not used during lithotripsy. Aortic valve velocity, gradient, and valve area were measured before and after the procedure by echocardiogram. Transvalvular pressure gradient was recorded intra-procedurally. Periprocedural and ninety-day clinical outcomes were followed.

RESULTS

Procedure was technically successful in 9 out of 10 patients and aborted in one patient due to cardiogenic shock. One patient had femoral closure device related complication. There was a statistically significant decrease in valvular gradient and increase in aortic valve area. 9 out of 10 patients recovered from acute episode and were discharged. 6 patients had improvement in NYHA class. 4 patients were subsequently able to receive TAVR. 90-day mortality occurred in 3 patients. There was no stroke or bradyarrhythmia peri-procedurally and no heart failure hospitalization at 90 days.

CONCLUSION

Aortic valve lithotripsy-facilitated balloon valvuloplasty has reasonable feasibility, safety and technical reproducibility and acute clinical result. Hemodynamic effect is similar to that of balloon valvuloplasty reported in the literature. Subsequent Prognosis is not altered in critically ill patients.

Doppler Echocardiographic Phenotypes in Suspected 'Severe' Aortic Stenosis: Matrix-Based Approach to Diagnosis and Management

BACKGROUND

Among patients with suspected severe aortic stenosis (AS), Doppler echocardiographic (DE) data are often discordant, and further analysis is required for accurate diagnosis and optimal management. In this study, an automated matrix-based approach was applied to an echocardiographic database of patients with AS that identified 5 discrete echocardiographic data patterns, 1 concordant and 4 discordant, each reflecting a particular pathophysiology/measurement error that guides further workup and management.

METHODS

A primary/discovery cohort of consecutive echocardiographic studies with at least 1 DE parameter of severe AS and analogous data from an independent secondary/validation cohort were retrospectively analyzed. Parameter thresholds for inclusion were aortic valve area (AVA) <1.0 cm2, transaortic mean gradient (MG) ≥ 40 mmHg, and/or transaortic peak velocity (PV) ≥ 4.0 m/sec. Doppler velocity index (DVI) was also determined. Logic provided by an in-line SQL query embedded within the database was used to assign each patient to 1 of 5 discrete matrix patterns, each reflecting 1 or more specific pathophysiologies. Feasibility of automated pattern-driven triage of discordant cases was also evaluated.

RESULTS

In both cohorts, data from each patient fitted only 1 data pattern. Of the 4,643 primary cohort patients, 39% had concordant parameters for severe AS and DVI <0.30 (pattern 1); 35% had AVA < 1.0 cm2, MG < 40 mm Hg, PV < 4 m/sec, DVI < 0.30 (pattern 2); 9% had MG ≥ 40 mmHg and/or PV ≥ 4 m/sec, DVI > 0.30 (pattern 3); 10% had AVA < 1.0 cm2, MG < 40 mmHg, PV < 4 m/sec, DVI >0.30 (pattern 4); and 7% had MG > 40 mmHg and/or PV ≥ 4 m/sec, AVA > 1.0 cm2, DVI < 0.30 (pattern 5). Findings were validated among the 387 secondary cohort patients in whom pattern distribution was remarkably similar.

CONCLUSIONS

Matrix-based pattern recognition permits automated in-line identification of specific pathophysiology and/or measurement error among patients with suspected severe AS and discordant DE data.

Prognostic effect of stress hyperglycemia ratio on patients with severe aortic stenosis receiving transcatheter aortic valve replacement: a prospective cohort study

BACKGROUND

Stress hyperglycemia ratio (SHR) has recently been recognized as a novel biomarker that accurately reflects acute hyperglycemia status and is associated with poor prognosis of heart failure. We evaluated the relationship between SHR and clinical outcomes in patients with severe aortic stenosis receiving transcatheter aortic valve replacement (TAVR).

METHODS

There were 582 patients with severe native aortic stenosis who underwent TAVR consecutively enrolled in the study. The formula used to determine SHR was as follows: admission blood glucose (mmol/L)/(1.59×HbA1c[%]-2.59). The primary endpoint was defined as all-cause mortality, while secondary endpoints included a composite of cardiovascular mortality or readmission for heart failure, and major adverse cardiovascular events (MACE) including cardiovascular mortality, non-fatal myocardial infarction, and non-fatal stroke. Multivariable Cox regression and restricted cubic spline analysis were employed to assess the relationship between SHR and endpoints, with hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

During a median follow-up of 3.9 years, a total of 130 cases (22.3%) of all-cause mortality were recorded. Results from the restricted cubic spline analysis indicated a linear association between SHR and all endpoints (p for non-linearity > 0.05), even after adjustment for other confounding factors. Per 0.1 unit increase in SHR was associated with a 12% (adjusted HR: 1.12, 95% CI: 1.04-1.21) higher incidence of the primary endpoint, a 12% (adjusted HR: 1.12, 95% CI: 1.02-1.22) higher incidence of cardiovascular mortality or readmission for heart failure, and a 12% (adjusted HR: 1.12, 95% CI: 1.01-1.23) higher incidence of MACE. Subgroup analysis revealed that SHR had a significant interaction with diabetes mellitus with regard to the risk of all-cause mortality (p for interaction: 0.042). Kaplan-Meier survival analysis showed that there were significant differences in the incidence of all endpoints between the two groups with 0.944 as the optimal binary cutoff point of SHR (all log-rank test: p < 0.05).

CONCLUSIONS

Our study indicates linear relationships of SHR with the risk of all-cause mortality, cardiovascular mortality or readmission for heart failure, and MACE in patients with severe aortic stenosis receiving TAVR after a median follow-up of 3.9 years. Patients with an SHR exceeding 0.944 had a poorer prognosis compared to those with lower SHR values.

Atrial electrical remodeling and function after transcatheter aortic valve replacement in patients with aortic stenosis

To examine reverse atrial electrical remodeling in patients with aortic stenosis (AS) after trans-catheter aortic valve replacement (TAVR). In 65 consecutive patients with severe AS (83 ± 4 years, 47 (72.3%) females), we analyzed ECG records for the P wave duration (PWD) in lead II and P-terminal force (PTFV1) in V1, and measured cardiac dimensions and function by echocardiography (ECHO) following TAVR. Biomarkers were measured to assess myocardial injury by TAVR. TAVR was successfully performed without major complications: the aortic valve area increased from 0.62 ± 0.14 cm2 to 1.52 ± 0.24cm2, and the trans-aortic pressure gradient decreased from 58.4 ± 15.9 mmHg to 15.0 ± 19.6 mmHg. PWD and PTFV increased immediately after TAVR and returned to the pre-TAVR levels on the next day. Then, the PWD declined toward 6 months after TAVR non-significantly in all patients, but significantly in 25 patients with baseline PWD ≥ 130 ms (P = 0.039). PTFV1 showed no long-term change. Improvement was observed in the ejection fraction, all thickness of the left ventricle and in the left atrial dimensions on ECHO. After recovery from transient aggravation by TAVR procedure, PWD reversed slowly, and the change was significant in those with baseline PWD ≥ 130 ms while change in PTFV1 was not significant at 6 months of follow-up. ECHO showed a reversal of remodeling in the left ventricle and in the left atrial dimension after TAVR.

Commissural alignment during TAVR reduces the risk of overlap to coronary ostia

BACKGROUND

Transcatheter aortic valve replacement (TAVR) showed safety and efficacy in patients with severe aortic stenosis. Commissural alignment (CA) during TAVR has the potential to reduce the impact of the prostheses on accessibility of coronary arteries, as misalignment of the neocommissures could cause partial overlap with coronary ostia. Therefore, the aim of this study was to investigate the impact of CA on coronary overlap rates.

METHODS

We examined the techniques of CA and their impact on coronary access. Eligible studies were searched for on Pubmed, SCOPUS and DOAJ and selected using PRISMA guidelines. The primary endpoint was the incidence of a severe coronary overlap or failed coronary re-access. Results of the analysis are expressed as Risk Ratio (RR) with 95% CI.

RESULTS

Four studies were included in this analysis. In these, 681 patients underwent TAVR with CA and 210 underwent TAVR without CA. We examined Evolut valves and Acurate Neo valves. The primary endpoint occurred in 138 patients undergoing TAVR with CA and in 154 patients without CA (RR = 0.279; 95% CI 0.201-0.386; p < 0.001). Neither prosthesis-related, nor patient-related factors had a significant interaction with the measured effect.

CONCLUSIONS

Commissural alignment was associated with significantly lower rates of commissure-to-coronary ostia overlap and failure of coronary access. Consequently, a modified insertion technique could reduce coronary overlap and coronary occlusion, particularly in supra-annular valves. Therefore, controlled orientation of prostheses by CA during TAVR could favour coronary access, especially in younger patients that could require coronary re-access after TAVR.

Prognostic Signals From Moderate Valve Disease in Big Data: An Artefact of Digital Imaging and Communications in Medicine Structured Reporting?

BACKGROUND

Recent studies have identified an association between moderate aortic stenosis (AS) and outcome. We assessed whether Digital Imaging and Communications in Medicine (DICOM) structured reporting (SR), which captures and inserts echocardiographic measurements and text data directly into radiological reports, may lead to misclassifying patients with severe AS as moderate.

METHODS

Moderate or severe AS cases were filtered from an echocardiography data set based on aortic valve area (AVA) < 1.5 cm2, indexed AVA (AVAi) ≤ 0.85 cm2/m2, mean pressure gradient ≥ 25 mm Hg, dimensionless severity index (DSI) ≤ 0.5, or peak velocity > 3 m/sec. Data validation was conducted by verification of each parameter. All echocardiographic parameters and definitions of AS were compared pre- and postvalidation by taking differences in measurements. Misclassification rates were assessed by determining the percentage of cases that changed AS severity classification and impact on outcomes. Patients were followed over 4.3 ± 1.5 years.

RESULTS

Of 2,595 validated echocardiograms with AS, up to 36% of the echocardiographic parameters for AS criteria had a >10% difference between DICOM-SR and manual validation, the highest with mean pressure gradient (36%) and the lowest with DSI (6.5%). The validation process changed the reported degree of AS in up to 20.6% of echocardiograms with resultant changes in AS severity and its association with mortality or heart failure-related hospitalizations. In contrast to multiple quantitative metrics in DICOM-SR after manual validation, clinicians' evaluation of AS severity was unable to distinguish composite outcomes over 3 years between moderate and severe AS. The risk of composite outcomes was significantly increased when severe AS was evidenced by at least 1 echocardiographic parameter of severe AS (hazard ratio = 1.24; 95% CI, 1.12-1.37; P < .001). The greatest hazard was based on DSI only (hazard ratio = 1.26; 95% CI, 1.10-1.44; P < .001), which was higher after manual validation compared to DICOM-SR. Averaging of repeated echo measures including invalid values contributed the most to erroneous data.

CONCLUSIONS

Nonpeak data in DICOM-SR led to incorrect categorization of a high proportion of patients based on AS severity definitions. Standardization of data fields and curation to ensure that only peak values are imported from DICOM-SR data are essential.

TAVR vs balloon aortic valvotomy for severe aortic stenosis and cardiogenic shock: An insight from the National Inpatient Sample database

BACKGROUND

Severe Aortic stenosis (AS) complicated by cardiogenic shock (CS) represents a grave clinical condition with limited treatment options. Evidence from small observation studies favors that Transcatheter Aortic Valve Replacement (TAVR) might be a feasible option in these patients in contrast to emergent Balloon Aortic Valvuloplasty (BAV) which is associated with very high short and long-term mortality.

METHODS

11,405 hospitalizations with severe AS complicated by CS between 2016 and 2020 were identified using the National Inpatient Sample (NIS) Database, and patients were then stratified according to whether they received TAVR or BAV. Propensity-score matching was used to account for differences in the baseline characteristics. Primary and secondary outcomes were then compared between 3485 hospitalizations in direct TAVR group and with 3485 matched hospitalizations in the BAV group. The primary outcome was a composite of all-cause in-hospital death, acute cerebrovascular accident (CVA), and myocardial infarction (MI). Secondary outcomes and safety outcomes were also compared between the two groups.

RESULTS

TAVR was associated with fewer primary outcomes events as compared to BAV {36.8 % vs 56.8 %, aOR (95%CI) = 0.38(0.30-0.47)}, due to fewer all-cause in-hospital deaths {17.8 % vs 38.9 %, aOR (95%CI) =0.34 (0.26-0.43)} and MI {12.3 % vs 32.4 %, aOR (95%CI) = 0.29 (0.22-0.39)}. TAVR was associated with higher rates of acute CVA {6.17 % vs 3.44 %, aOR (95%CI) = 1.84 (1.08-3.21)} and pacemaker implantation post procedure {11.9 % vs 6.03 %, aOR (95%CI) = 2.10 (1.41-3.18)}.

CONCLUSION

Direct TAVR in shock and severe Aortic stenosis is a better strategy than rescue Balloon aortic valvotomy.

Rotational atherectomy of left main stem immediately after transcatheter aortic valve implantation in a patient with symptomatic severe aortic stenosis and an impaired left ventricular systolic function: a case report

Background

Severe aortic stenosis (AS) and coronary artery disease (CAD) often coexist since they both share the same risk factors and pathophysiology. Patients with severe AS with prohibitive surgical risk are often treated with transcatheter aortic valve implantation (TAVI) and percutaneous coronary intervention (PCI) as a staged or concurrent procedure. Significant calcified CAD and left ventricular (LV) systolic impairment in such patients would add more challenges to the management. A clear consensus on the timing of revascularization of such patients in relation to the TAVI procedure is lacking.

Case summary

Herein, we present an 86-year-old male who presented to a local district hospital with non-ST-segment elevation myocardial infarction (N-STEMI) and decompensated heart failure. His transthoracic echocardiography showed moderate LV systolic impairment with low-flow severe AS. He was initially treated with dual anti-platelet and diuretic therapy and subsequently underwent coronary angiography that revealed severe calcified shelf-like left main stem (LMS) and moderate left anterior descending (LAD) disease. He was successfully treated with TAVI and rotational atherectomy (RA)-assisted PCI to LMS and LAD in the same setting.

Conclusion

There is limited evidence on effective strategies to tackle high-risk angioplasty with concurrent TAVI in patients with impaired LV function. We performed TAVI and RA to LMS and LAD in the same setting using no mechanical circulatory support (MCS). Management strategies should be individualized to highly selected patients taking into account LMS involvement, calcium modulation strategies, haemodynamic instability, or cardiogenic shock and whether MCS is needed.

Procoagulant effect of extracellular vesicles in patients after transcatheter aortic valve replacement or transcatheter aortic valve replacement with percutaneous coronary intervention

Patients with severe aortic stenosis (AS) after replacement of the transcatheter aortic valve (TAVR) are more likely to develop thrombotic complications such as cerebral embolism and artificial valve thrombosis. However, the mechanism is not yet well defined. We aimed to explore the plasma extracellular vesicles (EVs) levels and their role in the induction of procoagulant activity (PCA) in patients receiving TAVR alone or TAVR with percutaneous coronary intervention (PCI). EVs were analyzed with flow cytometer. Markers of platelet and endothelial cell activation were quantified using selective enzyme-linked immunosorbent assay (ELISA) kits. Procoagulant activity (PCA) was assessed by clotting time, purified clotting complex assays, and fibrin production assays. Our results confirmed that EVs with positive phosphatedylserin (PS⁺EV), platelet EVs (PEVs) and positive tissue factor EVs (TF⁺EVs) were higher in patients following TAVR than before TAVR, particularly in TAVR with PCI. Furthermore, endothelial-derived EVs (EEVs) were also higher in patients after TAVR with PCI than pre-TAVR, however, the EEVs levels in TAVR alone patients were gradually reduce than pre-TAVR. In addition, we further proved that total EVs contributed to dramatically shortened coagulation time, increased intrinsic/extrinsic factor Xa and thrombin generation in patients after TAVR, especially in TAVR with PCI. The PCA was markedly attenuated by approximately 80% with lactucin. Our study reveals a previously unrecognized link between plasma EV levels and hypercoagulability in patients after TAVR, especially TAVR with PCI. Blockade of PS⁺EVs may improve the hypercoagulable state and prognosis of patients.

The outcomes of fetal aortic valvuloplasty in critical aortic stenosis: A systematic review and meta-analysis

BACKGROUND

Critical aortic stenosis that appears in mid-gestation tends to develop to growth retardation of left ventricle, known as hypoplastic left heart syndrome (HLHS). Despite better clinical management of HLHS, the morbidity and mortality rates of univentricular circulation patients remain high. In this paper, we sought to perform a systematic review and meta-analysis to know the outcomes of fetal aortic valvuloplasty in critical aortic stenosis patients.

METHODS

This systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) statement. A systematic search on fetal aortic valvuloplasty procedure for critical aortic stenosis was performed through PubMed, Scopus, EBSCOhost, ProQuest, and Google Scholar. The primary endpoint of each group was overall mortality. We used R software (version 4.1.3) to estimate the overall proportion of each outcome using random-effects model of proportional meta-analysis.

RESULTS

A total of 389 fetal subjects from 10 cohort studies were included in this systematic review and meta-analysis. Fetal aortic valvuloplasty (FAV) was successfully performed in 84% of patients. It revealed a successful conversion to biventricular circulation rate of 33% with a mortality rate of 20%. Bradycardia and pleural effusion requiring treatment were two most common fetal complications, whereas maternal complication reported was only placental abruption in one patient.

CONCLUSIONS

FAV has a high technical success rate with the ability to achieve biventricular circulation and a low rate of procedure-related mortality if carried out by experienced operators.

Machine learning-based predictive risk models for 30-day and 1-year mortality in severe aortic stenosis patients undergoing transcatheter aortic valve implantation

BACKGROUND

Predictive risk score for mortality plays an important role in the decision-making in patient selection and risk stratification for TAVI. Existing established predictive risk scores had poor discrimination performance in the prediction of mortality after the TAVI.

OBJECTIVES

The present study aimed to develop machine learning-based predictive models for 30-day and 1-year mortality in severe aortic stenosis patients undergoing TAVI.

METHODS

A total of 186 patients in a retrospective cohort study were analyzed. The models were fitted by a decision tree. Each model was tested in 100 iterations of 80:20 stratified random splitting into training/testing samples and 10-fold cross-validation.

RESULTS

Variables that predict 30-day mortality are a set of factors driven mainly by height, chronic lung disease, STS score, preoperative LVEF, age, and preoperative LVOT VTI. Variables that predict 1-year mortality are a set of factors consisting of preoperative LVEF, STS score, heart rate, systolic blood pressure, home oxygen use, serum creatinine level, and preoperative LVOT Vmax. This decision tree-generated predictive models for 30-day and 1- year mortality provided the most precise accuracy of 0.97 and 0.90 with the AUC-ROC curves of 0.83 and 0.71 on 30-day and 1-year mortality on testing data and had better discrimination performance compared to the existing established TAVI predictive risk scores.

CONCLUSIONS

These machine learning models show excellent accuracy and have a better prediction for 30-day and 1-year mortality than the existing established TAVI predictive risk scores. A customized predictive model deems to be properly developed for better risk discrimination among cohorts.

TAVR in 2023: Who Should Not Get It?

Since the first transcatheter delivery of an aortic valve prosthesis was performed by Cribier et al in 2002, the picture of aortic stenosis (AS) therapeutics has changed dramatically. Initiated from an indication of inoperable to high surgical risk, extending to intermediate and low risk, transcatheter aortic valve replacement (TAVR) is now an approved treatment for patients with severe, symptomatic AS across all the risk categories. The current evidence supports TAVR as a frontline therapy for treating severe AS. The crucial question remains concerning the subset of patients who still are not ideal candidates for TAVR because of certain inherent anatomic, nonmodifiable, and procedure-specific factors. Therefore, in this study, we focus on these scenarios and reasons for referring selected patients for surgical aortic valve replacement in 2023.

Dedicated Next Day Discharge Post Minimalist TAVI: The Tasmanian Experience

OBJECTIVES

To assess the safety, feasibility and independent predictors of next day discharge (NDD) in patients undergoing minimalist transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS) in a real-world Australian population.

METHODS

This single centre study reviewed 135 consecutive patients who underwent minimalist transfemoral TAVI from June 2020 to February 2022. Baseline demographics, procedural characteristic and outcomes were obtained. All patients were assessed by the local protocol for NDD. Patients were then divided into two groups: those who achieved next day discharge (NDD) and those requiring >1 overnight hospital stay. Univariate, bivariate and stepwise multivariate logistic regression modelling was used to identify the predictors of successful next day discharge.

RESULTS

The mean age of the cohort was 82.9±5.7 years with 62.3% patients male, the average STS score was 4.1±2.4. All 135 patients underwent a successful transfemoral TAVI procedure, with 131 (97%) receiving a balloon-expandable valve. Ninety-seven (97) (71.9%) patients achieved NDD. Thirty (30)-day outcomes were excellent with a 30-day mortality of 0.7%, transient ischaemic attack/cardiovascular accident (TIA/CVA) 1.5%, major vascular complication 1.5% and 11.4% need for permanent pacemaker (PPM). In patients not achieving NDD, the average length of stay (LOS) was 3.0 days. Baseline characteristics demonstrated pre-existing first degree atrioventricular (AV) block and right bundle branch block (RBBB) as statistically significant negative predictors of NDD on univariate analysis. Next day discharge was achievable in only 50% of patients who suffered any minor or major procedural complication (15/30). Stepwise multivariate logistic regression modelling demonstrated female gender (OR 3.094, 95% CI 1.141-8.391, p=0.026), smaller aortic valve area (AVA) (OR 48.265, 95% CI 2.269-102.6, p=0.013), the presence of diabetes mellitus (OR 0.594, 95% CI 0.356-0.991, p=0.046) and a longer procedure time (OR 0.960, 95% CI 0.935-0.986, p=0.002) as statistically significant negative predictors of NDD. In addition, there was no difference in 30-day readmission rates between the NDD and non-NDD cohort (7.2% vs 10.5%, p=0.386).

CONCLUSION

Next day discharge is safe and feasible in almost three quarters of patients undergoing minimalist TAVI for severe AS in a predominantly balloon expandable valve cohort, with a very low rate of 30-day readmission. NDD provides advantages for hospital efficiency and improved cost-effectiveness. Female gender, smaller AVA, the presence of diabetes mellitus and a longer procedure time were independent negative predictors of successful NDD.

Effectiveness and safety of transcatheter aortic valve replacement in elderly people with severe aortic stenosis with different types of heart failure

BACKGROUND

Impaired left ventricular function is an independent predictor of adverse clinical outcomes in patients with aortic stenosis. The aim of this study is to evaluate the short-term changes of echocardiographic parameters, New York Heart Association (NYHA) class and B-type natriuretic peptide (BNP) level and adverse events amongst patients with heart failure (HF) after transcatheter aortic valve replacement (TAVR) procedure.

METHODS

This was a retrospective cohort study conducted at affiliated Yantai Yuhuangding Hospital of Qingdao University between September 2017 and September 2022. TAVR cases were stratified into three groups [heart failure with reduced ejection fraction (HFrEF), heart failure with mildly reduced ejection fraction (HFmrEF), heart failure with preserved ejection fraction (HFpEF)] by left ventricular ejection fraction (LVEF). Baseline characteristics, changes in echocardiographic parameters (1 week and 1 month), BNP (1 month), and NYHA class (6 months) post-TAVR were compared across the three groups. Meanwhile, we observed the adverse events of the patients after TAVR.

RESULTS

A total of 96 patients were included, of whom 15 (15.6%) had HFrEF, 15 (15.6%) had HFmrEF, and 66 (68.8%) had HFpEF. Compared to the HFpEF subgroup, patients in the HFrEF subgroup were younger (p < 0.05), and with a higher BNP (p < 0.05). The left ventricular end-diastolic dimension (LVEDD) in HFrEF group decreased significantly after TAVR. HFmrEF and HFrEF patients showed significant improvements in LVEF after TAVR. The pulmonary artery systolic pressure (PASP), aortic valve peak gradient (AVPG) and aortic valve peak gradient (V_max) decreased significantly 1 month after TAVR in all three groups compared to the baseline (all p < 0.05). BNP significantly reduced in HFrEF group compared to HFpEF patients after TAVR (p < 0.05). The majority of patients experienced an improvement at least one NYHA class in all three groups 6 months post-TAVR. There is no significant increase in the risk of adverse events in the HFrEF group.

CONCLUSIONS

Patients who underwent TAVR achieved significant improvements in BNP, NYHA class, LVEDD, LVEF, and PASP across the three HF classes, with a more rapid and pronounced improvement in the HFrEF and HFmrEF groups. Complication rates were low in the different HF groups. There is no significant increase in the risk of periprocedural complications in the HFrEF and HFmrEF groups.

Life expectancy after surgical aortic valve replacement for low-gradient aortic stenosis with preserved ejection fraction

INTRODUCTION AND OBJECTIVES

Surgical aortic valve replacement (SAVR) can modify the natural history of severe aortic stenosis (SAS). However, compared with the general population, these patients have a loss of life expectancy. The life expectancy of patients who undergo SAVR due to low-gradient SAS with preserved left ventricular ejection fraction (LVEF) is unknown.

METHODS

We included all patients between 50 and 65 years who underwent isolated SAVR in 27 Spanish centers during an 18-year period. We analyzed observed and expected survival at 18 years in patients with low-gradient SAS with preserved LVEF and all other types of SAS. We used propensity score matching to compare the life expectancy of patients with low-gradient SAS with preserved LVEF vs those with high-gradient SAS with preserved LVEF.

RESULTS

We analyzed 5084 patients, of whom 413 had low-gradient SAS with preserved LVEF. For these patients, observed survival at 10, 15 and 18 years was 86.6% (95%CI, 85.3-87.8), 75% (95%CI, 72.7-77.2), and 63.5% (95%CI, 58.8-67.8). Expected survival at 10, 15 and 18 years was 90.2%, 82.1%, and 75.7%. In the matched sample, survival of patients with low-gradient SAS with preserved LVEF was similar to that of patients with high-gradient with preserved LVEF, log-rank test, P=.95; HR=1 (95%CI, 0.7-1.4; P=.95).

CONCLUSIONS

There is a loss of life expectancy in patients with all types of SAS undergoing SAVR. This loss is higher in patients with left ventricular dysfunction and lower in patients with low-gradient or high-gradient aortic stenosis with preserved LVEF. The benefit of surgery is similar between these last 2 groups.

Transcatheter aortic valve implantation and frailty

Over the last decade, transcatheter aortic valve implantation (TAVI) has emerged as a treatment option for patients with severe aortic stenosis. With exponential increase in the number of TAVI procedures, frailty assessments have been considered important for patients undergoing TAVI, and a number of studies have indicated a relationship between the frailty and post-TAVI outcomes. In this review, using studies searched systematically in the PubMed database, we review important frailty assessment tools that can be used as prognostic factors for patients before TAVI. The assessment tools were categorized as quantitative single marker, semi-quantitative single marker, or quantitative combined marker. Studies were further stratified by whether they used frailty markers to predict patients' prognosis pre-TAVI or to evaluate frailty improvement post-TAVI. The Clinical Frailty Scale (CFS), a semi-quantitative assessment, is one of the frailty assessment tools discussed. It may be easily used even in an outpatient consultation room. The CFS classifies patients' activity into nine categories, based on a simple interview and the patient's appearance. Gait speed and serum albumin levels were considered as qualitative frailty assessment tools. Compared to other methods, the Essential Frailty Toolset had the highest inter-rater reliability for accuracy in predicting mortality, thereby allowing better identification of vulnerable old age people and optimization of outcomes. A few studies have also focused on changes in frailty pre- and post-TAVI. Serum albumin-level measurements are important for assessing the frailty improvement in the chronic phase. Each frailty assessment tool had its own characteristics, strengths, and weaknesses, and therefore, these tools need to be selected based on where they are being used and the patient's condition.

The safety and feasibility of retrograde balloon aortic valvuloplasty using the INOUE-BALLOON with severe aortic stenosis

In the transcatheter aortic valve implantation (TAVI) era, the indications for balloon aortic valvuloplasty (BAV) are increasing. Previously, the INOUE-BALLOON® (IB) was used only for antegrade BAV, but recently, it has also been used for retrograde BAV. However, the safety and feasibility of retrograde BAV using an IB are not fully understood. In this study, we investigated the safety and feasibility of retrograde BAV using an IB in elderly Japanese patients with severe aortic stenosis (AS). We compared 39 cases of retrograde BAV using an IB performed from June 2018 to September 2020 and 34 cases of antegrade BAV using an IB performed from August 2013 to May 2018. The total number of complications was lower in retrograde BAV than in antegrade BAV (p = 0.020). The procedure time was significantly shorter in retrograde BAV than in antegrade BAV (p < 0.001), and the maximum balloon size and number of balloon inflations were smaller in retrograde BAV than in antegrade BAV (p = 0.002 and p < 0.001, respectively). There was no significant difference in the degree of improvement in the aortic valve area or ejection fraction between retrograde and antegrade BAV. In conclusion, the present study showed the safety and feasibility of retrograde BAV using an IB in elderly Japanese patients with severe AS compared with antegrade BAV using an IB.

The mechanistic pathways of oxidative stress in aortic stenosis and clinical implications

Despite the elucidation of the pathways behind the development of aortic stenosis (AS), there remains no effective medical treatment to slow or reverse its progress. Instead, the gold standard of care in severe or symptomatic AS is replacement of the aortic valve. Oxidative stress is implicated, both directly as well as indirectly, in lipid infiltration, inflammation and fibro-calcification, all of which are key processes underlying the pathophysiology of degenerative AS. This culminates in the breakdown of the extracellular matrix, differentiation of the valvular interstitial cells into an osteogenic phenotype, and finally, calcium deposition as well as thickening of the aortic valve. Oxidative stress is thus a promising and potential therapeutic target for the treatment of AS. Several studies focusing on the mitigation of oxidative stress in the context of AS have shown some success in animal and in vitro models, however similar benefits have yet to be seen in clinical trials. Statin therapy, once thought to be the key to the treatment of AS, has yielded disappointing results, however newer lipid lowering therapies may hold some promise. Other potential therapies, such as manipulation of microRNAs, blockade of the renin-angiotensin-aldosterone system and the use of dipeptidylpeptidase-4 inhibitors will also be reviewed.

Implementation of a CT-derived correction factor to refine the measurement of aortic valve area and stroke volume using Doppler echocardiography improves grading of severity and prediction of prognosis in patients with severe aortic stenosis

AIMS

To assess rates of reclassification of severity and associated 5-year survival in patients with severe aortic stenosis (AS) and preserved left ventricular ejection fraction (LVEF) after application of a CT-derived correction factor (CF) to refine the measurement of aortic valve area (AVA) and stroke volume index (SVi) using Doppler echocardiography.

METHODS AND RESULTS

We enrolled 1450 patients with severe AS and preserved LVEF from a French registry. Multiplication of echocardiographic LV outflow tract diameter by a CT-derived CF of 1.13 to calculate the AVA and SVi using the continuity equation resulted in reclassification of 39% of patients from severe to moderate AS (AVA > 1 cm²) and 77% from low flow (LF, SVi < 35 ml/m²) to normal flow (NF, SVi ≥ 35 ml/m²). After application of the CF, 5-year survival with conservative management was 50 ± 4% for severe AS compared to 62 ± 4% for moderate AS (p < 0.001). A strategy of medical management followed by intervention for severe AS was associated with higher risk of mortality over 5-year follow-up after adjustment for covariates and application of the CF (HR 1.35 [1.10-1.55], p = 0.015). Five-year survival was also poorer in patients remaining in the LF group after application of the CF, even after valve intervention (72%, 66% and 47% for NF to NF, LF to NF and LF to LF, respectively). After adjustment for covariates (including intervention), risk of mortality was higher in LF to LF patients compared to NF to NF (HR 1.78 [1.25-2.56]), but similar for NF to NF and LF to NF (HR 1.20 [0.90-1.60]).

CONCLUSION

Refined accuracy of echocardiographic LV outflow tract diameter measurement using a CF of 1.13 before derivation of AVA and SVi in patients with severe AS and preserved LVEF allows improved grading of severity, and prediction of prognosis. We recommend implementation of the CF during routine echocardiography when using the continuity equation for Doppler haemodynamic measurements.

Severe Aortic Stenosis: More Than an Imaging Diagnosis

The definition of severe aortic stenosis has undergone significant change casting a wider net to avoid missing patients who could benefit from valve replacement. The presence or absence of symptoms remains the key decision-making element; however, individuals presently undergoing evaluation are older, more likely asymptomatic, and have lower gradients. Due to numerous potential measurement errors, attention to detail when performing diagnostic testing and understanding their limitations are necessary to render appropriate treatment. Exercise testing adds useful information for individuals with severe aortic stenosis felt to be asymptomatic. Dobutamine echocardiography, in low flow-low gradient aortic stenosis, distinguishes between a myopathic and valvular cause of left ventricular dysfunction. Evaluation of patients when normotensive minimizes measurement errors. The amount of aortic valve calcification adds useful information when the degree of aortic stenosis is uncertain. A good history and physical integrated with high-quality imaging data allows for appropriate clinical treatment decisions for patients with aortic stenosis. The goal is simultaneously to provide aortic valve replacement for patients in need while avoiding overdiagnosis and performance of unnecessary procedures.

Harnessing feature extraction capacities from a pre-trained convolutional neural network (VGG-16) for the unsupervised distinction of aortic outflow velocity profiles in patients with severe aortic stenosis

Aims

Hypothesizing that aortic outflow velocity profiles contain more valuable information about aortic valve obstruction and left ventricular contractility than can be captured by the human eye, features of the complex geometry of Doppler tracings from patients with severe aortic stenosis (AS) were extracted by a convolutional neural network (CNN).

Methods and results

After pre-training a CNN (VGG-16) on a large data set (ImageNet data set; 14 million images belonging to 1000 classes), the convolutional part was employed to transform Doppler tracings to 1D arrays. Among 366 eligible patients [age: 79.8 ± 6.77 years; 146 (39.9%) women] with pre-procedural echocardiography and right heart catheterization prior to transcatheter aortic valve replacement (TAVR), good quality Doppler tracings from 101 patients were analysed. The convolutional part of the pre-trained VGG-16 model in conjunction with principal component analysis and k-means clustering distinguished two shapes of aortic outflow velocity profiles. Kaplan-Meier analysis revealed that mortality in patients from Cluster 2 (n = 40, 39.6%) was significantly increased [hazard ratio (HR) for 2-year mortality: 3; 95% confidence interval (CI): 1-8.9]. Apart from reduced cardiac output and mean aortic valve gradient, patients from Cluster 2 were also characterized by signs of pulmonary hypertension, impaired right ventricular function, and right atrial enlargement. After training an extreme gradient boosting algorithm on these 101 patients, validation on the remaining 265 patients confirmed that patients assigned to Cluster 2 show increased mortality (HR for 2-year mortality: 2.6; 95% CI: 1.4-5.1, P-value: 0.004).

Conclusion

Transfer learning enables sophisticated pattern recognition even in clinical data sets of limited size. Importantly, it is the left ventricular compensation capacity in the face of increased afterload, and not so much the actual obstruction of the aortic valve, that determines fate after TAVR.

Life expectancy after aortic valve replacement in young patients

INTRODUCTION AND OBJECTIVES

In young patients with severe aortic stenosis, it is unknown whether their life expectancy restored after aortic valve replacement (AVR) is unknown.

METHODS

We analyzed all patients aged between 50 and 65 years who underwent isolated AVR in 27 Spanish centers during an 18-year period. We compared observed and expected survival at 15 years of follow-up. We repeated all analyses for patients without complications in the postoperative period.

RESULTS

A total of 5084 patients were analyzed. For the overall sample, observed survival at 10 and 15 years was 85.3% (95%CI, 84.1%-86.4%) and 73.7% (95%CI, 71.6%-75.6%), respectively. Expected survival was 90.1% and 82.1%. Cumulative relative survival for 1, 5, 10 and 15 years of follow-up was 97.4% (95%CI, 96.9%-97.9%), 96.5% (95%CI, 95.7%-97.3%), 94.7% (95%CI, 93.3%-95.9%), and 89.8% (95%CI, 87.3%-92.1%). For patients without complications, cumulative relative survival for 1, 5, 10 and 15 years was 100.3% (95%CI, 99.8%-100.5%), 98.9% (95%CI 97.6% -99.9%), 97.3% (95%CI, 94.9%-99.4%), and 91.9% (95%CI, 86.5%-96.8%).

CONCLUSIONS

Life expectancy in young patients who have severe aortic stenosis and undergo AVR is lower than that of the general population. Life expectancy of individuals without complications during the postoperative period is also reduced. Therefore, baseline characteristics are likely the main factors that explain the reduction in life expectancy.

Bioprosthetic valve failure. Comparative trial of two balloon-expandable transcatheter heart valve systems in intermediate-risk patients: a propensity score analysis

BACKGROUND

The comparative mid and long-term durability, including the rates of bioprosthetic valve failure (BVF) of the Sapien XT^® and Sapien 3^® transcatheter heart valve (THV) in patients with intermediate surgical risk has not been reported.

METHODS

Consecutive intermediate-risk patients with severe aortic stenosis from the Mexican registry of transcatheter aortic valve replacement (TAVR) with Sapien^® THVs were included. The primary endpoint was to compare the BVF rate between THVs at 2 years of follow-up. Secondary endpoints were comparisons of the composite of global mortality, cardiovascular mortality, and neurological events at 30 d and 24 months of follow-up.

RESULTS

During 2014-2019, 115 (60 Sapien XT^® and 55 Sapien 3^®) patients met the inclusion criteria in five medical centres. The mean age was 77.3 ± 8.4 years. The average Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) was 5.6 ± 2.9. There was no statistically significant difference between the groups in BVF rate. At 30 d, overall, cardiovascular and non-cardiovascular mortality was 4.3%, 2.6%, and 1.7%, respectively. Neurological events rate was 1.73%. The mean long-term follow-up was 25.3 ± 14.2 months with an overall mortality of 9.56% but lower for the Sapien 3^® group (15% vs. 3.6%, p=.037). The only independent predictor of composite mortality and neurological events that occurred in the long term was using a Sapien XT^® [OR 1.6, CI 95%, 1.0-24.9; p=.049].

CONCLUSIONS

The BVF rate at 25 months of follow-up was similar with the XT and S3 systems. During this follow-up period, the major composite events of death from any cause and neurological events were significantly lower with the S3 system.

Clinical, echocardiographic and prognostic outcomes of patients with concordant and discordant high-gradient aortic stenosis in an Asian cohort

Literature of patients with severe high-gradient aortic stenosis (HG AS) (mean pressure gradient [MPG] ≥ 40 mmHg and aortic valve area [AVA] ≥ 1.0 cm2) remains limited. This study seeks to compare the prognostic outcomes of patients with high-gradient concordant (HGCON-AS) and discordant AS (HGDIS-AS) in an Asian cohort. From 2010 to 2015, patients with moderate-to-severe AS with preserved left ventricular ejection fraction (LVEF ≥ 50%) were recruited and stratified into 3 groups based on index echocardiogram-(1) HGDIS-AS, (2) HGCON-AS and (3) moderate AS (MOD-AS). The primary study endpoints was all-cause mortality, with secondary endpoints of congestive heart failure (CHF) admissions and aortic valve replacement (AVR). Multivariable Cox regression was used and Kaplan-Meier curves were constructed to evaluate associations between HGDIS-AS, HGCON-AS and MOD-AS, and the study outcomes. A total of 467 patients were studied, comprising of 6.2% HGDIS-AS, 13.9% HGCON-AS and 79.9% MOD-AS patients. There was significantly higher AVR rates in the HGCON-AS group (58.5%), followed by HGDIS-AS (31.0%) and MOD-AS (4.6%), p < 0.001) groups. After adjusting for confounders, HGCON-AS was significantly associated with all-cause mortality (HR 3.082, 95% CI 1.479-6.420, p = 0.003) and CHF admissions (HR 12.728, 95% CI 2.922-55.440 p = 0.001) but not HGDIS-AS, with MOD-AS as the reference group. Both HGDIS-AS (HR 7.715, 95% CI 2.927-20.338; p < 0.001) and HGCON-AS (HR 21.960, 95% CI 10.833-44.515, p < 0.001) were independent predictors of AVR. After exclusion of reversible high-flow states, HGDIS-AS patients appear to have a more favourable prognostic profile compared to HGCON-AS patients. Large prospective interventional studies examining the prognostic differences between the two groups will be the next important step.

Annular size and interaction with trans-catheter aortic valves for treatment of severe bicuspid aortic valve stenosis: Insights from the BEAT registry

BACKGROUND

Transcatheter aortic valve replacement (TAVR) is safe and feasible in patients with bicuspid aortic valve (BAV), but whether annular size may influence TAVR results in BAV patients remains unclear. We aimed at evaluating the impact of aortic annular size on procedural and clinical outcomes of BAV patients undergoing TAVR, as well as potential interactions between annular dimension and trans-catheter heart valve (THV) type (balloon-expandable (BEV) vs. self-expanding (SEV).

METHODS

BEAT is a multicenter registry of consecutive BAV stenosis undergoing TAVR. For this sub-study patients were classified according to annular dimension in small-annulus (area < 400 mm² or perimeter <72 mm), medium-annulus (area ≥ 400 and < 575 mm², perimeter ≥72 mm and< 85 mm), large-annulus (area ≥ 575 mm² or perimeter ≥85 mm). Primary endpoint was Valve Academic Research Consortium-2 (VARC-2) device success.

RESULTS

45(15.5%) patients had small, 132(45.3%) medium, and 114(39.2%) large annuli. Compared with other groups, patients with large annuli were more frequently male, younger, with higher body mass index, larger aortic valve area, higher rate of moderate-severe calcification, lower mean trans-aortic valve gradient and lower left ventricular ejection fraction. In large-annuli SEVs were associated with a lower VARC-2 device success (75.9% vs. 90.6%, p = 0.049) driven by a higher rate of paravalvular valvular leak (PVL) compared to BEVs (20.7% vs. 1.2%, p < 0.001). However, no differences in clinical outcomes were observed according to annular size nor THV type.

CONCLUSIONS

TAVR in BAV patients is feasible irrespective of annular size. However in patients with large aortic annulus SEVs were associated with a significantly higher rate of PVLs compared to BEVs.

Early clinical outcomes after transaxillary versus transfemoral TAVI. Data from the Spanish TAVI registry

INTRODUCTION AND OBJECTIVES

Transaxillary access (TXA) has become the most widely used alternative to transfemoral access (TFA) in patients undergoing transcatheter aortic valve implantation (TAVI). The aim of this study was to compare total in-hospital and 30-day mortality in patients included in the Spanish TAVI registry who were treated by TXA or TFA access.

METHODS

We analyzed data from patients treated with TXA or TFA and who were included in the TAVI Spanish registry. In-hospital and 30-day events were defined according to the recommendations of the Valve Academic Research Consortium. The impact of the access route was evaluated by propensity score matching according to clinical and echocardiogram characteristics.

RESULTS

A total of 6603 patients were included; 191 (2.9%) were treated via TXA and 6412 via TFA access. After adjustment (n=113 TXA group and n=3035 TFA group) device success was similar between the 2 groups (94%, TXA vs 95%, TFA; P=.95). However, compared with the TFA group, the TXA group showed a higher rate of acute myocardial infarction (OR, 5.3; 95%CI, 2.0-13.8); P=.001), renal complications (OR, 2.3; 95%CI, 1.3-4.1; P=.003), and pacemaker implantation (OR, 1.6; 95%CI, 1.01-2.6; P=.03). The TXA group also had higher in-hospital and 30-day mortality rates (OR, 2.2; 95%CI, 1.04-4.6; P=.039 and OR, 2.3; 95%CI, 1.2-4.5; P=.01, respectively).

CONCLUSIONS

Compared with ATF, TXA is associated with higher total mortality, both in-hospital and at 30 days. Given these results, we believe that TXA should be considered only in those patients who are not suitable candidates for TFA.

Moderate gradient severe aortic stenosis: diagnosis, prognosis and therapy

Aortic stenosis (AS) is defined as severe in the presence of: mean gradient ≥40 mmHg, peak aortic velocity ≥4 m/s, and aortic valve area (AVA) ≤1 cm² (or an indexed AVA ≤0.6 cm²/m²). However, up to 40% of patients have a discrepancy between gradient and AVA, i.e. AVA ≤1 cm² (indicating severe AS) and a moderate gradient: >20 and <40 mmHg (typical of moderate stenosis). This condition is called ‘low-gradient AS’ and includes very heterogeneous clinical entities, with different pathophysiological mechanisms. The diagnostic tools needed to discriminate the different low-gradient AS phenotypes include colour-Doppler echocardiography, dobutamine stress echocardiography, computed tomography scan for the definition of the calcium score, and recently magnetic resonance imaging. The prognostic impact of low-gradient AS is heterogeneous. Classical low-flow low-gradient AS [reduced left ventricular ejection fraction (LVEF)] has the worst prognosis, followed by paradoxical low-flow low-gradient AS (preserved LVEF). Conversely, normal-flow low-gradient AS is associated with a better prognosis. The indications of the guidelines recommend surgical or percutaneous treatment, depending on the risk and comorbidities of the individual patient, both for patients with classic low-flow low-gradient AS and for those with paradoxical low-flow low-gradient AS.

Timing of aortic valve replacement in high-gradient severe aortic stenosis: impact of left ventricular ejection fraction

BACKGROUND

Patients with high-gradient (HG) severe aortic stenosis (AS) and left ventricular (LV) dysfunction are at high risk of death. The optimal timing for aortic valve replacement (AVR) is not defined by guidelines. The objective was to define the optimal timing to perform isolated AVR in patients with HG-AS and severe LV dysfunction.

METHODS

We retrospectively included 233 consecutive patients admitted for severe HG-AS (aortic valve area <1cm² and mean gradient ≥40mmHg). Severe LV dysfunction was defined by LV ejection fraction ≤35% (LVEF). All-cause mortality while waiting for AVR and after the intervention (30 days) was compared in patients with (n = 28) and without (n = 205) LVEF ≤35%.

RESULTS

Patients with HG-AS and severe LV dysfunction had a higher risk profile than those with LVEF >35%. AVR was performed in 93% (218/233) of patients, 41% by surgery (SAVR) and 53% by transcatheter (TAVR). TAVR was the preferred method to treat HG-AS patients with LVEF ≤35%. All-cause mortality while waiting for AVR was higher in patients with severe LV dysfunction (22% vs. 2.0%, p < 0.001) and occurred within a shorter time (12 [8-26] days vs. 63 [58-152] days, p = 0.010) compared to those with LVEF >35%. All death in HG-AS patients with a severe LV dysfunction occurred within the first month. Postoperative mortality was low (1.3%), irrespective of LVEF.

CONCLUSIONS

AVR should be performed promptly after Heart Team decision in patients with HG severe AS and LVEF ≤35% because of a very high and premature risk of death while waiting for intervention.

Percutaneous coronary intervention of complex calcific coronary lesions utilizing orbital atherectomy prior to transcatheter aortic valve replacement

BACKGROUND

Coronary artery disease (CAD), often with severe calcification, is present in up to 75% of patients with severe aortic stenosis (AS) referred for transcatheter aortic valve replacement (TAVR). Management of CAD in such patients is challenging. Orbital atherectomy (OA) is an effective treatment of severely calcified coronary lesions prior to stent implantation. However, there is limited data on the use of OA for percutaneous coronary intervention (PCI) to treat calcific CAD patients prior to TAVR (OA PCI + TAVR).

METHODS

Retrospective analysis of patients with moderate/severe calcific CAD and moderate/severe AS who underwent staged OA PCI + TAVR at one high-volume institution. Data were analyzed to assess the 1-year major adverse cardiac events after index OA PCI [MACE: death, target lesion revascularization (TLR), and myocardial infarction (MI)].

RESULTS

There were 18 patients (mean age of 82) treated with staged OA PCI + TAVR, and of those, 10 (56%) were male, 7 (39%) Caucasian, and 11 (61%) Hispanic/Latino. The average left ventricular ejection fraction was 49% and congestive heart failure was present in 12 patients (67%). There were no angiographic complications (0%), stent thrombosis (0%), or stroke events (0%). The 30-day and 1-year MACE rates were 5.6% (0% death, 0% TLR, 5.6% MI) and 17% (0% death, 11% TLR, and 17% MI [all non-Q-wave MI]), respectively.

CONCLUSIONS

In this single-center observational cohort series, patients with heavily calcified coronary lesions treated with OA prior to TAVR had low rates of MACE at 30 days and 1 year. The results demonstrate the feasibility and safety of OA for the treatment of complex calcific coronary lesions prior to TAVR. An up-to-date literature review of atherectomy before, during, or after TAVR in patients with concomitant severe AS and calcific CAD is also provided.

TABLE OF CONTENTS SUMMARY

There is limited data on the use of orbital atherectomy (OA) for percutaneous coronary intervention (PCI) to treat calcific coronary artery disease (CAD) patients prior to transcatheter aortic valve replacement (TAVR). Our primary aim was to evaluate the feasibility, safety, and 1-year outcome of OA PCI pre-TAVR in patients with complex CAD and severe aortic stenosis (AS). We also aimed to provide a brief up-to-date literature review of atherectomy before, during, or after TAVR in patients with concomitant severe AS and calcific CAD. This retrospective cohort study found that OA is feasible and safe for the treatment of severely calcified coronary lesions before TAVR, resulting in acceptable 30-day and 1-year outcomes.

Rapidly progressive aortic stenosis treated with transcatheter aortic valve implantation in a patient with Fabry disease: a case report

Background

Fabry disease (FD) is a rare lysosomal storage disease, caused by mutations in the gene encoding the enzyme α-galactosidase A (α-Gal A). Cardiac involvement is one of the main causes of death and it is characterized by progressive concentric left ventricular hypertrophy (LVH), which in most cases is symmetric. Mild thickening of the left-sided valves is seen in as many as a quarter of patients. Severe aortic stenosis is an extremely rare disorder in FD.

Case summary

In this report, we describe the case of a 57-year-old male, who was diagnosed with a cardiac variant of FD 10 years ago. Since the patient had severe LVH, he was started on enzyme replacement therapy when he was 47 years old with an intravenous infusion of 0.2 mg/kg of agalsidase alpha every 14 days. The patient remained stable and asymptomatic for 9 years, until he presented with dyspnoea in New York Heart Association functional class II-III and severe aortic stenosis (aortic valve area: 0.97 cm²) together with severe systolic dysfunction [ejection fraction (EF): 29%]. Because of the patient's comorbidities and high surgical risk, he underwent successful transfemoral transcatheter aortic valve implantation (TAVI). At 2 months following TAVI, the patient was asymptomatic and, in spite of his Fabry cardiomyopathy, the EF had increased to 45%.

Discussion

To our knowledge, this is the first case in the literature to demonstrate a rapid progression of aortic stenosis with severe impairment of left ventricular function and worsening in functional class in a patient with FD, who following TAVI improved his EF, with disappearance of symptoms and ventricular arrhythmias.

Exercise Training for Patients With Severe Aortic Stenosis in a Convalescent Rehabilitation Ward - A Retrospective Cohort Study

Background: Exercise loading is contraindicated for patients with severe aortic stenosis (AS); however, everyday activities mandate the inclusion of a light load. The aim of this study was to investigate the efficacy and safety of exercise training for patients with severe AS who were admitted to a rehabilitation ward because of physical disability. Methods and Results: This historical cohort study was conducted at a single rehabilitation center in Japan. Patients admitted for rehabilitation of physical disability and those who met the definition of severe AS were analyzed. An exercise training program was implemented for patients with disability and severe AS. Cardiovascular symptoms during hospitalization were evaluated. Improvements in the performance of activities of daily living were assessed using the Functional Independence Measure (FIM). Eighteen patients undertook an exercise training program. The median patient age was 87 years (range 76-95 years). Of these patients, 3 died and another 3 were transferred to another hospital due to causes other than the exercise training program. None of the other patients experienced cardiovascular symptoms, and the FIM scores of 12 patients were significantly improved (median [range] scores at admission and discharge of 63 [32-88] and 87 [51-104], respectively; P<0.001). Conclusions: An exercise training program could be applied to patients with severe AS who were admitted for convalescent rehabilitation, because it can improve FIM scores.

Is preoperative balloon aortic valvuloplasty of interest for severe aortic stenosis in hip fracture surgery?

PURPOSE

In elderly patients, the discovery and management of a severe aortic stenosis (AS) prior to emergency non-cardiac surgery is a frequent and controversial issue. The objective of this study was to evaluate preoperative balloon aortic valvuloplasty (BAV) for severe AS in hip fracture surgery.

METHODS

We conducted an observational, monocentric, retrospective study from 2011 to 2018. Survival (30-day, 90-day and 180-day mortality) and the occurrence of perioperative complications were analyzed and compared between control (i.e. no BAV prior to surgery) and preoperative BAV groups in patients with hip fracture surgery and a formal transthoracic echocardiographic diagnosis of severe AS (aortic valve area < 1 cm²). Patients' allocation to the intervention and control groups was after a discussion between cardiologist, anesthesiologist and the surgeon.

RESULTS

Among the 8506 patients who underwent hip fracture surgery, 29 patients in the control group and 30 patients in the BAV group were finally included. Kaplan-Meier survival analysis demonstrated a significant decrease in mortality in the BAV group (p=0.014) despite an increase in median time to operation of about 48 hours (p<0.0001). Multivariate analysis (stepwise logistic regression) showed that postoperative delirium (OR [95%CI]: 17.5 [1.8-168]; p=0.013) and postoperative acute congestive heart failure (OR [95%CI]: 59.4 [5.0-711.1]; p=0.0013) were predictive factors of 30-day mortality with an area under ROC curve of 0.90 (95%CI: 0.80-0.97; p<0.0001).

CONCLUSIONS

preoperative BAV for severe AS could reduce the mortality of hip fracture patients despite an increase in time to operation. This improved survival could be linked to the decrease in cardiologic and neurologic adverse events. A larger prospective randomized study is necessary before generalizing our results.

Predictors of calcification distribution in severe tricuspid aortic valve stenosis

We investigated aortic valve calcification (AVC) distribution and predictors for leaflet calcification patterns in patients with severe tricuspid aortic valve stenosis undergoing transcatheter aortic valve replacement (TAVR). Patients undergoing routine multi-sliced computed tomography (MSCT) for procedural planning were enrolled. MSCT data were transferred to a dedicated workstation for evaluation (3mensio Structural Heart™, Pie Medical Imaging BV, Maastricht, The Netherlands) and analyzed. Participants were separated into asymmetrical (AC) and symmetrical (SC) leaflet calcification and potential predictors for calcification distribution were identified with univariate and multivariate regression analysis. 567 Participants with severe tricuspid AS were divided into asymmetrical (AC, n = 443; 78.1%) and symmetrical (SC, n = 124; 21.9%) AVC. In AC, the non-coronary cusp was the most calcified cusp (n = 238; 57.7%). SC is more common in females (AC/SC: 49.2% vs. 67.7%; p < 0.0001). AVC was more severe in patients with AC, who also have larger aortic root dimensions. Multivariate analysis depicted, inter alia, left ventricular outflow tract (LVOT) calcification < 25 Agatston units (OR 1.81 [1.09-3.00], p = 0.021), a mean pressure gradient < 36 mmHg (OR 1.77 [1.03-3.05], p = 0.039), and an annulo-apical angle > 67° (OR 1.68 [1.00-2.80], p = 0.049) as predictors for SC, although with only moderate predictive value. Data from this retrospective analysis indicate that SC occurs more frequently in females. The cumulative leaflet calcification burden is higher in patients with AC, who also present with larger aortic root dimensions. The predictive value for prominent calcification of different aortic valve cusps in AC patients was only low to moderate.Trial registration number: NCT01805739.

A risk prediction model in asymptomatic patients with severe aortic stenosis: CURRENT-AS risk score

AIMS

Early aortic valve replacement (AVR) might be beneficial in selected high-risk asymptomatic patients with severe aortic stenosis (AS), considering their poor prognosis when managed conservatively. This study aimed to develop and validate a clinical scoring system to predict AS-related events within 1 year after diagnosis in asymptomatic severe AS patients.

METHODS AND RESULTS

We analysed 1274 asymptomatic severe AS patients derived from a retrospective multicentre registry enrolling consecutive patients with severe AS in Japan (CURRENT AS registry), who were managed conservatively and completed 1-year follow-up without AVR. From a randomly assigned derivation set (N = 849), we developed CURRENT AS risk score for the AS-related event (a composite of AS-related death and heart failure hospitalization) within 1 year using a multivariable logistic regression model. The risk score comprised independent risk predictors including left ventricular ejection fraction <60%, haemoglobin ≤11.0 g/dL, chronic lung disease (2 points), diabetes mellitus, haemodialysis, and any concomitant valve disease (1 point). The predictive accuracy of the model was good with the area under the curve of 0.79 and 0.77 in the derivation and validation sets (N = 425). In the validation set, the 1-year incidence of AS-related events was much higher in patients with score ≥2 than in patients with score ≤1 (Score 0: 2.2%, Score 1: 1.9%, Score 2: 13.4%, Score 3: 14.3%, and Score ≥4: 22.7%, P < 0.001).

CONCLUSION

The CURRENT-AS risk score integrating clinical and echocardiographic factors well-predicted the risk of AS-related events at 1 year in asymptomatic patients with severe AS and was validated internally.

Differences in life expectancy between men and women after aortic valve replacement

 

OBJECTIVES

Some researchers have observed an increased number of deaths during the follow-up of young patients who undergo aortic valve replacement due to severe aortic stenosis, suggesting that this procedure does not restore their life expectancy. Our goal was to confirm these findings and explore sex-based differences.

METHODS

All patients between 50 and 65 years of age who underwent isolated aortic valve replacement in 27 Spanish centres during an 18-year period were included. We compared observed and expected survival at 15 years of follow-up and estimated the cumulative incidence of death from a competing risks point of view. We stratified by sex and analysed if being a woman was an independent risk factor for death.

RESULTS

For men, the observed survival at 10 and 15 years of follow-up was 85% [95% confidence interval (CI) 83.6%-86.4%] and 72.3% (95% CI 69.7%-74.7%), respectively whereas the expected survival was 88.1% and 78.8%. For women, the observed survival at 10 and 15 years was 85% (95% CI 82.8%-86.9%) and 73% (95% CI 69.1%-76.4%), whereas the expected survival was 94.6% and 89.4%. At 15 years of follow-up, the cumulative incidence of death due to the disease in men and women was 8.2% and 16.7%, respectively. In addition, being a woman was an independent risk factor for death (hazard ratio = 1.23 (95% CI 1.02-1.48; P = 0.03).

CONCLUSIONS

After the aortic valve replacement, men and women do not have their life expectancy restored, but this loss is much higher in women than in men. In addition, being a woman is a risk factor for long-term death. Reasons for these findings are unknown and must be investigated.

Augmentation index predicts mortality in patients with aortic stenosis: an echo-tracking study

Aortic valve stenosis (AS) shares similarities with the atherosclerotic process but little is known about the effect of the mechanical properties of large arteries on outcome in patients with AS. The aims of this study were (1) to determine the relationship between indexes of carotid stiffness/compliance and the severity of AS and (2) to identify whether local arterial stiffness is independently associated with mortality. 133 patients with moderate to severe isolated AS and preserved LV ejection fraction (LVEF) were included. All underwent transthoracic echocardiography and local carotid stiffness evaluation by means of high-definition echo-tracking ultrasound with the calculation of stiffness/compliance parameters included augmentation index (AIx). None of the carotid stiffness parameters were significantly associated with AS severity parameters. During a mean follow-up of 51.6 ± 39.4 months, 70 patients received aortic valve replacement, 45 died and 18 were alive with no surgery. Who died were older (79.2 ± 6.9 vs. 73 ± 8.8 years, p < 0.0001), had higher carotid AIx (21.3 ± 14 vs. 16 ± 12%, p = 0.028). In multivariate Cox regression analysis AIx was independently associated with mortality (HR 1.048, 95% CI 1.01-1.07, p = 0.001), also after inclusion of age and creatinine. There was a significant association between the level of AIx and mortality in those patients who did not have surgery (p = 0.016). In severe AS and a normal LVEF, carotid AIx measured by echo-tracking system was independently associated with death. No relationship between AS severity and local carotid stiffness was found. These data emphasize the importance of arterial stiffness has a hallmark of long-term atherosclerotic burden and impaired prognosis.

Vaginal delivery in a patient with severe aortic stenosis under epidural analgesia, a case report

BACKGROUND

A history of previous cardiac disease increases the maternal mortality risk by as much as 100%. There is no consensus on the absolute contraindications to vaginal delivery in valvular heart disease, but central regional anesthesia is traditionally considered contraindicated in patients with severe aortic stenosis.

CASE PRESENTATION

A 29-year-old primigravid woman with severe aortic stenosis was admitted to the obstetrics department for programmed labor induction. With epidural anesthesia and mini-invasive hemodynamic monitoring labor and operative vaginal delivery were well tolerated, and hemodynamic stability was always maintained.

CONCLUSIONS

Epidural analgesia and oxytocin induction are possible for the labor management of parturients with severe aortic stenosis given that continuous non-invasive followed by invasive hemodynamic monitoring can be provided and given the absence of any obstetric or cardiologic contraindications and the strong will of the patient.

Procedural and clinical outcomes of type 0 versus type 1 bicuspid aortic valve stenosis undergoing trans-catheter valve replacement with new generation devices: Insight from the BEAT international collaborative registry

BACKGROUND

Although bicuspid aortic valve (BAV) is not considered a "sweet spot" to trans-catheter aortic valve replacement (TAVR), a certain number of BAV underwent TAVR. Whether BAV phenotype affects outcomes following TAVR remains debated. We aimed at evaluating the impact of BAV phenotype on procedural and clinical outcomes after TAVR using new generation trans-catheter heart valves (THVs).

METHODS

patients included in the BEAT registry were classified according to the BAV phenotype revealed at multi-slice computed tomography (MSCT) in type 0 (no raphe) vs. type 1 (1 raphe). Primary end-point was Valve Academic Research Consortium-2 (VARC-2) device success. Secondary end-points included procedural complications, rate of permanent pacemaker implantation, clinical outcomes at 30-day and 1-year.

RESULTS

Type 0 BAV was present in 25(7.1%) cases, type 1 in 218(61.8%). Baseline characteristics were well balanced between groups. Moderate-severe aortic valve calcifications at MSCT were less frequently present in type 0 vs. type 1 (52%vs.71.1%,p = 0.05). No differences were reported for THV type, size, pre and post-dilation between groups. VARC-2 success tended to be lower in type 0 vs. type 1 BAV (72%vs86.7%;p = 0.07). Higher rate of mean transprosthetic gradient ≥20 mmHg was observed in type 0 vs. type 1 group (24%vs6%,p = 0.007). No differences were reported in the rate of post-TAVR moderate-severe aortic regurgitation and clinical outcomes between groups.

CONCLUSIONS

Our study confirms TAVR feasibility in both BAV types, however a trend toward a lower VARC-2 device success and a higher rate of mean transprosthetic gradient ≥20 mmHg was observed in type 0 vs. type 1 BAV.

Transcatheter aortic valve-in-valve post-dilatation as an overlooked risk factor of delayed coronary obstruction: a case report

Background

The risk of coronary obstruction during transcatheter aortic valve-in-valve replacement (VIV-TAVR) in patients deemed at high risk for surgical re-intervention is still a concerning issue.

Case summary

A 78-year-old woman with a past medical history of hypertension, chronic kidney disease, and rheumatoid arthritis was referred for a symptomatic and severely stenotic surgical Mitroflow n.21 bio-prosthesis and was subsequently recommended for a VIV procedure. Multiple anatomical risk factors for coronary occlusion required a pre-emptive coronary chimney stenting protection. The implantation of an Evolut-R 23 mm valve resulted in a gradient of 21 mmHg thus, a post-dilatation with an 18 mm balloon was performed. Both electrocardiographic and haemodynamic parameters remained excellent, however, a hazardous leaflet dislodgment became evident. Regardless, a prophylactic chimney stenting was performed because of the operator’s perceived high risk of late coronary occlusion.

Discussion

The implantation of transcatheter valves inside failed surgically implanted aortic bio-prosthesis is broadly recognized as a safe and less-invasive alternative to repeated high-risk surgery. Although procedural success is achieved in the great majority of patients, this therapy may be jeopardized by rare but serious complications such as impending or established acute coronary occlusion. Several specific anatomical and procedural risk factors have been identified and primary coronary prevention strategies are often mandatory when they arise. Valve-in-valve post-dilation has been overlooked in its role as an additional risk factor of late coronary obstruction. Therefore, chimney stenting, performed after balloon post-dilation to prevent delayed coronary obstruction, even if the acute coronary event does not occur intra-procedurally, is strongly advisable.

Aortic annular dimensions by non-contrast MRI using k-t accelerated 3D cine b-SSFP in pre-procedural assessment for transcatheter aortic valve implantation: a technical feasibility study

To evaluate k-t accelerated 3D cine b-SSFP (balanced steady state free precession) as magnetic resonance imaging (MRI) technique for aortic annular area measurement in transcatheter aortic valve replacement (TAVR) planning compared to computed tomography angiography (CTA) and other non-contrast MRI sequences with reduced imaging time and without contrast administration. 6 volunteers and 7 TAVR candidates were prospectively enrolled. The volunteers underwent an MRI while TAVR candidates underwent an MRI and CTA. The following non-contrast MRI sequences were obtained at the level of the aortic root: 2D cine b-SSFP [GRAPPA (GeneRalized Autocalibrating Partially Parallel Acquisitions), R = 2], 3D cine b-SSFP [GRAPPA R = 2], navigator triggered 3D b-SSFP MRA [GRAPPA, R = 2] and k-t accelerated 3D cine b-SSFP [PEAK GRAPPA, R = 5]. Qualitative analysis and aortic annular area measurements in systole and diastole were obtained. k-t accelerated 3D cine b-SSFP provided image quality that is acceptable for confident diagnosis with very good interrater agreement. There was no statistically significant difference in aortic annular measurements between k-t accelerated 3D cine b-SSFP and CTA or other MRI sequences (p > 0.05). Bland-Altman analysis showed no systemic difference of annular area measurements between k-t accelerated 3D cine b-SSFP and each of the other techniques. There was excellent inter-rater agreement on aortic annular area measurements during systolic (ICC = 0.976, p < 0.001) and diastolic (ICC = 0.971, p < 0.001) phases using k-t accelerated 3D cine b-SSFP. K-t accelerated 3D cine b-SSFP is a promising alternative for the assessment of annular sizing in pre-TAVR evaluation while offering a reasonable combination of imaging parameters during one breath-hold.

Successful Transfemoral Transcatheter Aortic Valve Replacement in a Patient with Double Aortic Arch: An Interesting Imaging Case

Transcatheter aortic valve replacement (TAVR) has become a mainstay of treatment in the management of severe aortic stenosis. It is a challenging procedure that requires expertise in obtaining proper access, delivery of catheters to and beyond the aortic valve, and finally accurate deployment of the aortic bioprosthesis. Patients with aortic anomalies portend an added challenge in performing TAVR procedures. We present the case of a patient incidentally found to have a right dominant double aortic arch who underwent successful TAVR for severe aortic stenosis.

Unveiling outcomes in coexisting severe aortic stenosis and transthyretin cardiac amyloidosis

AIMS

Advances in diagnostic imaging have increased the recognition of coexisting transthyretin cardiac amyloidosis (ATTR-CA) and severe aortic stenosis (AS), with a reported prevalence between 8-16%. In this prospective study, we aimed to evaluate the implications of ATTR-CA on outcomes after transcatheter aortic valve replacement (TAVR).

METHODS AND RESULTS

At two academic centres, we screened patients with severe AS undergoing TAVR for ATTR-CA. Using Kaplan-Meier analysis, we compared survival free from death and a combined endpoint of death and first heart failure hospitalization between patients with and without ATTR-CA. Cox proportional-hazards models were used to determine the association of ATTR-CA with these endpoints. The rate of heart failure hospitalization was compared amongst those with and without ATTR-CA. Overall, 204 patients (83 years, 65% male, Society of Thoracic Surgeons score 6.6%, 72% New York Heart Association class III/IV) were included, 27 (13%) with ATTR-CA. Over a median follow-up of 2.04 years, there was no difference in mortality (log rank, P = 0.99) or the combined endpoint (log rank, P = 0.79) between patients with and without ATTR-CA. In Cox proportional-hazards models, the presence of ATTR-CA was not associated with death. However, patients with ATTR-CA had increased rates of heart failure hospitalization at 1 year (0.372 vs. 0.114 events/person-year, P < 0.004) and 3 years (0.199 vs. 0.111 events/person-year, P = 0.087) following TAVR.

CONCLUSION

In moderate-risk patients with severe AS undergoing TAVR, there was a 13% prevalence of ATTR-CA, which did not affect mortality. The observed increase in heart failure hospitalization following TAVR in those with ATTR-CA suggests the consequences of the underlying infiltrative myopathy.

Survival in elderly patients with transcatheter aortic valve implants compared with the general population

INTRODUCTION AND OBJECTIVES

Severe symptomatic aortic stenosis carries a very poor prognosis. Transcatheter aortic valve replacement has been demonstrated to change the natural history of the disease. However, it is not known whether the probability of survival in older patients receiving this treatment returns to a similar value to that in the general population. Our objective was to determine survival in these patients vs that in the general population.

METHODS

We retrospectively analyzed the survival curves of patients older than 75 years who underwent transcatheter aortic valve implantation (TAVI) at our hospital and compared them with those in the general population of the same age, sex, and geographic region by using data from the Spanish National Institute of Statistics.

RESULTS

We analyzed 526 patients. Among postoperative survivors, survival curves were similar between the 2 groups during most of the follow-up. In TAVI patients, the probability of survival at 1, 3, 5, and 8 years of follow-up was 90.58% (confidence interval [CI] 95%, 87.54-92.91), 72.51% (95%CI, 67.38-76.97), 53.23% (95%CI, 46.52-59.48), and 35.73% (95%CI, 27.72-43.80). In the reference population, these percentages were 91.93%, 75.63%, 59.6%, and 37.47%.

CONCLUSIONS

Long-term survival in elderly patients undergoing TAVI is influenced by postoperative mortality. In patients surviving the postoperative period, the probability of survival returns to a similar value to that in the general population of the same age, sex, and geographical area.