Annular Rupture Research Articles

Transcatheter aortic valve replacement with the balloon-expandable SAPIEN 3 valve: Impact of calcium score on valve performance and clinical outcomes

BackgroundAortic valve calcification severity has been associated with higher rates of aortic regurgitation (AR) following TAVR, but scarce data exist on its impact with the use of newer generation transcatheter heart valves. MethodsThis was a multicenter study including 626 patients with severe aortic stenosis who underwent TAVR with the SAPIEN 3 valve. Patients were divided in 2 groups according to the median index calcium score (iCS) for each sex: high CS (HCS, iCS ≥ median), and low iCS (LCS, iCS < median). Another analysis was performed in those patients with extreme iCS (ECS, iCS >75th percentile for each sex). Clinical and echocardiographic data were collected prospectively in a dedicated database. ResultsThe mean CS was 3758 ± 1417 AU and 1616 ± 691 AU in the HCS and LCS groups, respectively (p < 0.001). There were no differences between groups in 30-day mortality (HCS:2.6%, LCS:1.0%, p = 0.13) and stroke (HCS:2.6%,LCS:2.6%, p = 1.0) rates, but all cases (n = 5) of annulus rupture occurred in the HCS group (1.6% vs. 0%, p = 0.061). The incidence of moderate-severe AR post-TAVR was low in both groups (HCS:1.6%,LCS:1.6%, p = 1.0), and valve gradient and area were similar between groups. The results remained similar in the ECS group (mean CS:4607 ± 1424 AU), but a mildly increased mean transvalvular gradient post-TAVR was observed in ECS patients (12.1 ± 5.6 vs 11.0 ± 4.3 mmHg; p = 0.015). ConclusionAortic valve calcification severity failed to impact mortality/stroke rates following TAVR with the SAPIEN 3 valve. Low rates of significant AR were observed irrespective of CS, and a mild increase in transvalvular gradient was observed in ECS patients.

Transcatheter Aortic Valve-in-Valve Implantation Complicated by Aorto-Right Ventricular Fistula

We describe the case of a degenerative, sutureless bioprosthetic valve (BPV) with deformation and stent infolding in a patient with elevated surgical risk. Following discussion among the heart team, balloon valve fracture was performed to facilitate deployment of an aortic valve-in-valve transcatheter heart valve. Post-procedural imaging demonstrated BPV frame protrusion and contained annular rupture, which required operative intervention. (Level of Difficulty: Intermediate.)

807 Comparison of 30-Day Outcomes Between Balloon-Expandable and Self-Expanding Transcatheter Heart Valves in Patients With Moderate or Severe Device Landing Zone Calcification

Patients undergoing TAVI who have a significant volume of calcium at the device landing zone (DLZ) have been shown to have a high risk of death, annular rupture and paravalvular leak. Self-expanding (SE) valves have predominantly been used in this patient cohort due to a perceived reduced risk of annular rupture. A recently published propensity-matched cohort study of the French TAVI registry suggested that balloon expanding valves have lower rates of device related complications. A retrospective study comparing 30-day TAVI outcomes between balloon-expandable (BE) and SE valves in patients with moderate or severe device landing zone calcification (DLZC) as defined by SCCT guidelines. The endpoint was a composite of death, stroke, >mild PVL, urgent surgery, annular rupture or second valve deployed. A total of 120 patients (Mean age 82.3±9.2 with 46.7% female) with moderate or severe DLZC were included. 16.7% (20) patients were treated with SE valves. 35% (7/20) of SE valves were post dilated. BE valves had a lower 30-composite endpoint (BE 10% vs SE 45%, p<0.0001). 27 of the 120 patients (22.5%) had severe DLZC. In severe DLZC, the composite endpoint in both groups increased: BE valves 15.8% (3/19); SE valves 50% (4/8). No difference in pacemaker rates was observed. This is the first comparison of TAVI valves in moderate or severely calcified device landing zones. Balloon expandable valves were found to provide a lower rate of early valve related complications than self-expanding valves. This supports recent registry findings however, randomised data is needed.

P1718 Multi-modal imaging characterization of contained aortic subannular rupture after transcatheter aortic valve implantation

Abstract INTRODUCTION Aortic annular rupture is a potentially catastrophic complication after transcatheter aortic valve implantation (TAVI), with an estimated incidence of 1%. Rupture occurs in the anatomical device landing zone, that extends from the aortic root to the distal left ventricular outflow tract (LVOT). It usually occurs in the context of highly calcified aortic valve and LVOT, implantation of balloon-expandable valves, valve oversizing and overdilation to treat paravalvular leakage. CASE REPORT An 80-year old woman with no past relevant medical history was admitted to our Cardiology Department with decompensated heart failure because of symptomatic severe aortic stenosis, moderate aortic regurgitation and mild left ventricular (LV) dysfunction. She was already in waiting list for TAVI procedure, after being refused for conventional aortic valve replacement due to a "porcelain" aorta. Her pre-operative angiography showed no significant coronary heart disease, and the cardiac computed tomography (cardiac-CT) revealed a severely calcified aortic valve (Agatston score = 4940). An Acurate neo L (27mm) valve was implanted after clinical stabilization with no immediate complications. Because of paravalvular regurgitation, sequential post-dilation was performed with 25mm and 26mm balloons. Post-procedural angiography showed no contrast extravasation (Panel A). In the first hours after the procedure, she was hypotensive with non-specific mild chest discomfort. The EKG showed sinus rhythm with left anterior fascicular block. A transthoracic echocardiogram revealed a moderate pericardial effusion, with no signs of tamponade, and a moderate "paravalvular leak "at the level of the non-coronary cusp to a pulsatile cavity, between the aortic root and the left atrium (Panel B and C). The patient evolved with haemodynamic and electrical stability with no recurrence of chest discomfort. A retrospective cardiac-CT was performed that confirmed the presence of a multilobular cavity below the left coronary artery in continuous with the LVOT, compatible with a contained subannular aortic rupture (Panel E and F), at the level of previous gross calcification in the pre-operative cardiac-CT (Panel D). The case was discussed in Heart Team and a conservative strategy was adopted due to clinical stability and inoperable condition. The patient was discharged at day 28, after CT reavaluation,, that demonstrate similar findings. CONCLUSION We report a rare and potentially fatal complication of TAVI with a self-expandable valve. This clinical case illustrates how balloon post-dilation to treat moderate post-procedural paravalvular regurgitation lead to tearing of a highly calcified aortic annulus. A multi-modality imaging approach, with echocardiography and computer tomography, was essential for full anatomical definition of the subannular rupture, clinical decision-making and for follow-up surveillance. Abstract P1718 Figure. Panel A,B,C,D,E,F.

Intrathoracic complications associated with trans-femoral transcatheter aortic valve replacement: Implications for emergency surgical preparedness.

Intrathoracic complications (ITC) requiring emergency surgical intervention occur during transcatheter aortic valve replacement (TAVR). Characterize the incidence, outcomes and predictors of ITC in a large cohort of transfemoral (TF) TAVR cases over a 5 year period. Retrospective registry and chart review of all nonclinical trial TF-TAVR patients from seven centers within one hospital system from 2012-2016. ITC were defined as cardiac perforation, new or worsening pericardial effusion/tamponade, annular rupture, thoracic aortic injury, aortic valve dislodgement, and coronary artery occlusion. Procedural and 30-day outcomes and 1-year mortality were compared between ITC and no ITC patients. Multivariable logistic regression was used to identify predictors of ITC. Over the study period, 1,581 patients had TF-TAVR and 68 ITC occurred in 46 patients (2.9%). The most common ITCs were pericardial effusion/tamponade (59%), cardiac perforation (33%), and valve dislodgement (33%). ITC rate did not decline over time (rate (95% confidence interval) for 2012 = 0% (0-8.8%), 2013 = 1.3% (0-7.2%), 2014 = 4.4% (2.2-8.0%), 2015 = 3.5% (2.0-5.6%), and 2016 = 2.4% (1.5-3.8%)). ITC patients had worse 1-year survival (ITC: 60.7% (45.1-73.1%), no ITC: 88.7% (87.0-90.3%); p < .001). The majority of ITC patient deaths occurred within the first 30 days. Multivariable models to predict ITC were not successful. ITC did not decline over time in our cohort. Predictors of ITC could not be identified. While these events are rare, they are associated with worse procedural outcomes and mortality. Heart teams should continue to be prepared for emergency intervention.

Safety and effectiveness of a transaortic approach for TAVI: procedural and midterm outcomes of 265 consecutive patients in a single centre.

Transcatheter aortic valve implantation with a transaortic approach (TAo-TAVI) is an alternative to transapical or femoral access. We studied the procedural and midterm efficacy and safety of TAo-TAVI with Edwards Sapien XT and Medtronic CoreValve devices. Among 901 patients receiving TAVI since 2006, 265 consecutive patients underwent TAo-TAVI between January 2011 and September 2014. Procedural and midterm results were evaluated according to Valve Academic Research Consortium-2 criteria. The mean age was 83 ± 5 years. Sapien XT and CoreValve were used in 191 (72.1%) and 74 (27.9%) patients, respectively. Full sternotomy made elective concomitant off-pump coronary artery bypass grafting possible in 38 patients (14.3%) with severe coronary artery disease unsuitable for percutaneous coronary intervention. The device success rate was 95.5%. Postprocedural paravalvular leak ≥2/4 was observed in 16 patients (6.4%). Emergency open chest surgery was required in 10 patients (3.8%) (3 aortic dissections, 3 valve embolizations, 2 LMCA occlusions, 1 aortic annulus rupture and 1 aortic rupture). Cerebrovascular accidents occurred in 3 patients (1.1%). Transfusions ≥4 units were required in 36 patients (13.6%). New pacemakers were implanted in 26 patients (9.8%). Thirty-day and 1-year mortality were 8.7% and 16.2%, respectively. Mean follow-up duration was 24 ± 6 months. At 3 years, freedom from all-cause death was 80% ± 4%. New York Heart Association class <III included 81% (n = 172) of patients alive and without prosthetic echocardiographic dysfunction at follow-up (mean gradient 10.5 ± 5.6 mmHg). The TAo-TAVI approach confirms its safety and effectiveness with satisfactory procedural and midterm outcomes with both currently available devices.

Effect of sIL-13R\u03b12-Fc on the progression of rat tail intervertebral disc degeneration

BackgroundThe incidence of degenerative disc disease caused by intervertebral disc injury is increasing annually, seriously affecting the quality of life of patients and increasing the disease burden on society. The mechanisms of intervertebral disc degeneration include changes in extracellular matrix (ECM) deposition and tissue fibrosis. sIL-13Rα2-Fc potently inhibits interleukin (IL)-13, as well as blocks related cell signaling pathways and inhibits fibrosis in certain tissues. However, it is unknown whether sIL-13Rα2-Fc inhibits fibrosis in injured intervertebral discs and slows the process of degeneration. We hypothesized that sIL-13Rα2-Fc delays the progression of intervertebral disc degeneration by inhibiting intervertebral disc fibrosis and improving ECM deposition.MethodsA rat tail intervertebral disc degeneration model was established. Pathological changes in rat intervertebral disc tissue were observed by hematoxylin and eosin staining and Masson staining. Glycosaminoglycan (GAG), chondroitin sulfate (CS), keratan sulfate (KS), and hyaluronic acid (HA) contents were quantitatively analyzed by enzyme-linked immunosorbent assay. Type I and type II collagen expression levels were analyzed by reverse transcription-PCR and western blotting.ResultsHematoxylin and eosin staining and Masson staining revealed annulus fibrosus rupture, disordered arrangement, decreased nucleus pulposus tissue, and decreased collagen fiber in the rat intervertebral disc tissue. Following treatment with sIL-13Rα2-Fc, pathological changes in the rat intervertebral disc were reduced. Rat intervertebral disc tissue showed decreased GAG, CS-KS, and (HA) contents, increased type I collagen levels, and decreased type II collagen levels in degenerated intervertebral discs. sIL-13Rα2-Fc intervention increased the contents of GAG, CS, KS, and HA; inhibited the expression of type I collagen; and promoted the expression of type II collagen.ConclusionThese results demonstrate that intervertebral disc degeneration is associated with tissue fibrosis. sIL-13Rα2-Fc can regulate type I and type II collagen expression levels by increasing GAG, CS, KS, and HA contents, thereby slowing the progression of intervertebral disc degeneration.

Routine Left Ventricular Pacing for Patients Undergoing Transcatheter Aortic Valve Replacement

ABSTRACT Background : Rapid ventricular pacing is often required during transcatheter aortic valve replacement (TAVR) procedures. Pacing via the retrograde left ventricular guidewire (LV-GW) is an alternative strategy to conventional pacing using a right ventricular temporary pacing wire (RV-TPW). We report our single center experience with this strategy. Methods : Two-hundred twenty-six patients who underwent transfemoral TAVR using pacing via LV-GW were included in this retrospective observational study. Results : LV-GW pacing was successful in 224 (99%) of the cases. In two (1%) patients, a RV-TPW was inserted after attempted LV-GW pacing because of stimulation failure (n = 1) or instability (n = 1). Procedural TAVR success was obtained in 94.7% of the cases. Procedural complication rate was low and included 2.7% vascular complications, 0.9% unsuccessful valve deployment and 3.1% in-hospital death. Pericardial effusion requiring intervention occurred in three (1.3%) cases and was related to LV perforation (0.9%) and annular rupture (0.4%). As expected, no case of RV perforation was observed. Conclusions : Pacing using LV-GW is a valuable alternative to RV-TPW for TAVR procedures. This avoids the need for an RV-TPW placement and reduces the risk of cardiac tamponade from RV perforation.

Preoperative evaluation of transcatheter aortic valve replacement with assistance of 3D printing technique: Reanalysis of 4 death cases

IntroductionTranscatheter aortic valve replacement (TAVR) can have some fatal complications during and after the operation. Until recently, pre-procedural imaging with cardiac computed tomography (CT), which is required to evaluate for TAVR, had its own imperfections. We aimed to determine whether 3D printed models can predict complications when other pre-procedural imaging techniques failed. MethodsVascular center patients with aortic valve stenosis, who died after TAVR between June 2011 and June 2016, were enrolled in this retrospective study. The CT datasets of the patients were imported into a three-dimensional (3D) construction software and then printed by flexible material. To predict complications during and after operations, we designed a release test using the non-valved stent mode that was consistent with the Edwards Sapien XT valve in size and radial support force. ResultThe 3D model predicted the coronary obstruction and annular rupture in the in vitro release process, which was consistent with what happened in the actual operation. ConclusionThree-dimensional modeling facilitates pre-operative assessment of patients receiving TAVR, with accurate simulation of intraoperative status.

Implications médicolégales de l’implantation transcathéter de la valve aortique (TAVI)

Compassionally reserved for inoperable patients in 2002, Transcatheter Aortic Valve Implantation has now a place almost equivalent to surgical valve replacement. The pioneering teams first succeeded in demonstrating a benefit on the mortality of extremely serious patients, while managing a learning curve that seemed unreachable without a strong partnership with cardiac surgeons. This win/win challenge enabled cardiologists to surpass the limits they did not dare to brave (management of large arterial approach, annular rupture and tamponade) and surgeons to appropriate the endovascular's culture. The technological contribution, the maturity of the teams and the expansion to less severe populations have reduced the perioperative mortality of TAVI to less than 3%. At this stage, it seemed interesting to take stock of forensic developments around this technique. After a review of the studies and the healthcare requirements, we reported and analyzed the claims received from one of the leaders of the medical insurance in France. From this feedback, attempts will be made to identify ways of improving the prevention and subsequent treatment of complications, which will undoubtedly limit the risk of subsequent complaints.

94Course of contained annulus ruptures after TAVI: the ENCORE (European contained rupture)-registry

Abstract Background An asymptomatic contained rupture (CR) of the aortic annulus is a rare complication of transcatheter aortic valve implantation (TAVI). Their clinical implication is unclear so far. Purpose To determine the long-term outcomes in patients with CR. Methods The ENCORE-registry is a multicenter registry (6 centers across Europe) of patients with CR diagnosed on post-TAVI computed tomography angiography (CTA) or transesophageal echocardiography (TEE). Results A total of 21 patients (mean age 81.9±4.1 years, 81% balloon-expandable TAVI-prostheses) were diagnosed with CR (62% located adjacent to the left coronary cusp, mean size of lesions was 15.3±6.9 x 8.5±3.3 x 8.5±2.3 mm). Seventeen were diagnosed among a total of 1602 consecutive routine post-TAVI CTA (incidence 1.1%), two in TEE and two in post-TAVI CTA (each conducted due to suspicion of periinterventional complications). During a mean follow-up of 2.3±1.7 years nine patients (43%) died from non-cardiac causes. None of the patients exhibited symptoms or underwent interventional treatment related to the CR, no sudden cardiac death occurred. A follow-up CTA, performed in eleven patients 240±176 days post-TAVI, revealed stable CR findings in seven, regression in one, and remission in three patients. Conclusion The results of our ENCORE-registry demonstrate a benign course of initially asymptomatic contained ruptures of the aortic annulus after TAVI supporting a watch-and-wait approach in these patients. Thus, no specific treatment seems to be necessary.

P1787Peripheral vascular access for transcatheter aortic valve implantation: transcarotid versus femoral access

Abstract Objectives The transcarotid (TC) approach for transcatheter aortic valve implantation (TC-TAVI) is potentially an optimal alternative to the gold standard, transfemoral approach. Unfortunately, few studies are reported regarding the safety and efficacy of TC-TAVI. Methods Using data from the national prospective French registry in France - the FRANCE TAVI registry – included a total of 12804 patients entered in the dataset between January 2013 and December 2015. Patients who underwent TF-TAVI or TC-TAVI were 11033 (10598 and 435 respectively) and represented our study cohort. The primary endpoints were perioperative all-cause mortality (either in-hospital mortality or 30-day mortality) and in-hospital complications (annulus rupture, aortic dissection, valve migration, cardiac tamponade, stroke, STEMI, permanent pacemaker implantation, pulmonary embolism, renal failure, renal dialysis). All-cause mortality at follow-up was a secondary endpoint of the study. Results Among 11033 patients included in the current study 10598 (96%) underwent a femoral TAVI, and 435 (4.1%) a TC-TAVI. Patients in the TC-TAVI access group presented with a higher risk profile (mean logistic EuroSCORE1 8.2 vs. 20.3, P&lt;0.001), with a higher rate of peripheral vascular disease, known coronary artery disease, chronic pulmonary disease and renal failure, dialysis and urgent status of TAVI. Four hundred and nineteen patients (3.8%) died during in-hospital stay, with no differences between the two groups (p-value 0.73). TC-TAVI had higher postoperative incidence of stroke (4.4% vs 1.9%, chi-square p-value 0.001), ST elevated myocardial infarction (STEMI) (0.7% vs 0.2%, chi-square p-value 0.05), permanent pacemaker implantation (18.9% vs 15.2%, chi-square p-value 0.04), infections (6.7% vs 4.0%, chi-square p-value 0.01), bleeding (9.2% vs 4.7%, chi-square p-value &lt;0.001), renal failure (5.1% vs 3.3%, chi-square p-value 0.06) and dialysis (5.1% vs 3.1%, chi-square p-value 0.03). Conversely, TF-TAVI was likely to have vascular complications (7.7% vs 3.2%, &lt;0.001) There was no difference in short or midterm mortality rates. The Kaplan-Meier estimates of survival at 1 and 2 years were respectively 85.8%±0.4%, and 75.8%±0.6%. Conclusion Compared to femoral peripheral TAVI, TC-TAVI is safe, and associated with similar outcome except for a higher postoperative incidence of stroke and a twice-lower rate of access site-related complications. It should be considered in case of non-femoral peripheral access as the second access choice, to increase the overall safety of TAVI procedures.

Effusion in transverse sinus: a primary echocardiographic sign for aortic annular rupture in transcatheter aortic valve replacement.

Effusion in transverse sinus: a primary echocardiographic sign for aortic annular rupture in transcatheter aortic valve replacement.

Minimally Invasive Mitral Valve Surgery for Rheumatic Valve Disease.

The development of minimally invasive mitral valve surgery has created the motivation for using this approach in young patients with chronic rheumatic valve disease. We report our recent experience with patients undergoing minimally mitral valve surgery in this group of patients. Between July 2014 and June 2018, 142 patients with rheumatic mitral valve dysfunction underwent minimally invasive surgery through a right thoracotomy approach at the University Medical Center of Ho Chi Minh City in Vietnam. Diagnosis was confirmed with transthoracic and transesophageal echocardiography (TTE and TEE). We analyzed the in-hospital and midterm follow-up outcomes of this group. The mean age was 42.6 ± 9.6 years. Sixty patients (42.3%) were male. Sixty-three patients were diagnosed with functional severe tricuspid regurgitation, 29 patients were identified with moderate tricuspid regurgitation, and tricuspid annulus was more than 21 mm/m²). Mitral valve repair was performed in 16 patients (11.3%), and 126 patients underwent mitral valve replacement. Mitral valve repair techniques included annuloplasty, leaflet peeling, and commissurotomy. Thirty-day mortality was 0.7%. Two patients had to be converted to conventional sternotomy, due to left atrial appendage laceration and mitral annular rupture. The overall survival rate was 98.6%. Freedom from reoperation was 97.1%. In patients with rheumatic valve disease, minimally invasive mitral surgery safely and effectively can be performed with few perioperative complications and good midterm results.

Transcatheter aortic valve replacement for bicuspid aortic valve stenosis with first- and new-generation bioprostheses: A systematic review and meta-analysis

BackgroundSubjects with bicuspid aortic valve (BAV) have been excluded from transcatheter aortic valve replacement (TAVR) randomized trials. MethodsWith this meta-analysis of observational studies we first compared TAVR outcomes of BAV vs. tricuspid aortic valve (TAV) patients, stratifying the results by device generation. Then, we looked for differences between balloon-expandable (BE) and self-expandable (SE) bioprostheses in BAV patients. Primary outcome was 30-day mortality. Secondary outcomes were 30-day stroke, moderate-severe paravalvular leakage, new pacemaker implantation, vascular complications and 1-year mortality. ResultsThirteen studies (11,032 patients, 7291 TAV and 3741 BAV) and seven studies (706 patients, 367 treated with BE, 339 with SE valve) met inclusion criteria. Thirty-day (OR = 1.13; 95% CI 0.88–1.46, p = 0.33) and 1-year mortality (OR = 1.02; 95% CI 0.77–1.37, p = 0.87) were similar between patients receiving TAVR for BAV or TAV. Subjects treated for BAV were at higher risk of conversion to conventional surgery (OR = 2.35; 95% CI 1.30–4.23, p = 0.005), implantation of a second valve (OR = 2.06; 95% CI 1.31–3.25; p = 0.002), moderate/severe paravalvular leakage (PVL) (OR = 1.67; 95% CI 1.29–2.17; p = 0.0001) and device failure (OR = 1.26; 95% CI 1.02–1.56; p = 0.04). Rates of adverse events decreased significantly with the use of new-generation devices, but outcome differences remained consistent. BAV patients treated with BE vs. SE valves had similar 30-day and 1-year mortality, stroke and moderate-severe PVL. Balloon-expandable valves were associated with lower rates of a second valve and new pacemaker implantation but carried higher risk of annular rupture. ConclusionsBAV patients treated with TAVR had similar 30-day and 1-year mortality as well as stroke and new pacemaker implantation rates compared to TAV subjects, but carried higher risk of moderate/severe PVL, conversion to surgery and device failure. Event rates significantly decreased with the use of new-generation devices, but TAVR still showed better procedural results in TAV compared to BAV.

Incidence and Outcomes of Surgical Bailout During TAVR: Insights From the STS/ACC TVT Registry

ObjectivesThe aim of this study was to evaluate the incidence and outcomes of surgical bailout during transcatheter aortic valve replacement (TAVR). BackgroundThe incidence and outcomes of unplanned conversion to open heart surgery, or “surgical bailout,” during TAVR are not well characterized. MethodsData from the Society of Thoracic Surgeons/American College of Cardiology TVT (Transcatheter Valve Therapy) Registry was analyzed with respect to whether surgical bailout was performed during the index TAVR procedure. A Cox proportional hazards models was used to evaluate 1-year mortality and major adverse cardiovascular events. ResultsBetween November 2011 and September 2015, a total of 47,546 patients underwent TAVR. Surgical bailout during TAVR was performed in 1.17% of the cases (n = 558); the most frequent indications were valve dislodgement (22%), ventricular rupture (19.9%), and aortic valve annular rupture (14.2%). The incidence of surgical bailout significantly decreased over time (first tertile 1.25%, second tertile 1.43%, third tertile 1.04%; p = 0.0088). The 30-day and 1-year incidence of major adverse cardiovascular events (54.6% vs. 7.4% [p < 0.0001] and 63.92% vs. 20.29% [p < 0.0001]) and all-cause mortality (50.00% vs. 4.98% [p < 0.0001] and 59.79% vs. 17.06% [p < 0.0001]) were significantly higher in those who underwent bailout. Independent predictors of surgical bailout included female sex, hemoglobin, left ventricular ejection fraction, nonelective cases, and nonfemoral access. Body surface area was the only independent predictor of survival after surgical bailout. ConclusionsIn a large, nationally representative registry, the need for surgical bailout in patients undergoing TAVR is low, and its incidence has decreased over time. However, surgical bailout after TAVR is associated with poor outcomes, including 50% mortality at 30 days.

Coronary Artery Obstruction Caused by Contained Annulus Rupture After Transcatheter Aortic Valve Replacement

An 84-year-old woman was admitted to undergo transcatheter aortic valve replacement (TAVR) because of severe aortic valve stenosis. On the basis of computed tomographic findings ([Figure 1A][1]), transfemoral TAVR using 23-mm Sapein 3 (Edwards Lifesciences, Irvine, California) at 1-ml underfilling

Impact of severe left ventricular outflow tract calcification on device failure and short-term mortality in patients undergoing TAVI

BackgroundTo investigate the impact of left ventricular outflow tract (LVOT) calcification on the incidence of device failure and mortality in patients undergoing transcatheter aortic valve implantation (TAVI). MethodsOf 690 consecutive patients undergoing transfemoral TAVI in our center from January 2013 to December 2015, 600 presented with non-severe (NSCALVOT) and 90 (13.0%) with severe (SCALVOT) LVOT calcification. Primary outcome of interest was device failure defined as a composite of procedural death, prosthesis dislocation, annulus rupture or significant para-valvular leakage (PVL). Secondary outcome of interest was 30-day and one-year all-cause mortality. ResultsMean age of the population was 80.8 ± 7.2 years, mean STS score was 5.7 ± 4.6% and 50.6% of the patients were women. Patients with SCALVOT more frequently experienced device failure (10.0% vs. 3.8%, p = 0.009) and were at higher risk of 30 day (10.0% vs. 2.8%, p < 0.001) all cause mortality as compared to those with NSCALVOT. Furthermore, patients with SCALVOT were more frequently in need of post-dilation (15.6% vs. 8.5%, p = 0.032) and showed higher incidence of significant PVL (7.8% vs. 2.5%, p = 0.007). In multivariate analysis, SCALVOT (hazard ratio 2.87; 95% CI 1.20 to 6.34) and use of balloon-expandable prosthesis (hazard ratio 0.32; 95% CI 0.15 to 0.73) were identified as independent predictors of device failure. ConclusionPresence of severe LVOT calcification in patients undergoing transfemoral TAVI is associated with a higher risk of device failure and short-term mortality.

Minimizing the risk for left ventricular rupture during transcatheter aortic valve implantation by reducing the presence of stiff guidewires in the ventricle.

The presence of a stiff guidewire in the apex of the left ventricle (LV) is a known risk factor for LV perforation. Our goal was to minimize the risk of LV rupture during transcatheter aortic valve implantation (TAVI) by omitting the interaction between the stiff guidewire and the LV apex using a modified procedure. A TAVI protocol designed to allow minimal interaction between a stiff guidewire and the LV was developed in Linköping University Hospital in Sweden. A total of 316 patients were treated exclusively by this approach between March 2014 and May 2018. All procedures were completed successfully. There were no cases (0%) of ventricular perforation. Only 1 patient (0.3%) had a pericardial effusion, and it was due to annulus rupture. There was 1 case of acute kidney injury (0.3%). Five patients (1.6%) required a new permanent pacemaker. Stroke occurred in 3 patients (0.9%). No patient had valve embolization. Vascular complications were experienced by 6 patients (1.9%). A mild paravalvular leak occurred in 27 (8.5%) patients. At 30 days post-TAVI, 6 patients (2%) had died. The mortality rate at 1 year was 8.6% (n = 20/232). Our series shows that TAVI without the prolonged use of a stiff guidewire in the LV apex is feasible. The risk of LV perforation is eliminated by this approach, and other procedural complications are limited.

Annular Rupture Successfully Salvaged by Valve-in-Valve Implantation

Transcatheter aortic valve replacement (TAVR) is an accepted treatment for patients with severe symptomatic aortic stenosis, with an intermediate or high risk of surgical mortality. 1,2 Despite bei...