Aortic Mean Research Articles

B-42 | Increase in Aortic Valve Mean Gradients Day After Transcatheter Aortic Valve Implantation: Role of Mitral Regurgitation

B-42 | Increase in Aortic Valve Mean Gradients Day After Transcatheter Aortic Valve Implantation: Role of Mitral Regurgitation

B-38 | Impact of Antithrombotic Strategies on Prosthetic Valve Gradients Following Valve-in-Valve Transcatheter Aortic Valve Replacement

Valve-in-valve (ViV) transcatheter aortic valve replacements (TAVRs) are being performed more frequently in patients with degenerated bioprosthetic AVRs at high-risk for redo surgery. Antiplatelet (AP) and anticoagulation (AC) strategies after these procedures are not well established. This study examines changes in aortic valve mean gradients (MG) in patients on different antithrombotic strategies following ViV TAVR. Patients undergoing ViV TAVRs from January 1, 2019 to December 31, 2022 at our center were included. Changes in discharge-to-1-month MG, discharge-to-1-year MG, and 1-month-to-1-year MG were obtained by transthoracic echocardiogram. Independent two-tailed t-tests were used to compare changes in MG between patients discharged only on AP therapy (single or double antiplatelet therapy) and those discharged on both AP and AC therapy (AP/AC) after ViV TAVR. This cohort included 45 patients (10 in the AP group and 35 in the AP/AC group). 31 patients received Sapien 3 and 14 received Evolut TAVRs. The mean discharge gradient was 17.4 mmHg for the AP group and 17.8 mmHg for the AP/AC group. There were no significant changes in MG at 1 month or 1 year between groups (Table). TAVR type (p=0.931) and TAVR size (p=0.322) did not predict the initial choice of antithrombotic therapy. There were no significant differences in TAVR gradients at one month or one year between patients discharged on AP alone and combination AP/AC after ViV TAVR. This suggests that the initial selection of antithrombotic therapy does not impact short term ViV TAVR gradients.

Association between coronary flow and aortic stenosis during transcatheter aortic valve implantation.

In patients with aortic stenosis (AS), the coronary flow reserve decreases even in the absence of epicardial coronary artery stenosis. Systolic coronary flow reversal (SFR) reflecting reduced coronary microcirculation, often seen in patients with severe AS, has a potential negative impact on the pathogenesis of cardiac dysfunction. However, there are limited data on the relationship between the severity of AS and SFR, as well as on the benefits of transcatheter aortic valve implantation (TAVI). The aim of this study was to evaluate the relationship between the severity of AS and efficacy of TAVI in improving SFR. Consecutive patients with AS who had undergone TAVI using transoesophageal echocardiography (TEE) from November 2020 to February 2022 were prospectively enrolled. Coronary flow in the left anterior descending artery as well as the aortic valve peak velocities, and the mean aortic valve pressure gradients (AVPGs), indicating the severity of AS, were measured using intraprocedural TEE before and after TAVI. The following parameters were measured as coronary flow: systolic and diastolic peak velocity (cm/s) and systolic and diastolic velocity-time integral (VTI) (cm). SFR was defined as the presence of a reversal coronary flow component in systole. The enrolled patients were classified into two groups according to the presence or absence of SFR before TAVI. A total of 25 patients were included: 13 had SFR and 12 who had no SFR, before TAVI. Patients with SFR had significantly higher aortic valve peak velocities (451.1±45.9 vs. 372.1±52.1cm/s; P<0.001) and mean AVPGs (49.2±14.5 vs. 30.3±11.6mmHg; P=0.002) than those without. The optimal binary cut-off aortic valve peak velocity values and the mean AVPG associated with the presence of SFR before TAVI were >410.0cm/s (specificity, 75.0%; sensitivity, 92.3%) and >37.4mmHg (specificity, 83.3%; sensitivity, 92.3%), respectively. After TAVI, SFR immediately disappeared in 11 of 13 patients with SFR (84.6%). Overall, the systolic coronary VTI significantly increased after TAVI (2.0±4.7 vs. 6.4±3.2cm, P<0.001), and this increase was greater in patients with SFR than in those without SFR before TAVI (interaction P=0.035). SFR was found to be associated with the severity of AS and with a greater increase in systolic coronary flow immediately after TAVI.

Subtotal Nephrectomy Associated with a High-Phosphate Diet in Rats Mimics the Development of Calcified Aortic Valve Disease Associated with Chronic Renal Failure

Introduction. This study addressed the hypothesis that subtotal nephrectomy associated with a high-phosphorus diet (5/6Nx + P) in rats represents a suitable animal model to mimic the cardiovascular consequences of chronic kidney disease (CKD) including calcified aortic valve disease (CAVD). Indeed, the latter contributes to the high morbidity and mortality of CKD patients and sorely lacks preclinical models for pathophysiological and pharmacological studies. Methods. Renal and cardiovascular function and structure were compared between sham-operated and 5/6 Nx rats + P 10 to 12 weeks after surgery. Results. As expected, 11 weeks after surgery, 5/6Nx + P rats developed CKD as demonstrated by their increase in plasma creatinine and urea nitrogen and decrease in glomerular filtration rate, estimated by using fluorescein-isothiocyanate-labelled sinistrin, anemia, polyuria, and polydipsia compared to sham-operated animals on a normal-phosphorus diet. At the vascular level, 5/6Nx + P rats had an increase in the calcium content of the aorta; a decrease in mesenteric artery dilatation in response to a stepwise increase in flow, illustrating the vascular dysfunction; and an increase in blood pressure. Moreover, immunohistology showed a marked deposition of hydroxyapatite crystals in the aortic valve of 5/6Nx + P rats. Echocardiography demonstrated that this was associated with a decrease in aortic valve cusp separation and an increase in aortic valve mean pressure gradient and in peak aortic valve velocity. Left-ventricular diastolic and systolic dysfunction as well as fibrosis were also present in 5/6Nx + P rats. Conclusion. This study demonstrates that 5/6Nx + P recapitulates the cardiovascular consequences observed in humans with CKD. In particular, the initiation of CAVD was shown, highlighting the interest of this animal model to study the mechanisms involved in the development of aortic stenosis and test new therapeutic strategies at an early stage of the disease.

Correlation between artificial intelligence-enabled electrocardiogram and echocardiographic features in aortic stenosis.

An artificial intelligence-enabled electrocardiogram (AI-ECG) is a promising tool to detect patients with aortic stenosis (AS) before developing symptoms. However, functional, structural, or haemodynamic components reflected in AI-ECG responsible for its detection are unknown. The AI-ECG model that was developed at Mayo Clinic using a convolutional neural network to identify patients with moderate-severe AS was applied. In patients used as the testing group, the correlation between the AI-ECG probability of AS and echocardiographic parameters was investigated. This study included 102 926 patients (63.0 ± 16.3 years, 52% male), and 28 464 (27.7%) were identified as AS positive by AI-ECG. Older age, atrial fibrillation, hypertension, diabetes, coronary artery disease, and heart failure were more common in the positive AI-ECG group than in the negative group (P < 0.001). The AI-ECG was correlated with aortic valve area (ρ = -0.48, R2 = 0.20), peak velocity (ρ = 0.22, R2 = 0.08), and mean pressure gradient (ρ = 0.35, R2 = 0.08). The AI-ECG also correlated with left ventricular (LV) mass index (ρ = 0.36, R2 = 0.13), E/e' (ρ = 0.36, R2 = 0.12), and left atrium volume index (ρ = 0.42, R2 = 0.12). Neither LV ejection fraction nor stroke volume index had a significant correlation with the AI-ECG. Age correlated with the AI-ECG (ρ = 0.46, R2 = 0.22) and its correlation with echocardiography parameters was similar to that of the AI-ECG. A combination of AS severity, diastolic dysfunction, and LV hypertrophy is reflected in the AI-ECG to detect AS. There seems to be a gradation of the cardiac anatomical/functional features in the model and its identification process of AS is multifactorial.

149 QUANTIFICATION OF FIBROCALCIFIC VOLUME IN AORTIC VALVE STENOSIS BY A NOVEL CONTRAST COMPUTED TOMOGRAPHY METHOD BASED ON A GAUSSIAN MIXTURE MODEL

Abstract Background Discordant echocardiographic measurements are observed in up to one third of patients with aortic stenosis (AS), in whom computed tomography (CT) derived aortic valve calcium scoring is now recommended. Nonetheless, CT calcium scoring only evaluates calcific valve thickening and is unable to assess non-calcific fibrotic thickening, which could be a relevant contributor of AS. Aim of the present study was to generate a quick and robust contrast-CT method based on a gaussian mixture model (GMM) for the assessment of fibro-calcific aortic valve thickening in AS patients, and to investigate its reproducibility and associations with echocardiographic parameters of AS severity and disease progression. Methods A post-hoc analysis of 136 patients with calcific AS (24 with severe, 81 moderate and 31 mild AS) enrolled in the SALTIRE2 trial (Study Investigating the Effects of Drugs used to Treat Osteoporosis on the Progression of Aortic Stenosis) (NCT-02132026) was performed. Aortic valve fibrocalcific volume was calculated using a GMM applied on contrast-CT at baseline and at 1-year follow up. The software estimated the Hounsfield Units (HU) distribution of 3 compartments (blood pool, non-calcific and calcific tissue) within the aortic valve volume of interest, automatically generating thresholds for non-calcific and calcific volumes, respectively computed as the lower 99.7 and the upper 99.7 percentile of the blood pool HU distribution (Figure). Thus, Fibrocalcific volume was measured as the sum of non-calcific and calcific volumes, indexed for CT annulus area and compared to echo parameters of AS severity. Scan-rescan reproducibility and analysis of AS progression were also assessed. Results Image analysis took 5.8 ± 1.0 minutes per scan and showed excellent scan-rescan reproducibility (mean difference -1%, limits of agreement -9% to 7%). Indexed-fibrocalcific volume correlated well with echocardiographic aortic peak velocity (rho=0.70, p&amp;lt;0.0001), better than non-calcific and calcific volumes alone (rho=0.30 and rho=0.61 respectively, both p&amp;lt;0.0001) and Agatston calcium score (rho=0.63, p&amp;lt;0.0001). Baseline indexed-fibrocalcific volume was also the strongest predictor of subsequent AS progression in terms of change in aortic valve peak velocity (rho=0.29, p=0.006) and mean gradient (rho=0.39, p&amp;lt;0.0001). Progression-to-noise ratio for fibrocalcific volume was favourable (Cohen's statistic d=0.62), indicating that groups sizes of 21, 46 and 170 participants would be required to demonstrate 30%, 20% and 10% reductions in fibro-calcific volume progression with a novel drug respectively (alpha=0.05, power=80%). Conclusions This contrast CT-based approach based on a GMM is able to provide robust and relatively rapid assessment of fibrocalcific thickening in patients with AS. Fibrocalcific volume measured using this method, correlates well with other markers of AS severity, predicts disease progression and holds promise in tracking disease progression and response to novel therapies.

One-year clinical and echocardiographic outcomes of transcatheter aortic valve replacement with SAPIEN 3 Ultra versus SAPIEN 3.

The newest-generation balloon-expandable valve, SAPIEN 3 Ultra (S3U), is expected to function well with the enhanced sealing skirt compared with SAPIEN 3 (S3). However, current literature on the comparison between these two valves is limited to short-term follow-ups. Therefore, we aimed to evaluate the 1-year outcomes and echocardiographic changes of S3U compared with S3. We retrospectively identified patients who underwent transfemoral-transcatheter aortic valve replacement with S3U or S3 (20/23/26 mm) at our institution in 2018-2020. Outcomes were 1-year clinical events and echocardiographic parameters, and were compared between S3U and S3 after adjustment with inverse probability of treatment weighting. The S3U and S3 groups included 297 (25.7%) and 858 (74.3%) patients, respectively. There were no significant differences between the two groups in clinical events (death 5.8% vs. 5.5%, hazard ratio [HR] 1.07, 95% confidence interval [CI] 0.81-1.90; death or heart failure hospitalization 10.3% vs. 10.1%, HR 1.04, 95% CI 0.67-1.62). The S3U group had a lower prevalence of mild paravalvular leakage (PVL) (13.7% vs. 22.3%, p = 0.044), with similar moderate PVL (0.7% vs. 1.2%, p > 0.99). No significant differences were observed in aortic valve mean gradient and Doppler velocity index at 1 year. However, the S3U group had a larger increase in mean gradient from implantation to 1 year (median +4.70 vs. +1.63 mmHg, p < 0.001). S3U and S3 carried similarly favorable clinical event risks. Nonetheless, S3U was associated with less frequent mild PVL but a larger increase in transprosthetic gradient. Further studies are needed to determine the prognostic impact of these hemodynamic differences.

An Additional Structure in the Left Atrium in a Patient Undergoing Aortic Valve Replacement: Artifact or Something Else?

A 68-year-old, 42- kg, 149- cm woman presented with chief complaints of dyspnea and palpitations of 4 months' duration. Transthoracic echocardiography revealed severe aortic stenosis due to bicuspid aortic valve disease, with peak and mean gradients of 125 and 85 mmHg, respectively. Coronary angiography was normal. She denied a history of syncopal episodes, transient ischemic attack, or cerebrovascular accident. She was afebrile. Normal sinus rhythm was present. Transesophageal echocardiography (TEE) performed before cardiopulmonary bypass confirmed the preoperative diagnosis. A highly mobile structure also was seen in the left atrium in the midesophageal 4-chamber view. The structure was attached to the base of the posterior mitral leaflet (Fig 1, A). Color-flow Doppler did not reveal any turbulence across the mitral valve (Fig 1, B; Video 1). What is the diagnosis?

Aortic valve reimplantation in patients with connective tissue disorders: Are the leaflets durable?

ObjectiveThe durability of reimplanted myxomatous aortic valves in root replacements for patients with connective tissue disorders (CTD) is unclear; therefore, we sought to evaluate the long-term resilience of these repairs. MethodsFrom January 1980 to January 2020, 214 patients with CTD and 645 without CTD underwent primary, elective aortic valve reimplantation operations at Cleveland Clinic. The CTD cohort included 164 (77%) with Marfan, 23 (11%) with Loeys-Dietz, and 7 (3.3%) with Ehlers-Danlos CTD. We accounted for differing patient characteristics between the groups by propensity score matching to compare outcomes, yielding 96 matched pairs. Longitudinal echocardiographic measures were compared using nonlinear mixed effects models. ResultsIn the CTD cohort, there were no operative mortalities (30-day or in-hospital), 1 (0.47%) stroke, and 1 (0.47%) early in-hospital reoperation for valve dysfunction. Ten-year prevalence of no aortic regurgitation was 86%, mild 11%, and moderate 3%. Ten-year freedom from reoperation was 97%. In propensity matched cohorts, there were no significant differences in in-hospital outcomes, longitudinal aortic regurgitation and mean gradient, risk of reoperation on the aortic valve, or risk of late death. ConclusionsAortic valve reimplantation is a durable operation in patients with CTD and root aneurysms. These patients do not experience early degeneration of their reimplanted aortic valves.

Abstract 12076: Longitudinal Echocardiographic Analysis of Aortic Valve Stenosis Progression

Introduction: Despite its high prevalence, the rate of progression of aortic valve stenosis (AS) remains incompletely characterized and assumed to be constant across the spectrum of AS severity. Previous studies involve limited number of patients, short follow-up, and focused on more severe stages of AS. Hypothesis: The annual rate of AS progression as defined by aortic valve mean gradient (AVMG) increases in magnitude as AS class severity increases. Methods: The study cohort included adult patients with native AS from the MGH echocardiography database from 1990 to 2020. Patients were included if AVMG was reported in at least two echocardiograms in mild, moderate, or severe AS stages. Generalized linear mixed models were employed to simultaneously model fixed effects and random effects stratified by AS severity grade. Multivariable models included age, sex, race, dyslipidemia, DM2, kidney disease, LVEF, moderate/severe AI, and AV morphology. A linear model identified risk factors for rapid progression in severe AS. Results: In 8,848 patients with 29,513 echocardiograms, baseline mean gradient for mild, moderate, and severe AS was 7.0, 20.9, and 43.0 mmHg, respectively. The annual rate of progression in mild, moderate, and severe AS was found to be 0.3, 1.0, and 4.0 mmHg/year. Female gender and white race increased the rate of AVMG by 0.57mmHg/year and 1.05mmHg/year. Conclusions: The progression of AS accelerates with worsening severity of AS. The rate of AVMG progression in severe AS is similar to historically accepted values, but rates are slower for mild and moderate AS. Female gender and white race may be associated with faster progression in severe AS.

Abstract 12566: Use Of Aortic Valve Area Index By Actual Body Weight Overestimates Aortic Stenosis Severity In Obese Patients

Introduction: Guidelines recommend indexing aortic valve area (AVA) to body surface area in grading the severity of aortic stenosis (AS), which overestimates severity in obese patients. The indexing of AVA to ideal or adjusted body weight has not been explored. Hypothesis: We hypothesized that using actual body weight compared to ideal or adjusted body weight in obese patients would result in overestimation of the severity of AS using AVAi. Methods: We conducted retrospective chart review on 305 individuals who received a transthoracic echocardiogram (TTE) at Tufts Medical Center from June 2021 to Sept. 2021 with AVA &lt;1.5cm 2 . We selected 73 subjects with moderate AS (AVA 1-1.5cm 2 ). These subjects were divided into an overweight and obese group (BMI &gt; 25; n = 56) and a normal weight group (BMI 18-24.9; n = 17). We recorded baseline characteristics and TTE data. AVAi was calculated with actual, ideal, and adjusted body weight. The primary outcome was reclassification, defined as a change in severity from severe AS to mild or moderate AS after recalculating AVAi using adjusted or ideal body weight. Results: The overweight and obese group was significantly younger (age 74.4±11.2 versus 80.7±5.7 years, P=0.018) with higher BSA (2.0±0.2 versus 1.7±0.2, P=0.010) compared to the normal weight group. The recorded median AVAi was 0.61 with interquartile range(IQR) of 0.17. There was no significant difference in blood pressure, ejection fraction, AVA, peak aortic velocity, peak gradient, and mean gradient. After calculating AVAi with adjusted and ideal body weight, 18 patients in the overweight and obese group were reclassified to a lower grade of AS based on AVAi (median AVAi 0.58, IQR 0.17), compared with 0 reclassifications in the normal weight group (0.67, 0.18). Patients who were reclassified had a significantly smaller AVA compared to patients who were not reclassified (1.09±0.11 versus 1.23±0.19 cm 2 , P&lt;0.001), while no differences were observed in peak gradient, mean gradient, and peak velocity. Conclusions: Using actual body weight to calculate AVAi in overweight and obese patients can lead to overestimation of AS severity. Further research is needed to investigate the optimal indexing strategy for AVAi and the effects of classification on cardiovascular outcomes.

Abstract 11036: Aortic Valve Calcification is Associated With an Increased Risk of Mortality in Patients With Low Flow Low Gradient Moderate Aortic Stenosis

Introduction: Aortic Valve Calcification (AVC) measured by computed tomography (C-CT) and Dobutamine stress echocardiography (DSE) are both important when determining AS severity in low flow low gradient (LFLG) AS. It is generally accepted that AS is moderate if aortic mean gradient is &lt;40mmHg on DSE and AVC is not severe. However, recent studies suggest that patients with moderate AS may have a worse outcome than expected when treated medically. Objective: To examine the correlation between AVC and mortality in patients with LFLG moderate AS on both DSE and C-CT when treated medically. Method: 88 Patients with LFLG AS (aortic mean gradient &lt;40 mmHg, aortic valve area &lt;1.0 cm 2 &amp; stroke volume index (SVi) &lt;35ml/m 2 ) and moderate AS on DSE and C-CT were identified from two prospective studies. AVC ratio was calculated as AVC divided by the sex-specific AVC threshold for severity; 2000 AU in males and 1200 AU in females. Results: Optimal threshold of AVC ratio to predict 2-year mortality was 0.68 on ROC-curve (AUC=0.72).Patients were stratified according to AVC ratio: 51 (58%) presented with AVC ratio &lt;0.7 and 37 (42%) with AVC ratio 0.7–1.0. 2 year survival was lower in the latter group (79.5±0.1 vs 46.9±0.1% - Figure 1). Age (78±9 vs 75±11, p=0.32), sex distribution (females 33 vs 41%, p=0.49) and DSE SVi increase (18±24 vs 18±12%, p=0.94) were similar in both groups. Patients with AVC ratio &lt;0.7 presented with higher LVEF (50±15 vs 44±15%, p=0.08) and lower aortic mean gradient at rest (20±7 vs 23±6 mmHg, p=0.01) and during DSE (21±14 vs 29±15 mmHg, p=0.03). In univariate Cox regression AVC ratio &gt;0.7 was associated with mortality: HR 2.91 [1.43-5.9], p=0.003. AVC ratio &gt;0.7 remained associated with mortality after adjustment for LVEF, aortic mean gradient, age and sex: HR 2.66 [1.24-5.7], p=0.012. Especially in patients with reduced LVEF: HR 3.47 [1.49-8.09], p=0.004. Conclusion: In patients with LFLG moderate AS an AVC ratio &gt; 0.7 is associated with increased risk of mid-term mortality.

Abstract 15165: Dobutamine Stress Echocardiography in Patients With Low Flow, Low Gradient Aortic Stenosis and Preserved Lvef

Introduction: Guidelines recommend the use of Dobutamine stress echocardiography (DSE) in case of low flow low gradient aortic stenosis (LFLG AS) when left ventricular ejection fraction (LVEF) &lt;50%, but few data support this threshold as most studies have tested DSE when LVEF &lt;35%. Hypothesis: To examine the feasibility of DSE in patients with LFLG AS, and the possible interaction between LVEF and accuracy of projected aortic valve area (AVA proj ) in correctly classifying severe AS defined by Cardiac Computer Tomography (C-CT). Methods: Patients with LFLG AS (aortic mean gradient &lt;40 mmHg &amp; AVA &lt;1.0 cm 2 &amp; stroke volume index (SV i ) &lt;35ml/m 2 ) undergoing DSE were identified from two prospective cohorts, and stratified according to LVEF (&lt;35%, 35-50% and &gt;50%). Severe AS was defined as AVC score ≥2000 AU in males, and ≥1200 AU in females on C-CT. Results: Of 214 patients, 65 (30%) presented with LVEF &lt;35%, 58 (27%) with LVEF 35-50%, and 91 (43%) with LVEF &gt;50%. 97 patients presented with severe AS (32 vs 21 vs 44, p=0.26). An inverse relationship was seen between LVEF and left ventricular diameter (60±10mm vs 54±7mm vs 47±6mm, p&lt;0.01). Although resting SV i was different between groups (26.4±6.4mL vs 27.3±5.6 vs 29.6±5.7, p&lt;0.01), no significant differences in SV i change was seen during DSE (7.3±5.9mL vs 5.5±6.2mL vs 6.7±6.7mL, p=0.30), and patients with LVEF &lt;35% were more likely to demonstrate flow-reserve, defined as an increase in SVi &gt;20%; 39 (63%) vs 21 (36%) vs 44 (49%), p=0.01. AVA proj provided similar AUCs (p=0.31) (Figure 1) and cut-off points in classifying severe AS across LVEF groups: LVEF&lt;35%: 1.02 cm 2 /accuracy 74%, vs LVEF 35-50%: 0.82cm 2 /accuracy 72% vs LVEF &gt;50%: 0.9cm 2 /accuracy 65%. Conclusion: DSE leads to similar increases in stroke volume index (SV i ) in patients with LVEF &gt;50% compared with LVEF ≤50%. Furthermore, the projected aortic valve area (AVA proj ) provides good accuracy for identification of true-severe AS, regardless of LVEF stratum.

Safety and Efficacy of a Bodyweight Exercise Training Program in Symptomatic Patients With Severe Aortic Valve Stenosis

Conventional exercise therapy including aerobic and resistance training is desirable for cardiovascular disease, whereas it is generally considered contraindicated for symptomatic severe aortic valve stenosis (AS). This study aimed to evaluate the safety and efficacy of bodyweight resistance exercise training (BRET), which is low-intensity exercise training in symptomatic patients with severe AS. A BRET program consisting of 8 exercises was performed 3 times a week by patients with AS with physical therapists. For the 78 symptomatic patients with severe AS, the median aortic valve area and mean transaortic valve pressure gradient were 0.56 cm2 and 48.9 mm Hg, respectively; none showed any harmful changes in blood pressure or heart rate in 11 sessions of the BRET program. There were no adverse events during hospitalization. Meanwhile, Barthel's Index score significantly improved at the time of hospital discharge. In conclusion, the BRET program in this study did not appear to cause harmful changes in hemodynamics during the program or adverse events during hospitalization, and it improved activities of daily living in symptomatic patients with severe AS, allowing doctors and physical therapists to conduct it safely, with less emotional stress, for cardiac rehabilitation for such patients.

Aortic valve calcium score: does it correlate with mean transaortic gradient?

Abstract Introduction Aortic valvular calcium score (AVCS) is useful in patients with aortic stenosis for whom echocardiography was not conclusive in grading its severity. Transcatheter aortic valve implantation (TAVI) is an established procedure of treatment in symptomatic severe AS. The burden of aortic valve calcification has been associated with some TAVI related complications (as perivalvular leaks), but at the same time it is well accepted that some degree of calcification is needed to ensure stable anchoring of the prosthesis to the aortic annulus. Purpose To assess if there is a correlation between aortic valve calcium score and mean transvalvular gradient 6 months after TAVI – is a higher AVCS correlated with lower mean transaortic gradient after TAVI? Methods We performed a single-center, retrospective cohort study including patients who underwent TAVI with a preoperative standardized contrast enhanced MSCT with AVCS available. Clinical and echocardiographic data were collected previously to TAVI (pre-TAVI) and at 6 months follow up (6M-FUP). Results A total of 187 patients were included, with 54% female and a mean age of 79.4±9.0 years old. Most patients had tricuspid aortic valve (95.7%); 5 patients had aortic bicuspidy and 3 had aortic valve bioprothesis. Concerning the valve type, 73.3% had new generation prosthesis and the main valve used was the CoreValve Evolut Pro (33.7%). Also, 38,5% needed balloon pre-dilation before TAVI. The mean pre-TAVI aortic transvalvular maximum and mean gradients were 76.5±23.2 mmHg and 48.3±15.5 mmHg, respectively; mean aortic valve area was 0.75±0.16 cm2. The mean AVCS was 2851±1524 AU (Agaston Units); 81.2% of women had AVCS&amp;gt;1300 AU and 74.4% men had AVCS &amp;gt;2000 AU. Comparing transvalvular aortic gradients previously and 6M-FUP after TAVI, there was an average differential of maximum gradient of 61±22 mmHg and of mean gradient of 40±15 mmHg. A negative and weak correlation was found between the AVCS and the maximum gradient (pearson coefficient of −0.181, p=0.02) and between mean gradient at 6M-FUP (pearson coefficient of −0.191, p=0.014). Discussion and conclusion AVCS is a significant predictor for death, stroke and perivalvular leaks after TAVI. On the other hand, high AVCS is associated with better seating in the native annulus during deployment. Nevertheless, high AVCS did not strongly correlated with mean transaortic gradient 6 months after TAVI. Funding Acknowledgement Type of funding sources: None.

Novel contrast-computed tomography method based on a Gaussian Mixture Model for assessment of fibrocalcific volume in aortic valve stenosis

Abstract Background Discordant echocardiography is observed in up to one third of patients with aortic stenosis (AS), in whom computed tomography (CT) derived aortic valve calcium scoring is now recommended. However, CT calcium scoring only assesses calcific valve thickening and ignores non-calcific fibrotic thickening, which could be an important contributor of AS. Purpose To generate a quick and robust contrast-CT method based on a gaussian mixture model (GMM) for assessment of fibro-calcific aortic valve thickening in patients with AS, and to investigate its reproducibility and associations with echo parameters of AS severity and disease progression. Methods A post-hoc analysis of 136 patients with calcific AS (24 with severe, 81 moderate and 31 mild AS) enrolled in the SALTIRE2 trial (NCT-02132026) was performed. Aortic valve fibrocalcific volume was calculated using a GMM applied on contrast-CT at baseline and at 1-year follow up. The software estimated the Hounsfield Units (HU) distribution of 3 compartments (blood pool, non-calcific and calcific tissue) within the aortic valve volume of interest, automatically generating thresholds for non-calcific and calcific tissue, respectively computed as the lower 99.7 and the upper 99.7 percentile of the blood pool HU distribution (Figure 1). Fibrocalcific volume was measured as the sum of calcific and non-calcific volumes, indexed for CT annulus area and compared to echo parameters of AS severity. Evaluation of scan-rescan reproducibility and AS progression were also assessed. Results Image analysis took 5.8±1.0 minutes per scan and showed excellent scan-rescan reproducibility (mean difference −1%, limits of agreement −9% to 7%). Indexed-fibrocalcific volume correlated well with echocardiographic aortic peak velocity (rho=0.70, p&amp;lt;0.0001), better than non-calcific and calcific volumes alone (rho=0.30 and rho=0.61 respectively, both p&amp;lt;0.0001) and Agatston calcium score (rho=0.63, p&amp;lt;0.0001). Baseline indexed-fibrocalcific volume was also the strongest predictor of subsequent AS progression in terms of change in aortic valve peak velocity (rho=0.29, p=0.006) and mean gradient (rho=0.39, p&amp;lt;0.0001). Progression-to-noise ratio for fibrocalcific volume was favourable (Cohen's statistic d=0.62), indicating that groups sizes of 21, 46 and 170 participants would be required to demonstrate 30%, 20% and 10% reductions in fibro-calcific volume progression with a novel drug respectively (alpha=0.05, power=80%). Conclusions This novel contrast CT-based approach can provide robust and rapid assessment of fibrocalcific thickening in AS patients. Fibrocalcific volume measured using this technique, correlates well with other markers of AS severity, predicts disease progression and holds promise in tracking disease progression and response to novel therapies. Funding Acknowledgement Type of funding sources: None.

Prognostic value of right ventricular dysfunction in patients undergoing transcatheter aortic valve replacement

Abstract Introduction Right ventricular dysfunction (RVD) in patients with severe aortic stenosis seems to increase the risk of worse long-term outcomes after transcatheter aortic valve replacement (TAVR). The purpose of this study was to investigate the association between RVD at baseline and the prognosis after TAVR (readmission for heart failure and death). Methods A cohort study was conducted. Consecutive patients undergoing TAVR from January 2012 to December 2020 were included and analysed depending on the right ventricular function prior to the procedure. RVD was assessed using tricuspid annular plane systolic excursion (≤17 mm). Clinical and follow-up characteristics were recorded. The median follow-up was 26±22 months. Results Of 292 patients who underwent TAVR, 64 (21.9%) met the criteria for RVD at baseline. Patients with RVD undergoing TAVR were significantly more often male (65% vs 46%) and smokers or former smokers (42% vs 23%). They had significantly a higher EuroScore risk score (9.1±7.2 vs 5.3±4) with greater prevalence of atrial fibrillation (55% vs 32%), previous heart valve surgery (20% vs 4%) or pacemaker implant (25% vs 14%), less left ventricular ejection fraction (48±15% vs 58±11%), lower aortic valve mean gradient (41±13 vs 50±13 mmHg) and higher estimated pulmonary artery pressure (50±18 vs 42±13 mmHg) compared with patients with preserved RV function. Procedural characteristics and complications were similar in both groups. Normalization of right ventricular function after TAVR was found in 50.8% of patients with RVD at baseline. Readmission for heart failure during the follow-up was more common in patients with RVD at baseline (29.7% vs 13.3%, p 0.04), also observing a higher trend in terms of mortality (29.7% vs 19.1%, p 0.08). Conclusions Patients with RVD undergoing TAVR had an increased risk of readmission for heart failure and a higher trend in mortality. Funding Acknowledgement Type of funding sources: None.

Natural history of severe aortic stenosis in elderly heart failure patients who declined transcatheter aortic valve implantation

Abstract Background Transcatheter aortic valve implantation (TAVI) is an established minimally invasive treatment for elderly patients with severe aortic stenosis (AS). Although it is a relatively minimally invasive procedure, many elderly patients cannot undergo TAVI due to advanced age, advanced dementia, significantly impaired ADL, or because the patient or family does not wish to undergo TAVI. In general, severe AS patients died 5 years after an angina attack, 3 years after syncope symptoms, and 2 years after heart failure symptoms. However, few studies have investigated the prognosis of elderly patients with severe AS who declined TAVI. Purpose This study aimed to comprehend the natural history of elderly severe AS patients who declined aortic valve intervention and identify risk factors for death in the TAVI era. Methods We retrospectively reviewed 2,786 echocardiographic data from our hospital between 2017 and 2021. We identified 504 patients with AS in the echocardiography database. The severe AS was defined by the following echocardiography parameters: peak aortic flow velocity ≥4.0 m/s, aortic valve mean gradient ≥40 mmHg, aortic valve area (AVA)&amp;lt;1.0 cm2, or AVA index&amp;lt;0.6 cm2/m2. Patients with mild and moderate AS and patients who underwent surgical or transcatheter aortic valve intervention were excluded. Eventually, 82 patients fulfilled the study criteria and were analyzed in this study. Clinical events were investigated, and Cox proportional hazards analysis was performed to elucidate risk factors for mortality. Results The mean age was 89±6 years, and 63 (77%) were women. AHA/ACC classification was Stage A/B/C/D: 0%/52.4%/39.0%/8.5%. As event occurrence, we detected 34 (41.5%) all-cause deaths, 41 (50.0%) major adverse cardiovascular events, 32 (39.0%) development of heart failure, 13 (15.9%) chest pain attacks, and 3 (3.7%) syncope. The time from diagnosis of severe AS to all-cause death was 227±273 days, and the 1-, 2-, and 3-year survival rates were 61.5%, 46.2%, and 36.9%, respectively. Of the heart failure-onset population, 16 (50.0%) were found to have severe AS on initial heart failure admission. The incidence of heart failure at 1, 2, and 3 years after diagnosis of severe AS was 60.1%, 56.7%, and 45.4%, respectively. The time from heart failure to death was 107±147 days. Cox proportional hazards analysis adjusted with age, sex, comorbidities revealed that dementia (HR 4.5, P=0.014) and Katz index &amp;lt;5 (HR7.8, P=0.009) were independent risk factors for mortality. Conclusions Compared to the comprehension of the natural history of AS patients, the prognosis in severe AS patients who declined TAVI was extremely poor. Although the elderly patients did not have a high rate of angina attacks or syncope symptoms, probably due to their reduced ADL, the results suggest that dementia prevention and maintenance of exercise tolerance are essential since dementia and reduced ADL (Katz&amp;lt;5) are independent risk factors for mortality. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Clinical Research Promotion Foundation Reiwa 2 Michinari Hieda

Sex differences in the impact of coronary artery disease on long-term survival after transcatheter aortic valve implantation

Abstract Background It has been suggested that the complexity of coronary artery disease (CAD) is a determinant of worse outcomes after transcatheter aortic valve implantation (TAVI). However, no data is available showing this applies equally to both sexes. Purpose Males are usually overrepresented in studies regarding CAD and care should be used when translating these results to the female population. The purpose of this analysis was to compare sex specific clinical outcomes in patients undergoing TAVI with and without coexisting CAD. Methods All patients undergoing TAVI at a tertiary referral centre between 2008 and 2020 were included and outcomes up to five years after TAVI were prospectively recorded. Baseline and residual (after revascularization) SYNTAX-scores (SS) were retrospectively calculated to make groups of different CAD complexity. Results A total of 605 patients, of whome 284 (46.9%) female patients, underwent TAVI. Five years after TAVI, females and males had similar overall survival (62 vs 59%, p=0.320) and cardiovascular mortality (22% vs 20%, p=0.540), respectively. Females were older (82.7y vs 80.8y, p&amp;lt;0.001), had a higher left ventricular ejection fraction (53.7% vs 49.4%, p&amp;lt;0.001) and higher aortic valve mean gradient (45.7 vs 41.6 mmHg, p=0.002). EuroScore II was comparable between both groups (26.8 vs 27.5, p=0.330). Females had less obstructive CAD (49% vs 64%, p&amp;lt;0.001) and less complex CAD (mean SS: 8.3 vs 12.6, p&amp;lt;0.001), despite reporting similar rates of angina (10% vs 11%, p=0.492). While in males CAD complexity was not predictive of survival (fig 1A) or cardiovascular mortality (fig 2A), females showed worse survival (fig 1B) and cardiovascular mortality (fig 2B) with increasing CAD complexity. This difference seems not to be driven by a lower rate of revascularization since women with CAD received significantly more percutaneous coronary interventions (PCI) (41% vs 24%, p=0.001) and trended towards more complete revascularization (residual SS &amp;lt;8 70% in females vs 52% in males, p=0.054). Background medical therapy with aspirin (70% vs 72%, p=0.710), other antiplatelet agents (61% vs 57%, p=0.390) and statins (71% vs 81%, p=0.065) was not different between both groups. A possible explanation for the similar rates of angina despite less complex CAD in females might be a higher prevalence of underlying microvascular dysfunction, which is also known to be related with an increased rate of cardiovascular events. Conclusion We show that in females outcomes after TAVI are significantly influenced by co-existing CAD and its complexity, while in males this is less pronounced. We identified a subgroup of females with a SS &amp;gt;22 that are at particular high risk for fatal cardiovascular events after TAVI. Therefore, awareness for CAD and close follow-up in combination with guideline-directed treatment of complex CAD in females undergoing TAVI is crucial. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Research Foundation Flanders

LACK OF PULMONARY HYPERTENSION REGRESSION IN PATIENTS WITH SEVERE AORTIC STENOSIS ASSOCIATED WITH CHRONIC LUNG DISEASE AFTER TRANSCATHETER AORTIC VALVE REPLACEMENT

LACK OF PULMONARY HYPERTENSION REGRESSION IN PATIENTS WITH SEVERE AORTIC STENOSIS ASSOCIATED WITH CHRONIC LUNG DISEASE AFTER TRANSCATHETER AORTIC VALVE REPLACEMENT