Aortic Valve Intervention Research Articles

Frequency and impact of incidental findings on computed tomography during work-up for transcatheter aortic valve implantation: single centre experience and review of the literature.

To assess the frequency and impact of incidental findings (IF) on CT during work-up for transcatheter aortic valve intervention (TAVI). A consecutive cohort of patients referred for consideration of TAVI who underwent a CT scan between 2009 and 2018 were studied retrospectively. CT reports were reviewed for the presence of IFs and categorised based upon their clinical significance: (a) insignificant-findings that did not require specific treatment or follow-up; (b) intermediate-findings that did not impact on the decision-making process but required follow-up; (c) significant-findings that either required urgent investigation or meant that TAVI was clinically inappropriate. A total of 652 patients were included, whose median age was 82 years. One or more insignificant IF was found in 95.6% of patients. Intermediate IFs were documented in 5.4%. 91 (14%) patients had at least one significant IF. These included possible malignancy in 67 (74%). The ultimate decision to offer aortic valve intervention was only changed by the presence of an IF in 3.5% of cases. Clinically significant IFs are detected in more than 1 in 10 of patients undergoing CT as part of a TAVI work-up, although just over half of these patients still receive aortic valve intervention. This study is the largest UK cohort, which, when combined with a review of existing literature, provides a clear picture of the frequency and clinical impact of IFs found at CT for TAVI assessment.

Pulmonary hypertension and valvular heart disease.

Pulmonary hypertension (PH) is an important contributor to morbidity and mortality in patients with left-sided heart disease, including valvular heart disease. In this context, elevated left atrial pressure primarily leads to the development of post-capillary PH. Despite the fact that repair of left-sided valvular heart disease by surgical or interventional approaches will improve PH, recent studies have highlighted that PH (pre- or post-interventional) remains an important predictor of long-term outcome. Here, we review the current knowledge on PH in valvular heart disease taking into account new hemodynamic PH definitions, and the distinction between post- and pre-capillary components of PH. Aspecific focus is on the precise characterization of hemodynamics and cardiopulmonary interaction, and on potential strategies for the management of residual PH after mitral or aortic valve interventions. In addition, we highlight the clinical significance of tricuspid regurgitation, which may occur as aprimary condition or as aconsequence of PH and right heart dilatation (functional). In this context, proper patient selection for potential tricuspid valve interventions is crucial. Finally, the article highlights gaps in evidence, and points toward future perspectives.

The Onco-cardiologist Dilemma: to Implant, to Defer, or to Avoid Transcatheter Aortic Valve Replacement in Cancer Patients with Aortic Stenosis?

Aging is associated with an increased prevalence of both cancer and heart disease. The progression of aortic valve calcification to aortic stenosis may be accelerated by both cardiovascular risk factors and cancer treatments, such as radiotherapy with mediastinal involvement. Symptomatic aortic stenosis is occasionally diagnosed in cancer patients undergoing cardiovascular evaluation; likewise, cancer is often recognized during assessment preceding aortic valve interventions. In these complex cases, physicians face difficult treatment decisions. Due to a myriad of clinical presentations of cancer and valve disease, specific guidelines for this patient population are not currently in place. Management is currently based on clinical judgment, on an individual basis. Patients with cancer in remission or with a favorable prognosis should be treated according to current cardiovascular guidelines. In these patients, aortic valve replacement can be performed either by surgery or transcatheter. Significant challenges arise in patients with active cancer, especially those receiving anti-cancer treatment. Recent data suggests that these patients can be offered aortic valve replacement, with a trend of favoring the transcatheter route in order to minimize perioperative risk and complications associated with major surgery. Patients with advanced cancer and severe aortic stenosis should be offered palliative care and can benefit from aortic balloon valvuloplasty if indicated. Modern cancer treatments associated with improved long-term prognosis may allow the appropriate cure of aortic stenosis. We discuss the protocol, outcomes, and evolving recommendations of aortic valve replacement in cancer patients with aortic stenosis.

Should we screen patients undergoing thoracic surgery for aortic stenosis pre-operatively?

Aortic stenosis (AS) is the most prevalent valvular heart disease in the elderly. Depending on the severity of the disease, an intervention is required through either surgical or percutaneous approach. Presence of AS adds significant morbidity and mortalities to non-cardiac pathologies. Current guidelines recommend postponing non-cardiac surgery in individuals with severe AS; however, this may not always be possible in thoracic surgery as having to postpone or cancel a surgery may be the difference between patients receiving life-prolonging treatment or not. Screening for AS therefore has a role in detecting asymptomatic patients prior to their development of severe, symptomatic AS which can allow us to intervene prior to further disease progression. This, as a result, serves as a mean of potentially prolonging patients’ wellbeing and have a satisfactory perioperative outcome. In this paper, we evaluate the role of screening in AS in patients undergoing thoracic surgery and the possibility of combined aortic valve intervention and resection of lung cancer.

Multidisciplinary transcatheter aortic valve replacement heart team programme improves mortality in aortic stenosis

ObjectivesTo analyse the effect of the implementation of a transcatheter aortic valve replacement (TAVR) and multidisciplinary heart team programme on mortality in severe aortic stenosis (AS).MethodsA retrospective, observational cohort study...

Early postoperative interventional aortic valve closure for severe aortic regurgitation in a neonate after Norwood procedure

A neonate presented with signs of heart failure early after a Norwood procedure, due to increase of aortic and mitral valve regurgitation. Because repeated surgery was considered risky, we closed the aortic valve by catheter intervention with an Amplatzer Duct Occluder. Aortic regurgitation was abolished almost completely and the child improved. Unfortunately, 2 weeks after discharge, the patient died suddenly.

Clinical Advances in Aortic Diseases: from Aortic Valve to Bifurcation

There is growing understanding to recognize the aorta as complex system and treat aortic diseases in an integrated fashion.The indication for interventional aortic valve replacement (TAVR) comprises patients with moderate and high perioperative risk and symptomatic, high grade aortic valve stenosis. In contrast "low risk" patients receive conventional therapy. Ongoing randomised trials analyse the expansion of indication towards low risk patients for interventional approaches. A final rating is owing, but first data support the assumption that both therapeutic options may be equivalent. Moreover, the interventional therapy of low flow, low gradient aortic valve stenosis has been revalued and interventional valve-in-valve therapy has been integrated into clinical routine as invidualised decision of the heart team.Aortic diseases include several entities which require specialised diagnostic and therapeutic tools. Studies to evaluate evidence of follow up options need to be performed in future to enable for surveillance tailored to suit medical need.

Transcatheter aortic valve replacement- management of patients with significant coronary artery disease undergoing aortic valve interventions: surgical compared to catheter-based approaches in hybrid procedures

BackgroundCoronary artery disease (CAD) is associated with poorer outcomes after aortic valve replacement (AVR). For high-risk patients with complex CAD, combined transcatheter aortic valve replacement (TAVR) plus off-pump/minimally-invasive coronary artery bypass (OPCAB/MIDCAB) has been proposed.MethodsA prospective registry analysis was performed to compare the characteristics and outcomes of patients undergoing TAVR+OP/MIDCAB with those undergoing TAVR plus percutaneous coronary intervention (PCI) and surgical AVR plus coronary artery bypass grafting (CABG) between 2008 and 2015 at a single site in Germany.Results464 patients underwent SAVR+CABG, 50 underwent TAVR+OP/MIDCAB, and 112 underwent TAVR+PCI. The mean ages (p < 0.001) and logistic EuroSCOREs (p < 0.001) were similarly higher in TAVR+OP/MIDCAB and TAVR+PCI patients compared to SAVR+CABG patients. Prior cardiac surgery was more common in TAVR+PCI than in TAVR+OP/MIDCAB and SAVR+CABG patients (p < 0.001). Procedural times were shortest (p < 0.001), creatine kinase (muscle brain) levels least elevated (p < 0.001), pericardial tamponade least common (p = 0.027), and length of hospital stay shortest (p = 0.011) in TAVR+PCI, followed by TAVR+OP/MIDCAB and SAVR+CABG patients. In-hospital mortality was highest for TAVR+OP/MIDCAB patients (18.0%) with comparable rates for TAVR+PCI and SAVR+CABG groups (9.0 and 6.9%; p = 0.009). Mortality by 12 months was more probable after TAVR+OP/MIDCAB (HR: 2.17, p = 0.002) and TAVR/PCI (HR: 1.63, p = 0.010) than after SAVR+CABG, with the same true of rehospitalisation (HR: 2.39, p = 0.003 and HR: 1.63, p = 0.033).ConclusionsTAVR+OP/MIDCAB patients share many characteristics with TAVR+PCI patients, with only slightly poorer long-term outcomes. In patients ineligible for SAVR+CABG and TAVR+PCI, hybrid interventions are reasonable second-line options.

Abstract 114: Trends in Aortic Valve Interventions in The Netherlands

Introduction: Aortic valve disease is the leading valvular pathology in the Western World. Transcatheter aortic valve implantation (TAVI) have emerged as alternatives to surgical aortic valve replacement (SAVR). The study’s objective is to describe clinical trends in TAVI and SAVR in patients with aorta valve disease. Method: Within the Netherlands Heart Registry (NHR) trends were analyzed in isolated TAVI and SAVR among 14 centers in the Netherlands. Results: Between 2013 and 2017, a total of 7432 isolated SAVR and 5929 TAVI procedures have been performed. An 43.9% (from 2174 to 3128) increase in the total number of SAVRs and TAVIs was observed, merely in het due to a 161% (from 669 to 1748) growth of TAVIs. In 2017, there was a slight decline in SVAR. In TAVI patients the 30-day and 120-day mortality decreased significantly, from 7.2% (40 of 558) and 10.6% (59 of 558) in 2013 to 3.4% (52 of 1540) and 5.7% (86 of 1509) in 2017 respectively. The risk adjusted outcomes showed a significant decrease in vascular complications in TAVI. The risk profile of TAVI patients has changed over time, with a trend towards decrease of risk: lower EuroSCORE and higher left ventricular ejection fraction. Conclusion: This registry showed a rapid increase in the use of TAVI for the treatment of aortic valve disease in the Netherlands. Importantly, early mortality rates declined as did the rate of complications. Furthermore, a trend towards decrease of risk was observed.

Prognostic Impact of Pre-Transcatheter and Post-Transcatheter Aortic Valve Intervention Troponin: A Large Cohort Study.

BackgroundBiomarkers were advocated as prognostic factors in patients undergoing transcatheter aortic valve intervention, with contradictory results concerning prognostic impact of troponin. Our aim was to assess the prognostic impact of preprocedural and postprocedural troponin in transcatheter aortic valve intervention.Methods and ResultsPreprocedural and postprocedural high‐sensitivity troponin levels were measured in all patients undergoing transcatheter aortic valve intervention. Primary end point was 1‐year mortality. This study included 1390 patients, with a mean age of 83.4±6.8 years. Patients were divided into 3 tertiles according to preprocedural troponin values: tertile 1: 0.001 to 0.023 μg/L; tertile 2: 0.024 to 1.80 μg/L; and T3: 1.81 to 12.1 μg/L. One‐year mortality was higher in patients in tertile 2 (hazard ratio, 2.1; P=0.001) and T3 (hazard ratio, 1.8; P=0.009) compared with those in tertile 1. Myocardial injury was predictive of 1‐year mortality (hazard ratio, 1.7; P=0.01). This effect may be stronger in the tertile 1 subgroup (hazard ratio, 5.1; P=0.03 [P value for interaction: 0.18]).ConclusionsElevated preprocedural troponin and myocardial injury are associated with 1‐year mortality after transcatheter aortic valve intervention.

Transcatheter mitral valve therapies.

Dr.O.P. Yadava, Editor-in-Chief, IJTC and Dr. V Bapat, Assistant Professor at Columbia University, New York, discuss issues related to slow development and uptake of transcatheter mitral valve replacement. Dr. Bapat stresses on the basic difference between transcatheter aortic and mitral valve interventions. He laments that issues related to mitral valve repair versus replacement and role of percutaneous MitraClip are still being hotly debated. He, however, is hopeful that technology shall evolve to make percutaneous options for secondary mitral regurgitation a viable proposition.

Predicting the future of TAVR: an obituary to open aortic valve replacement?

Transcatheter aortic valve replacement (TAVR) has become the cornerstone for aortic valve intervention since the first implantation in 2002. Recent advances with novel devices and introduction into lower risk cohorts have been successful. In this review, we discuss the ongoing limitations to transcatheter aortic valve therapy and whether it will replace surgical aortic valve replacement in the foreseeable future. A better understanding of valve durability, high-grade heart block, and stroke post TAVR has led to practice changes that improve patient outcome. Although there has been great progress made in treating severe aortic stenosis with TAVR, there are room for improvements before it becomes the default therapy for all patients.

Five-Year Clinical and Echocardiographic Outcomes From the NOTION Randomized Clinical Trial in Patients at Lower Surgical Risk.

The NOTION trial (Nordic Aortic Valve Intervention) was designed to compare transcatheter aortic valve replacement (TAVR) with surgical aortic valve replacement (SAVR) in patients ≥70 years old with isolated severe aortic valve stenosis. Clinical and echocardiographic outcomes are presented after 5 years. Patients were enrolled at 3 Nordic centers and randomized 1:1 to TAVR using the self-expanding CoreValve prosthesis (n=145) or SAVR using any stented bioprostheses (n=135). The primary composite outcome was the rate of all-cause mortality, stroke, or myocardial infarction at 1 year defined according to Valve Academic Research Consortium-2 criteria. Baseline characteristics were similar. The mean age was 79.1±4.8 years and mean Society of Thoracic Surgeons Predicted Risk of Mortality score was 3.0%±1.7%. After 5 years, there were no differences between TAVR and SAVR in the composite outcome (Kaplan-Meier estimates 38.0% versus 36.3%, log-rank test P=0.86) or any of its components. TAVR patients had larger prosthetic valve area (1.7 cm2 versus 1.2 cm2, P<0.001) with a lower mean transprosthetic gradient (8.2 mm Hg versus 13.7 mm Hg, P<0.001), both unchanged over time. More TAVR patients had moderate/severe total aortic regurgitation (8.2% versus 0.0%, P<0.001) and a new pacemaker (43.7% versus 8.7%, P<0.001). Four patients had prosthetic reintervention and no difference was found for functional outcomes. These are currently the longest follow-up data comparing TAVR and SAVR in lower risk patients, demonstrating no statistical difference for major clinical outcomes 5 years after TAVR with a self-expanding prosthesis compared to SAVR. Higher rates of prosthetic regurgitation and pacemaker implantation were seen after TAVR. URL: https://clinicaltrials.gov. Unique identifier: NCT01057173.

Durability of Transcatheter and Surgical Bioprosthetic Aortic Valves in Patients at Lower Surgical Risk

BackgroundTranscatheter aortic valve replacement (TAVR) is an alternative to surgical aortic valve replacement (SAVR) in patients with severe aortic stenosis and intermediate or high surgical risk. ObjectivesThe aim of this study was to compare the durability of transcatheter and surgical bioprosthetic aortic valves using standardized criteria. MethodsIn the NOTION (Nordic Aortic Valve Intervention) trial, all-comer patients with severe aortic stenosis and lower surgical risk for mortality were randomized 1:1 to TAVR (n = 139) or SAVR (n = 135). Moderate/severe structural valve deterioration (SVD) was defined as a mean gradient ≥20 mm Hg, an increase in mean gradient ≥10 mm Hg from 3 months post-procedure, or more than mild intraprosthetic aortic regurgitation (AR) either new or worsening from 3 months post-procedure. Nonstructural valve deterioration (NSVD) was defined as moderate/severe patient-prosthesis mismatch at 3 months or moderate/severe paravalvular leakage. Bioprosthetic valve failure (BVF) was defined as: valve-related death, aortic valve reintervention, or severe hemodynamic SVD. ResultsAt 6 years, the rates of all-cause mortality were similar for TAVR (42.5%) and SAVR (37.7%) patients (p = 0.58). The rate of SVD was higher for SAVR than TAVR (24.0% vs. 4.8%; p < 0.001), whereas there were no differences in NSVD (57.8% vs. 54.0%; p = 0.52) or endocarditis (5.9% vs. 5.8%; p = 0.95). BVF rates were similar after SAVR and TAVR through 6 years (6.7% vs. 7.5%; p = 0.89). ConclusionsIn the NOTION trial through 6 years, SVD was significantly greater for SAVR than TAVR, whereas BVF was low and similar for both groups. Longer-term follow-up of randomized clinical trials will be necessary to confirm these findings. (Nordic Aortic Valve Intervention Trial; NCT01057173)

Transcatheter aortic valve implantation versus surgical replacement in high-risk patients with aortic stenosis

Objectives The aim of this study was to demonstrate whether transcatheter aortic valve implantation (TAVI) improves mortality and morbidity compared with surgical aortic valve replacement in high-risk patients who require intervention for aortic valve stenosis (AS). Many patients with severe AS and coexisting conditions are not candidates for surgical replacement of the aortic valve. Recently, TAVI has been suggested as a less invasive treatment for high-risk patients with AS. Patients and methods Fifty patients with severe AS for aortic valve intervention were classified as follows: group A, as TAVI group, included 25 patients who underwent aortic valve replacement by transcatheter femoral approach, and group B, as surgical aortic valve replacement group, included 25 patients who underwent aortic valve replacement by median sternotomy. Results Intraoperatively, procedure duration was 101.8 ± 10.6 and 191.2 ± 7.5 min in group A and B, respectively (P Conclusion In high-risk patients with severe AS, transcatheter and surgical procedures for aortic valve replacement were comparable for survival at 3 months, although there were important differences in periprocedural outcomes.

First-Phase Ejection Fraction Is a Powerful Predictor of Adverse Events in Asymptomatic Patients With Aortic Stenosis and Preserved Total Ejection Fraction

ObjectivesThis study investigated the prognostic value of first-phase ejection fraction (EF1) in patients with aortic stenosis (AS), a condition in which left ventricular dysfunction as measured by conventional indices is an indication for valve replacement. BackgroundEF1, the ejection fraction up to the time of maximal ventricular contraction may be more sensitive than existing markers in detecting early systolic dysfunction. MethodsThe predictive value of EF1 compared to that of conventional echocardiographic indices for outcomes was assessed in 218 asymptomatic patients with at least moderate AS, including 73 with moderate, 50 with severe, and 96 with “discordant” (aortic area <1.0 cm2 and gradient <40 mm Hg) AS, all with preserved EF, followed for at least 2 years. EF1 was measured retrospectively from archived echocardiographic images by wall tracking of the endocardium. The primary outcome was a combination of aortic valve intervention, hospitalization for heart failure, and death from any cause. ResultsEF1 was the most powerful predictor of events in the total population and all subgroups. A cutoff value of 25% (or EF1 of <25% compared to ≥25%) gave hazard ratios of 27.7 (95% confidence interval [CI]: 13.1 to 58.7; p < 0.001) unadjusted and 24.4 (95% CI: 11.3 to 52.7; p < 0.001) adjusted for other echocardiographic measurements including global longitudinal strain, for events at 2 years in all patients with asymptomatic AS. Corresponding hazard ratios for all-cause mortality in the total population were 17.5 (95% CI: 5.7 to 53.3) and 17.4 (95% CI: 5.5 to 55.2) unadjusted and adjusted, respectively. ConclusionsEF1 may be potentially valuable in the clinical management of patients with AS and other conditions in which there is progression from early to late systolic dysfunction.

Aortic Valve Interventions in Pediatric Patients

Aortic valve (AV) disease in pediatric patients requires a complex decision process that has an impact on decades of life. The aim of this review is to summarize the current evidence surrounding AV interventions in this patient population. In neonates with critical aortic stenosis, the relative merit of surgical vs balloon valvuloplasty is debated and practices vary depending on centers' experience with little comparative literature. In children and adolescents, AV repair has regained interest in the last decades with encouraging early and mid-term results. The Ross procedure represents the best AV replacement option as it offers growth potential, excellent hemodynamics, low rates of endocarditis, and thromboembolism without the risks of anticoagulation. Based on contemporary literature, we propose a management algorithm for children AV disease.

VD16 SUTURELESS MINIAVR WITH RIGHT ANTERIOR THORACOTOMY AND ULTRA FAST TRACK ANAESTHESIA: OUR MULTIDISCIPLINARY APPROACH IN ANCONA

Abstract While anatomical and clinical indications to transcatheter aortic valve interventions are expanding, surgical aortic valve replacement continues to progress as demonstrated by improving clinical outcomes in contemporary patients’ cohorts. However, mainly due to the availability of significantly less invasive trans-catheter cardiac interventions, patients’ expectations have dramatically changed in the last decade with reduced trauma and fast recovery being now strongly valued. An increasing employment of minimally invasive multidisciplinary approaches that call surgeons, anaesthesiologists, perfusionists, nurses and physiotherapists to more efficacious collaborative efforts becomes so crucial to minimize surgical invasiveness as well as to decrease the psychological impact of surgery and fasten patient's return to pre-operative lifestyle. With this video we would like to share our multidisciplinary approach to aortic valve replacement. This involves a right anterior mini-thoracotomy, the implantation of a sutureless Livanova Perceval S valve and ultra fast track anaesthetic protocols.

Trends in diagnosis and treatment of aortic stenosis in the years 2006-2016 according to the SILCARD registry.

INTRODUCTION During the last decade, aortic stenosis (AS) has emerged as one of the most significant concerns in cardiovascular diseases. OBJECTIVES We aimed to characterize AS patients on the basis of data derived from a local registry. PATIENTS AND METHODS We used data from the SILesian CARDiovascular (SILCARD) registry, which was developed under the agreement between the Silesian Centre for Heart Diseases in Zabrze and the Silesian branch of the Polish National Health Fund in Katowice to conduct a comprehensive analysis of patients with cardiovascular diseases in Silesian Voivodeship. RESULTS A total of 15 158 patients hospitalized with a diagnosis of AS between 2006 and 2016 were included (mean [SD] age, 69.87 [11.97] years; male patients, 7644 [50.43%]). Heart failure was reported in 4187 patients (27.62%), and coronary artery disease, in 6217 (41.01%). During the first hospitalization, aortic valve intervention was performed in 2137 patients (14.10%), and during a 12‑‑ month follow‑‑ up, in 3416 (25.32%). During the first hospitalization, percutaneous coronary intervention (PCI) was performed in 666 patients (4.39%), and coronary artery bypass grafting (CABG), in 1071 (6.71%). At 12‑‑ month follow‑‑ up, PCI was reported in 560 patients (4.15%), and CABG, in 560 (4.15%). Between 2006 and 2016, 30‑‑ day mortality was 4.35% (659 patients) and remained stable throughout the study (5.4% in 2005 vs 4.0% in 2016, P = 0.28). The 1‑‑ year mortality was 15.88% (2142 patients) and increased from 14.3% in 2006 to 16% in 2015 (P = 0.07). CONCLUSIONS The SILCARD registry has revealed an increase in the number of AS diagnoses. AS has become one of the most critical issues among cardiovascular diseases in Silesian Voivodeship.

Transcatheter Aortic Valve Replacement for Severe Aortic Regurgitation in Singleton-Merten Syndrome

A 21-year-old woman affected by a rare autosomal-dominant disorder called Singleton-Merten syndrome [(1)][1] with symptomatic severe aortic regurgitation in New York Heart Association functional class III was referred for consideration of aortic valve intervention. Her clinical history was