Complication Of Transcatheter Aortic Valve Implantation Research Articles

Impact of Persistent Versus Paroxysmal Preoperative Atrial Fibrillation on In-Hospital, One-Year, and Late Clinical Outcomes Following Transcatheter Aortic Valve Implantation

Previous reports on the impact of preexisting atrial fibrillation (AF) on clinical outcomes after transcatheter aortic valve implantation (TAVI) have presented limited data on the relative impact of paroxysmal versus persistent AF subtypes. We compared in-hospital, 1-year, and late clinical outcomes in 1,098 patients who underwent TAVI with preoperative AF (556 paroxysmal, 542 persistent) versus 1,787 patients without AF. The propensity-matched cohorts with AF (n = 643) and without AF (n = 686) did not differ with respect to baseline clinical characteristics, operative technique, or in-hospital TAVI complications. At 1-year, patients with AF had higher all-cause mortality (9.0% vs 6.1%, p = 0.046) and readmission rates (13.1 vs 8.8%, p = 0.014), with lower Kansas City cardiomyopathy questionnaire scores (77.8 ± 21.8 vs 84.3 ± 17.1, p <0.001). Echocardiographic follow-up (mean time 455 ± 285 days) demonstrated no significant intergroup differences in hemodynamic findings other than a progressive increase in left atrial volume index in patient subgroups (without AF: 37.4 ± 14.7 ml/m2 vs paroxysmal AF: 46.4 ± 21.4 ml/m2 vs persistent AF: 60.5 ± 26.3 ml/m2, p <0.001). On late follow-up (mean time 49.0 [45.1 to 52.9] months), patients with persistent AF had worse all-cause mortality than patients without AF (hazard ratio 1.55, 95% confidence interval 1.17 to 2.06, p = 0.003), with no significant survival differences between the paroxysmal AF and without AF subgroups. In conclusion, patients with preexisting AF and patients without AF who underwent TAVI had similar in-hospital outcomes but worse 1-year mortality, hospital readmission, and quality of life outcomes. Compared with patients without AF, patients with persistent but not paroxysmal preexisting AF have higher late all-cause mortality at a mean follow-up of 49 months. Patients with persistent AF have higher levels of left atrial volume index than patients with paroxysmal AF and patients without AF on intermediate echocardiographic follow-up.

Depth of implantation in relation to membranous septum as a predictor of conduction disturbances after transcatheter aortic valve implantation

BackgroundConduction disturbances remain one of the most common complications occurring post TAVI. We aim to determine the predictors of cardiac conduction disturbances after Transcatheter Aortic Valve Implantation (TAVI) and propose a relevant predictive model.We included 70 consecutive patients with severe symptomatic AS who underwent TAVI using the self-expanding valve Evolut R or the balloon expandable Sapien XT valve. All patients were subjected to electrocardiographic evaluation pre- and post-TAVI and at 30 days. Clinical, echocardiographic, CT-derived, and procedural parameters were collected and analyzed. ResultsConduction disturbances affected 28 patients (40%): 16 patients (22.9 %) developed Left Bundle Branch Block (LBBB), 7 patients (10%) experienced transient Complete Heart Block (CHB), and 5 patients (7.1%) experienced permanent CHB requiring Permanent Pacemaker Implantation (PPI). We classified predictors into preprocedural and procedural predictors. Multivariate logistic regression analysis of pre-procedural predictors showed that the presence of basal septal calcification is the most powerful independent predictor (OR: 28.63, 95% CI: 4.59–178.68, p < 0.001). Multivariate logistic regression analysis for pre and post procedural predictors showed that the relationship between depth of implantation at the septum and membranous septum expressed in percentage (sDIMS) with cut-off >70.42% is the most powerful independent procedural predictor (OR: 1.11, 95% CI: 1.03–1.2, p 0.006). ConclusionConduction disturbances remain a common complication of TAVI. Presence of basal septal calcification is a non-modifiable risk factor that increase patient propensity of development such complication after TAVI. A depth of implantation exceeding 70% of the membranous septal length has been found to strongly predict conduction disturbances post TAVI. sDIMS can be used in planning the depth of implantation to reduce incidence of conduction disturbances post TAVI.

Acute Kidney Injury Following Transcatheter Aortic Valve Implantation—A Contemporary Perspective of Incidence, Predictors, and Outcomes

Acute kidney injury (AKI) is a known complication following transcatheter aortic valve implantation (TAVI), associated with increased morbidity and mortality. Most of this data relates to higher-risk patients with early-generation TAVI valves. With TAVI now established as a safe and cost-effective procedure for low-risk patients, there is a distinct need for updated analysis. We aimed to assess the incidence, predictors, and outcomes of AKI in a contemporary cohort of TAVI patients, concurrently examining the role of temporal evolution on AKI. A total of 2,564 patients undergoing TAVI from 2008-2023 included in the Alfred-Cabrini-Epworth (ACE) TAVI Registry were analysed. Patients were divided into AKI and no AKI groups. Outcomes were reported according to the Valve Academic Research Consortium-3 (VARC-3) criteria. Of 2,564 patients, median age 83 (78-87) years, 57.4% men and a median Society of Thoracic Surgeons score of 3.6 (2.4-5.5), 163 (6.4%) patients developed AKI with incidence falling from 9.7% between 2008-2014 to 6% between 2015-2023 (p=0.022). On multivariable analysis, independent predictors of AKI were male sex (adjusted odds ratio [aOR] 1.89, p=0.005), congestive cardiac failure (aOR 1.52, p=0.048), estimated glomerular filtration rate 30-59 (aOR: 2.79, p<0.001), estimated glomerular filtration rate <30 (aOR 8.65, p<0.001), non-femoral access (aOR 5.35, p<0.001), contrast volume (aOR 1.01, p<0.001), self-expanding valve (aOR 1.60, p=0.045), and bleeding (aOR 2.88, p=0.005). Acute kidney injury was an independent predictor of 30-day (aOR: 6.07, p<0.001) and 12-month (aOR: 3.01, p=0.002) mortality, an association that remained consistent when excluding TAVIs performed prior to2015. Acute kidney injury remains a relatively common complication of TAVI, associated with significant morbidity and mortality even in less comorbid, contemporary practice patients.

The impact of gender on outcomes of transcatheter aortic valve implantation between self-expanding valve and balloon-expandable valve

BackgroundWhile females have been found to have a higher rate of procedural complications with transcatheter aortic valve implantation (TAVI) than males, the effect of valve choice has not been fully elucidated. This study aimed to investigate the impact of gender and choice of balloon or self-expanding valve on TAVI complications. MethodsData from patients who received a TAVI in our institution from January 2016 to September 2021 were retrospectively analyzed. A total of 971 patients were included and divided into self-expanding valve (n = 315) and balloon-expandable valve (n = 656) groups. The endpoints were 30-day mortality, need for a new pacemaker, and major adverse cardiovascular events (MACE) which is defined as cardiac arrest, stroke, myocardial infarction, major bleeding, and unplanned vascular surgery/intervention. ResultsThere were more females in the self-expanding valve group than in the balloon-expandable valve group (64.1 % vs. 43.6 %: p < 0.0001). There is no significant difference in the prevalence of hypertension, diabetes mellitus, current smoker, hemodialysis, and the STS risk score between the 2 groups. Females had a higher rate of major adverse cardiovascular events (3.7 % in men vs. 6.8 % in women; p = 0.043), which was driven mostly by vascular complications. This difference was particularly observed in the self-expanding valve group (2.7 % in men vs. 9.4 % in women; p = 0.036). ConclusionsTAVI complications were more common in females than males, driven mostly by vascular complications. This difference was particularly observed in woman treated with a self-expanding valve. Particular attention should be given to access choices in females undergoing TAVI.

Factors associated with acute kidney injury in patients undergoing transcatheter aortic valve implantation: Short-term outcomes and impact of right heart failure.

Transcatheter aortic valve implantation (TAVI) was developed as an alternative to surgery for symptomatic, high-risk patients with severe aortic stenosis (AS). Acute kidney injury, a major complication of TAVI, is associated with a poor prognosis. In our study, we planned to investigate the effect of right heart failure on the development of acute kidney injury after TAVI and other factors contributing to the development of AKI. Between January 2015 and December 2020, 198 patients who underwent TAVI due to severe symptomatic aortic stenosis at Dr. Siyami Ersek Cardiovascular Surgery Hospital were screened. Local ethics committee approval was obtained (HNEAH-KAEK 2021/134-3343). Transthoracic echocardiographic findings and laboratory evaluations were recorded. Patients were evaluated according to Acute Kidney Injury Network (AKIN) criteria. The rate of AKI after TAVI was found to be 41.9%. The mean age of patients who developed AKI was higher (80.90±6.8). AKI development rates were higher in the female gender (68.7%) and patients with hypertension (44.8%). It was observed that the risk of developing AKI was higher in patients who underwent TAVI and developed AKI afterwards, especially in patients with stage-3 and stage-4 advanced CKD before TAVI (p<0.01) We did not find an independent relationship between AKI and right-heart failure in our analysis. We observed that chronic kidney disease before TAVI, advanced age, and female gender are important determinants of the development of AKI after TAVI. Although a relationship between TAVI and right heart failure has not been demonstrated, large-scale studies are needed in the future.

The Importance of Mehran Score to Predict Acute Kidney Injury in Patients with TAVI: A Large Multicenter Cohort Study.

Transcatheter aortic valve implantation (TAVI) has developed as an alternative to surgery for symptomatic high-risk patients with aortic stenosis (AS). An important complication of TAVI is acute kidney injury. The purpose of the study was to investigate if the Mehran Score (MS) could be used to predict acute kidney injury (AKI) in TAVI patients. This is a multicenter, retrospective, observational study including 1180 patients with severe AS. The MS comprised eight clinical and procedural variables: hypotension, congestive heart failure class, glomerular filtration rate, diabetes, age >75 years, anemia, need for intra-aortic balloon pump, and contrast agent volume use. We assessed the sensitivity and specificity of the MS in predicting AKI following TAVI, as well as the predictive value of MS with each AKI-related characteristic. Patients were categorized into four risk groups based on MS: low (≤5), moderate (6-10), high (11-15), and very high (≥16). Post-procedural AKI was observed in 139 patients (11.8%). MS classes had a higher risk of AKI in the multivariate analysis (HR 1.38, 95% CI, 1.43-1.63, p < 0.01). The best cutoff for MS to predict the onset of AKI was 13.0 (AUC, 0.62; 95% CI, 0.57-0.67), whereas the best cutoff for eGFR was 42.0 mL/min/1.73 m2 (AUC, 0.61; 95% CI, 0.56-0.67). MS was shown to be a predictor of AKI development in TAVI patients.

Strategies for Treatment of Annular Rupture Complicating Transcatheter Aortic Valve Implantation: A Retrospective Analysis of the Bern TAVI Registry.

HomeCirculation: Cardiovascular InterventionsAhead of PrintStrategies for Treatment of Annular Rupture Complicating Transcatheter Aortic Valve Implantation: A Retrospective Analysis of the Bern TAVI Registry Open AccessResearch ArticlePDF/EPUBAboutView PDFSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toOpen AccessResearch ArticlePDF/EPUBStrategies for Treatment of Annular Rupture Complicating Transcatheter Aortic Valve Implantation: A Retrospective Analysis of the Bern TAVI Registry Daijiro Tomii, Thomas Pilgrim, Taishi Okuno, Jonas Lanz, Fabien Praz, Stefan Stortecky, Matthias Siepe, Stephan Windecker and David Reineke Daijiro TomiiDaijiro Tomii Department of Cardiology, Cardiovascular Center, Bern University Hospital, Inselspital, University of Bern, Switzerland. (D.T., T.P., T.O., J.L., F.P., S.S., S.W.) Search for more papers by this author , Thomas PilgrimThomas Pilgrim https://orcid.org/0000-0001-8721-4068 Department of Cardiology, Cardiovascular Center, Bern University Hospital, Inselspital, University of Bern, Switzerland. (D.T., T.P., T.O., J.L., F.P., S.S., S.W.) Search for more papers by this author , Taishi OkunoTaishi Okuno https://orcid.org/0000-0001-7831-2934 Department of Cardiology, Cardiovascular Center, Bern University Hospital, Inselspital, University of Bern, Switzerland. (D.T., T.P., T.O., J.L., F.P., S.S., S.W.) Search for more papers by this author , Jonas LanzJonas Lanz https://orcid.org/0000-0002-5035-6625 Department of Cardiology, Cardiovascular Center, Bern University Hospital, Inselspital, University of Bern, Switzerland. (D.T., T.P., T.O., J.L., F.P., S.S., S.W.) Search for more papers by this author , Fabien PrazFabien Praz https://orcid.org/0000-0001-5416-165X Department of Cardiology, Cardiovascular Center, Bern University Hospital, Inselspital, University of Bern, Switzerland. (D.T., T.P., T.O., J.L., F.P., S.S., S.W.) Search for more papers by this author , Stefan StorteckyStefan Stortecky https://orcid.org/0000-0002-5076-0177 Department of Cardiology, Cardiovascular Center, Bern University Hospital, Inselspital, University of Bern, Switzerland. (D.T., T.P., T.O., J.L., F.P., S.S., S.W.) Search for more papers by this author , Matthias SiepeMatthias Siepe https://orcid.org/0000-0003-3305-9343 Department of Cardiac Surgery, Cardiovascular Center, Bern University Hospital, Inselspital, University of Bern, Switzerland. (M.S., D.R.) Search for more papers by this author , Stephan WindeckerStephan Windecker Correspondence to: Stephan Windecker, MD, Department of Cardiology, Inselspital, Bern University Hospital, Freiburgstrasse 18, CH-3010 Bern, Switzerland. Email E-mail Address: [email protected] https://orcid.org/0000-0003-2653-6762 Department of Cardiology, Cardiovascular Center, Bern University Hospital, Inselspital, University of Bern, Switzerland. (D.T., T.P., T.O., J.L., F.P., S.S., S.W.) Search for more papers by this author and David ReinekeDavid Reineke Department of Cardiac Surgery, Cardiovascular Center, Bern University Hospital, Inselspital, University of Bern, Switzerland. (M.S., D.R.) Search for more papers by this author Originally published22 May 2023https://doi.org/10.1161/CIRCINTERVENTIONS.122.012796Circulation: Cardiovascular Interventions. 2023;0:e012796FootnotesFor Sources of Funding and Disclosures, see page xxx.Correspondence to: Stephan Windecker, MD, Department of Cardiology, Inselspital, Bern University Hospital, Freiburgstrasse 18, CH-3010 Bern, Switzerland. Email stephan.[email protected]ch Previous Back to top Next FiguresReferencesRelatedDetails Advertisement Article InformationMetrics © 2023 The Authors.Circulation: Cardiovascular Interventions is published on behalf of the American Heart Association, Inc., by Wolters Kluwer Health, Inc. This is an open access article under the terms of the Creative Commons Attribution Non-Commercial-NoDerivs License, which permits use, distribution, and reproduction in any medium, provided that the original work is properly cited, the use is noncommercial, and no modifications or adaptations are made.https://doi.org/10.1161/CIRCINTERVENTIONS.122.012796PMID: 37212143 Originally publishedMay 22, 2023 Keywordsthoracic surgeryheart rupturetranscatheter aortic valve replacementaortic valve stenosisPDF download Advertisement SubjectsAortic Valve Replacement/Transcatheter Aortic Valve ImplantationCardiovascular SurgeryValvular Heart Disease

A comparison of neurological event and mortality rates between transcatheter aortic valve implantation and surgical aortic valve replacement.

Transcatheter aortic valve implantation (TAVI) is the treatment of choice for patients with symptomatic severe aortic stenosis. To evaluate the neurological event and mortality rates of TAVI in comparison with those of surgical aortic valve replacement (SAVR). A systematic literature search identified pertinent full-text journal articles published from 2000 to 2022 that were taken as the study materials. Patients were at the age of 79.3 ±2.8 years and 79.9 ±2.9 years at the time of intervention/open surgery in the TAVI and SAVR groups, respectively. Patients' age and preoperative comorbidity rates were similar in both groups. A self-expanding valve prosthesis and a percutaneous transfemoral route were the most commonly used in patients receiving TAVI. The duration of the procedure and the hospital stay were much shorter, and the number of transfused blood units was much lower in the TAVI group than in the SAVR group. No significant intergroup difference was found in the prevalence of postoperative stroke, 1-month all-cause mortality, and 1-month and 1-year cardiovascular mortality rates. However, 1-year all-cause mortality was much lower in the TAVI than the SAVR group. The subgroups of risk stratification showed better outcomes for non-high-risk patients compared with high-risk patients. Irrespective of other postoperative complications of TAVI, this study emphasizes the postoperative major neurological events and mortality. TAVI appears to be superior to SAVR with regard to 1-year all-cause mortality. TAVI is thus recommended for elderly patients with symptomatic severe aortic stenosis at very high surgical risk contraindicated for SAVR.

On site cardiac surgery for structural heart interventions: a fence to mend?

Current evidence supports device-based transcatheter interventions for the management of patients with structural heart disease, proving well their safety and efficacy; transcatheter aortic valve implantation (TAVI), transcatheter edge-to-edge repair (TEER) of mitral or tricuspid valves, and left atrial appendage occlusion (LAAO) are expanding their role in contemporary practice. Currently, guidelines recommend performing TAVI in 'Heart Valve Center' with interventional cardiology and institutional on-site cardiac surgery (iOSCS), while no site limitation has been defined for TEER and LAAO. The growing number of candidates for transcatheter interventions generates long waiting times with negative consequences on mortality, morbidity, hospitalization, and functional deterioration. Therefore, a debate on the feasibility of TAVI in centres without iOSCS has been set up. Data from randomized controlled trials and registries failed to document any difference in outcomes and in conversion rate to emergent surgical bailout in centres with or without iOSCS; on the other hand, a direct relationship with TAVI complications has been clearly documented for learning curve and centre volume. Therefore, the role of iOSCS for TAVI, as well as for other transcatheter interventions, should be carefully explored.

Long-Term Prognosis Value of Paravalvular Leak and Patient–Prosthesis Mismatch following Transcatheter Aortic Valve Implantation: Insight from the France-TAVI Registry

Background: Transcatheter aortic valve implantation (TAVI) is the preferred treatment for symptomatic severe aortic stenosis (AS) in a majority of patients across all surgical risks. Patients and methods: Paravalvular leak (PVL) and patient–prosthesis mismatch (PPM) are two frequent complications of TAVI. Therefore, based on the large France-TAVI registry, we planned to report the incidence of both complications following TAVI, evaluate their respective risk factors, and study their respective impacts on long-term clinical outcomes, including mortality. Results: We identified 47,494 patients in the database who underwent a TAVI in France between 1 January 2010 and 31 December 2019. Within this population, 17,742 patients had information regarding PPM status (5138 with moderate-to-severe PPM, 29.0%) and 20,878 had information regarding PVL (4056 with PVL ≥ 2, 19.4%). After adjustment, the risk factors for PVL ≥ 2 were a lower body mass index (BMI), a high baseline mean aortic gradient, a higher body surface area, a lower ejection fraction, a smaller diameter of TAVI, and a self-expandable TAVI device, while for moderate-to-severe PPM we identified a younger age, a lower BMI, a larger body surface area, a low aortic annulus area, a low ejection fraction, and a smaller diameter TAVI device (OR 0.85; 95% CI, 0.83–0.86) as predictors. At 6.5 years, PVL ≥ 2 was an independent predictor of mortality and was associated with higher mortality risk. PPM was not associated with increased risk of mortality. Conclusions: Our analysis from the France-TAVI registry showed that both moderate-to-severe PPM and PVL ≥ 2 continue to be frequently observed after the TAVI procedure. Different risk factors, mostly related to the patient’s anatomy and TAVI device selection, for both complications have been identified. Only PVL ≥ 2 was associated with higher mortality during follow-up.

Valve embolization during transcatheter aortic valve implantation: Incidence, risk factors and follow-up by computed tomography.

BackgroundIn most cases of transcatheter valve embolization and migration (TVEM), the embolized valve remains in the aorta after implantation of a second valve into the aortic root. There is little data on potential late complications such as valve thrombosis or aortic wall alterations by embolized valves.AimsThe aim of this study was to analyze the incidence of TVEM in a large cohort of patients undergoing transcatheter aortic valve implantation (TAVI) and to examine embolized valves by computed tomography (CT) late after TAVI.MethodsThe patient database of our center was screened for cases of TVEM between July 2009 and July 2021. To identify risk factors, TVEM cases were compared to a cohort of 200 consecutive TAVI cases. Out of 35 surviving TVEM patients, ten patients underwent follow-up by echocardiography and CT.Results54 TVEM occurred in 3757 TAVI procedures, 46 cases were managed percutaneously. Horizontal aorta (odds ratio [OR] 7.51, 95% confidence interval [CI] 3.4–16.6, p < 0.001), implantation of a self-expanding valve (OR 4.63, 95% CI 2.2–9.7, p < 0.01) and a left ventricular ejection fraction < 40% (OR 2.94, 95% CI 1.1–7.3, p = 0.016) were identified as risk factors for TVEM. CT scans were performed on average 26.3 months after TAVI (range 2–84 months) and detected hypoattenuated leaflet thickening (HALT) in two patients as well as parts of the stent frame protruding into the aortic wall in three patients.ConclusionTVEM represents a rare complication of TAVI. Follow up-CT detected no pathological findings requiring intervention.

Cerebral embolic protection in patients undergoing transcatheter aortic valve implantation: Recent advances.

Despite major advances in transcatheter aortic valve implantation (TAVI) technology during the last years, stroke remains one of the most serious complications of TAVI, tremendously increasing mortality and the loss of neurocognitive function. Since TAVI is expected to further spread into lower-risk patient groups, there will be greater emphasis to obviate such serious complications. One possible technique for preventing stroke is using cerebral embolic protection devices (CEPDs). CEPDs are designed for capturing or deflecting emboli that are en route to the brain and hence to protect the brain from embolism. Although their clinical utilization is increasing, the evidence for using CEPDs is not yet clear. Since this is a rapidly growing field with recent advances, and the impact of CEPD on preventing neurological events is still limited, there is an urgent need for understanding the role of CEPD in preventing clinically significant strokes. In this review, we present an overview of the available literature on CEPDs in patients undergoing TAVI and outline recent advances within this field.

Long-term morphological appearance of transcatheter valves left in the ascending aorta after valve dislocation during transcatheter aortic valve implantation

Abstract Background Transcatheter valve embolization and migration (TVEM) is a potential complication of transcatheter aortic valve implantation (TAVI) (1). Registries suggest low incidence but clinical relevance due to increased acute and mid-term mortality with the majority embolizing in the aorta. However, there is little data on potential late complications such as leaflet and stent thrombosis or aortic wall alterations by migrated valves. Purpose The aim of our study was to analyze the incidence and clinical characteristics of TVEM in a large single center cohort of TAVI patients and to examine dislocated valves by ECG-gated computed tomography (CT). Methods and results Between July 2009 and May 2020, 40 TVEM occurred in 3387 TAVI procedures performed in our center (1.18%). TVEM was defined according to Valve Academic Research Consortium-2 (VARC-2) criteria (3). Majority of TVEM were left in the ascending aorta (31 ascending, 3 arch, 1 descending aorta). 90% of TVEM occurred with a self-expanding valve (SEV), with no difference between older and newer valve generations, 10% with a ballon-expandable valve. Analyzing a TAVI sample cohort (n=200), horizontal aorta (p&amp;lt;0.001, OR 11.7, 95% CI: [3.9:34.8]), defined as aortic angulation &amp;gt;48°(4), as well as the use of SEV (p&amp;lt;0.001, OR 12.8, 95% CI: [3.1:53.9]) were identified as a predisposing risk factor for TVEM. OR in SEV was severely increased when isolating the analysis for patients with horizontal aorta only (p=0.003, OR 23.75, 95% CI: [2.8:129]). No other predisposing risk factors were identified in this cohort. Out of 35 patients still alive, 6 patients were willing to participate in our imaging sub-study. CT exams were performed on average 47 months after TAVI (IQR 50 months [25%Q: 16.8, 75%Q: 72.8]). We detected no leaflet or stent thrombosis, yet CT identified pin protrusions in the aorta in 3 out of 6 patients. Conclusions TVEM is a rare complication of TAVI. TVEM was significantly associated to the use of self-expanding valves and the presence of horizontal aorta. CT did detect pin protrusions in several cases which could bear the possible risk of perforation but showed no signs of long-term damage. Funding Acknowledgement Type of funding sources: None. Representative CT images after TVEM

How to reduce uncommon but severe transcatheter aortic valve implantation complications: stroke, thrombosis, endocarditis, cognitive decline?

Transcatheter aortic valve implantation has become a valid alternative to surgical aortic valve replacement for patients with symptomatic severe aortic stenosis, regardless of baseline surgical risk. The incidence of periprocedural complications has steadily declined over the years, thanks to technical advancement of transcatheter heart valves, delivery systems, and increased operators’ experience. Beyond the most common periprocedural complications, there are a few uncommon but potentially severe complications that more often occur during follow-up, although they may also arise in the periprocedural phase. Stroke, infective endocarditis, valve thrombosis, and cognitive decline are among them. In this brief review, we describe the incidence, predictive factors, and potential preventive measures for those events.

Thrombocytopenia Complicating Transcatheter Aortic Valve Implantation: Differences Between Two New-Generation Devices

Thrombocytopenia after TAVI is common and clinically detrimental. Retrospectively, we observed Portico recipients had a more profound platelet drop than Evolut recipients. We thus investigated periprocedural platelet damage and/orpro-inflammatory state in 64 TAVI recipients at baseline and after implantation. Platelet damage was assessed by annexin V staining and monocyte-phagocytic phenotype was assessed according to CD14/CD36 expression. Serum cytokines were measured in 20 patients. The formaldehyde-based storage solution altered platelets. When, before being loaded onto the delivery system, Portico underwent one additional flushing to those recommended, the receiving patients showed thrombocytopenia, platelet damage, and CD36-monocyte count were mitigated. A general increase in IL-6 was recorded in overall TAVI recipients, but a high serum level of IL-8, a potent thrombocytopenia inducer, was measured in Portico recipients only, including those with extra-rinsed valve. Our study suggests a platelet-injury effect by storage-solution and generates the hypothesis of a role for the biomaterial in stimulating innate-immunity. Larger prospective studies are needed.Graphical

Survival relative to pacemaker status after transcatheter aortic valve implantation

To determine whether a permanent pacemaker (PPM) in situ can enhance survival after transcatheter aortic valve implantation (TAVI), in a predominantly inoperable or high risk cohort. New conduction disturbances are the most frequent complication of TAVI, often necessitating PPM implantation before hospital discharge. We performed an observational cohort analysis of the UK TAVI registry (2007-2015). Primary and secondary endpoints were 30-day post-discharge all-cause mortality and long-term survival, respectively. Of 8,651 procedures, 6,815 complete datasets were analyzed. A PPM at hospital discharge, irrespective of when implantation occurred (PPM 1.68% [22/1309] vs. no PPM 1.47% [81/5506], odds ratio [OR] 1.14, 95% confidence interval [CI] 0.71-1.84; p=.58), or a PPM implanted peri- or post-TAVI only (PPM 1.44% [11/763] vs. no PPM 1.47% [81/5506], OR 0.98 [0.51-1.85]; p=.95) did not significantly reduce the primary endpoint. Patients with a PPM at discharge were older, male, had right bundle branch block at baseline, were more likely to have received a first-generation self-expandable prosthesis and had experienced more peri- and post-procedural complications including bailout valve-in-valve rescue, bleeding and acute kidney injury. A Cox proportional hazards model demonstrated significantly reduced long-term survival in all those with a PPM, irrespective of implantation timing (hazard ratio [HR] 1.14 [1.02-1.26]; p=.019) and those receiving a PPM only at the time of TAVI (HR 1.15 [1.02-1.31]; p=.032). The reasons underlying this observation warrant further investigation. A PPM did not confer a survival advantage in the first 30 days after hospital discharge following TAVI.

Real-time observation of a high-echoic mass in the left ventricle during transcatheter aortic valve implantation: a case report.

BackgroundIncreasing number of symptomatic patients with severe aortic stenosis is treated with transcatheter aortic valve implantation (TAVI). Stroke is one of the most serious complications of TAVI, and the majority of cerebral events in patients undergoing TAVI have an embolic origin.Case summaryA 90-year-old female underwent trans-femoral TAVI for symptomatic severe aortic stenosis. Just before the implantation of the transcatheter heart valve (THV), transoesophageal echocardiography (TOE) showed a mobile, high-echoic mass attached to the THV, which gradually enlarged to 26 mm, then spontaneously detached from the THV and flowed up the ascending aorta, disappearing from the TOE field of. After the procedure, the patient presented with ischaemic stroke. The patient’s stroke was thought to have resulted from the embolism migrating to the distal cerebral arteries.DiscussionThe detailed images acquired with TOE during TAVI enabled the prompt identification of the unusual intracardiac mass.

Predictors for permanent pacemaker implantation following transcatheter aortic valve implantation: trends over the past decade.

This study sought to identify risk factors for permanent pacemaker implantation (PPMI) after Transcatheter aortic valve implantation (TAVI) and explain their trends over the last decade. TAVI is performed nowadays for severe aortic stenosis in more patients with lower surgical risk. While most TAVI complications have been reduced, PPMI remains common. In this observational, retrospective cohort analysis, 338 TAVI patients treated between 2008 and 2017 were reviewed. Risk factors were compared between the early (2008-2013) and late years (2014-2017), and a multivariable logistic regression model was used. A decreasing trend in PPMI over time was observed (p for trend = 0.008), as was a lower rate of PPMI in the late period (19.3% vs. 31.7%, p = 0.009). Three variables were identified as independent risk factors for PPMI that also decreased significantly in the late period: valve implantation depth ≥ 8mm (OR = 4.3, 95% CI 2.3-8.2, p < 0.001), use of self-expandable valves (OR = 2.8, 95% CI 1.4-5.5, p = 0.004), and patient risk assessed by EuroSCORE II (OR = 1.07, 95% CI 1.0-1.1, p = 0.034). Indications for PPMI were also shown to change over time, with an increase in the prevalence of complete AVB as the main indication for PPMI (p = 0.048), and a trend towards a decrease in LBBB alone (p = 0.061). The decrease in post-TAVI PPMI over the past decade is multifactorial and can be explained by (1) lower baseline patient surgical risk, (2) modified procedural variables including decreased implantation depth and increased use of balloon-expandable valves, and (3) refined indications for PPMI.

Kidney injury as post-interventional complication of TAVI.

Transcatheter aortic valve implantation (TAVI) is an accepted treatment approach of aortic stenosis. In the beginning, this technique was executed in high-risk patients only. Today, intermediate-risk patients are also amenable for TAVI, as long as the transfemoral approach is chosen. Numerous predictors have been identified that could lead to periprocedural complications and are defined by patient co-morbidities as well as being inherent to the technical approach. Although vascular complications and postinterventional paravalvular regurgitation have been minimized over the past years by revised technologies and techniques, there is a prevailing individual risk brought about by the specific pathophysiology of the cardiorenal syndrome.

Midterm outcomes after the rescue THV-in-THV procedure: Insights from the multicenter prospective OCEAN-TAVI registry.

To confirm whether the rescue transcatheter heart valve in the transcatheter heart valve (THV-in-THV) procedure is effective and feasible, we aimed to assess the midterm outcomes following rescue THV-in-THV procedures. The trends in the usage of the rescue THV-in-THV procedure at the time of transcatheter aortic valve implantation (TAVI) have also been explored. Midterm outcomes of the rescue THV-in-THV procedure have been poorly defined, though it is popular as an effective method to bail-out some complications in TAVI. We reviewed data from the Optimized transCathEter vAlvular iNtervention-Transcatheter Aortic Valve Implantation (OCEAN-TAVI) registry and compared the outcomes of TAVI with rescue THV-in-THV and TAVI without rescue THV-in-THV. We also examined the annual rates of rescue THV-in-THV procedures in all the TAVI procedures between 2013 and 2017. Among 2,588 patients who underwent TAVI, 26 patients have required rescue THV-in-THV for valve malposition (n = 23) or severe transvalvular regurgitation because of stuck THV leaflets (n = 3). Three cases needed an open conversion, and two died in the hospital. The rates of new permanent pacemaker implantation, acute kidney injury, and stroke were higher in the THV-in-THV group. A two-year cumulative survival and echocardiographic outcomes succeeding rescue THV-in-THV procedure were comparable to non-THV-in-THV cases. The rate of rescue THV-in-THV procedure lessened from 2.6% in 2013 to 0.6% in 2017. The rescue THV-in-THV procedure is an effective and feasible option for THV malpositioning and stuck valve. It has given a comparable survival and a stable valve function over midterm observation periods.