Device Landing Zone Calcification Research Articles

Predictors of post-TAVI conduction abnormalities in patients with bicuspid aortic valves

ObjectivesThis study evaluates predictors of conduction abnormalities (CA) following transcatheter aortic valve implantation (TAVI) in patients with bicuspid aortic valves (BAV).BackgroundTAVI is associated with CA that commonly necessitate a permanent...

Computed tomography derived predictors of permanent pacemaker implantation after transcatheter aortic valve implantation: a meta-analysis

Abstract Background Transcatheter aortic valve implantation (TAVI) is a well-established alternative to surgery for the treatment of patients with severe symptomatic aortic stenosis at high and intermediate surgical risk. Unfortunately, the occurrence of electrical conduction disturbances remains one of the most frequent complications of the procedure. While the impact of electrocardiographic and procedural predictors on PPI is well examined, there is still a lack of knowledge regarding anatomical predictors screened by multislice computed tomography (MSCT). Purpose We performed a meta-analysis to summarize available studies that reported the incidence of PPI after TAVI with new-generation devices and provided raw data for preprocedural MSCT. Methods The authors conducted a literature search in PubMed database until December 31, 2019 to identify studies that investigated preprocedural MSCT data and rate of PPI following TAVI with new-generation devices. Twelve observational studies (n=3133) met inclusion criteria for final analysis. Results PPI was performed in 509 patients (16.2%) after TAVI, mostly due to high degree atrioventricular (AV) block (80.8%). The rate of PPI varied widely from 7.9% to 35.8% in individual studies. Regarding secondary endpoints' analysis of relative risk (RR) and mean difference (MD) electrocardiographic PPI-predictors after TAVI appeared to be pre-existing atrial fibrillation (AF) (RR 1.21; 95% CI 1.05–1.40; p=0.008), right bundle branch block (RBBB) (RR 4.22; 95% CI 3.30–5.41; p<0.0001) and AV block grade I (RR 1.63; 95% CI 1.16–2.29; p=0.005). Patients requiring PPI had larger annulus perimeter (MD 1.66 mm; 95% CI 0.67–2.66 mm; p=0.001) and shorter membranous septum length (MD −0.86 mm; 95% CI −1.74–0.02 mm; p=0.05) assessed by preprocedural MSCT. Concerning calcium load of device landing zone, pacemaker dependent patients showed increased calcification of the non-coronary cusp (MD 39.76 mm3; 95% CI 18.60–60.93 mm3; p=0.0002), the left-coronary cusp (LCC) (MD 47.60 mm3; 95% CI 19.40–75.81 mm3; p=0.0009) and the total left ventricular outflow tract (LVOT) (MD 19.17 mm3; 95% CI 6.68–31.66 mm3; p=0.003). Lower implantation depth (MD 0.83 mm from NCC; 95% CI 0.20–1.47 mm; p=0.01) and oversizing by annulus diameter/area (MD 1.76%; 95% CI 0.68–2.84%; p=0.001) were procedural predictors of PPI following TAVI. Conclusion This structured meta-analysis proved PPI rate in 16.2% of patients following TAVI. Beside well-known electrocardiographic (AF, RBBB, AV block grade I) and procedural predictors (implantation depth, oversizing) this meta-analysis showed for the first time that MSCT derived anatomical values (annulus perimeter, membranous septum length) and distribution of device landing zone's calcification (NCC, LCC, LVOT) are associated with increased risk of PPI following TAVI. Funding Acknowledgement Type of funding source: None

Impact of device landing zone calcification patterns on paravalvular regurgitation after transcatheter aortic valve replacement with different next-generation devices

ObjectiveResidual paravalvular regurgitation (PVR) has been associated to adverse outcomes after transcatheter aortic valve replacement (TAVR). This study sought to evaluate the impact of device landing zone (DLZ) calcification on...

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

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

RF11 CALCIUM LOADING AS RISK FACTOR FOR POST IMPLANTATION LEAKAGE IN TAVI PROCEDURES

Abstract Background and Aims: To assess aortic valve calcification with a reproducible method and the performance of different prostheses in relation to the occurrence of paravalvular leak (PVL) after transcatheter aortic valve implantation (TAVI) in a large single-center cohort. Methods: We retrospectively analyzed preoperative contrast-enhanced CT scans of patients who underwent TAVI in our center between 2009 and 2016. Calcium volume was calculated for each aortic cusp in the aortic valve (AV), in the left ventricular outflow tract (LVOT) and device-landing zone (DLZ). Multivariate analysis was performed to evaluate the risk factors for intraoperative PVL. Results: 539 patients were included in the study (Edwards SapienXT, n = 192; Edwards Sapien3, n = 206; Medtronic CoreValve EvolutR, n = 44; Symetis Acurate, n = 97). Median calcium volume in the DLZ was 757 mm3 (IQR 734.2), with no significant differences among the four prosthesis groups. None of the patients had severe PVL. The overall incidence of mild-to-moderate PVL was 15.8%. On multiple linear regression analysis, DLZ calcification, non-coronary cusp in LVOT calcification, transapical access, and use of the CoreValve and Acurate prostheses were found to be independently associated with PVL. In contrast, degree of oversizing, and use of Sapien3 were independently associated with a lower incidence of PVL. Conclusions: DLZ and non-coronary cusp in LVOT calcification are independently associated with PVL occurrence after TAVI. Among prostheses, Sapien3 seems to be associated with a lower incidence of PVL regardless of calcium volume.

Risk factors for paravalvular leak after transcatheter aortic valve replacement

ObjectiveTo assess risk factors for paravalvular leak (PVL) after transcatheter aortic valve implantation in a large single-center cohort, including measurement of aortic valve calcification using a reproducible method. MethodsWe retrospectively analyzed preoperative contrast-enhanced multidetector computed tomography scans of patients who underwent transcatheter aortic valve implantation in our center between 2009 and 2016. Calcium volume was calculated for each aortic cusp in the aortic valve, left ventricular outflow tract, and device landing zone. ResultsOverall, 539 patients were included in the study who had experience with 4 prothesis types (SapienXT [Edwards Lifesciences, Irvine, Calif] [n = 192], Sapien3 [Edwards Lifesciences] [n = 206], CoreValve EvolutR [Medtronic, Minneapolis, Minn] [n = 44], and Acurate [Symetis, Ecublens, Switzerland] [n = 97]). Median calcium volume in the device landing zone was 757 mm3, with no significant differences among the 4 prosthesis groups. None of the patients had severe PVL. The overall incidence of mild-to-moderate PVL was 15.8% (95% confidence interval [CI], 12.8%-19.1%). On multivariate logistic regression, device landing zone calcification (P = .00006; odds ratio for an increase of 100 mm3, 1.08; 95% CI, 1.04-1.13) and use of the CoreValve (P = .0028; odds ratio, 4.1; 95% CI, 1.6-10 with SapienXT as reference) prosthesis were found to be associated with mild or greater PVL. In contrast, degree of oversizing (P = .002; odds ratio, 0.97; 95% CI, 0.95-0.99), and use of Sapien3 (P = .00005; odds ratio, 0.23; 95% CI, 0.11-0.47 with SapienXT as reference) were associated with a lower incidence of mild or greater PVL. ConclusionsAortic calcification volume in the device landing zone is associated with residual PVL after transcatheter aortic valve implantation. When taking calcification into account, the balloon-expandable prosthesis Sapien3 seems to be associated with a lower incidence of PVL.

P6310Impact of device landing zone calcification on paravalvular regurgitation after transcatheter aortic valve replacement with different next generation devices

P6310Impact of device landing zone calcification on paravalvular regurgitation after transcatheter aortic valve replacement with different next generation devices

The ACURATE neo Transcatheter Heart Valve: A Comprehensive Analysis of Predictors of Procedural Outcome

ObjectivesThe aim of this study was to perform a comprehensive analysis of factors that affect procedural outcomes of transcatheter aortic valve replacement using the ACURATE neo prosthesis (Symetis/Boston, Ecublens, Switzerland). BackgroundPredictors of procedural outcomes using the ACURATE neo prosthesis are poorly understood. MethodsA total of 500 patients underwent transfemoral aortic valve replacement with the ACURATE neo prosthesis. Device landing zone calcification was stratified as severe, moderate, or mild. Anatomic and procedural predictors of second-degree or greater paravalvular leakage and permanent pacemaker implantation were assessed. ResultsPost-procedural second-degree or greater paravalvular leakage was more frequent with increasing device landing zone calcification (mild 0.8% vs. moderate 5.0% vs. severe 13.0%; p < 0.001), whereas permanent pacemaker implantation was independent of device landing zone calcification. More severe periannular calcification (odds ratio [OR]: 1.007; 95% confidence interval [CI]: 1.003 to 1.010; p < 0.001), less oversizing (OR: 0.867; 95% CI: 0.773 to 0.971; p = 0.014), the presence of annular plaque protrusions (OR: 2.756; 95% CI: 1.138 to 6.670; p = 0.025), and aortic movement of the delivery system after full deployment (OR: 5.593; 95% CI: 1.299 to 24.076; p = 0.02), and sinotubular junction height (OR: 1.156; 95% CI: 1.007 to 1.328; p = 0.04) independently predicted second-degree or greater paravalvular leakage. Predictors of permanent pacemaker implantation were pre-existing right bundle branch block (OR: 3.122; 95% CI: 1.261 to 7.731; p = 0.01) and more oversizing (OR: 1.111; 95% CI: 1.009 to 1.222; p = 0.03). ConclusionsSuccessful transcatheter aortic valve replacement using the ACURATE neo device predominantly depends on careful patient selection with appropriate oversizing and taking into account the individual anatomy and calcium distribution of the aortic root.

Predictors of paravalvular regurgitation and permanent pacemaker implantation after TAVR with a next-generation self-expanding device.

To identify predictors of paravalvular regurgitation (PVR) and permanent pacemaker implantation (PPI) following TAVR with a next-generation self-expanding device. Device landing zone (DLZ) calcification, angiographic implantation depth, and baseline and procedural characteristics were analyzed in 212 patients being treated with the ACURATE neo aortic bioprosthesis. PVR was none/trace in 57.1% and ≥ mild in 42.9% (37% mild, 6% moderate). DLZ calcification (705 (IQR 240-624) vs. 382 (IQR 240-624)mm3; P < 0.001) as well as absolute calcium asymmetry (233 ± 159 vs. 151 ± 151mm3; P < 0.001) was significantly higher in patients with PVR ≥ mild. On multivariate analysis, calcification of the aortic valve cusps (AVC) > 410.6mm3 was independently associated with PVR ≥ mild. PPI rate was 10.3% (n = 20). Patients with and without need for PPI had similar total DLZ calcium volume (740 (IQR 378-920) vs. 536 (IQR 315-822)mm3; P = 0.263), but exhibited different calcium distribution patterns: LVOT calcium > 41.4mm3 in the sector below the left coronary cusp (LVOTLC) was associated with increased PPI risk (26.9 vs. 7.7%; P = 0.008). The quantity of AVC calcium predicts residual PVR. Multivariable analysis identified LVOTLC calcium, pre-existing RBBB, and age > 82.7years as independent predictors of PPI. Based on these risk factors, a patient's individual PPI risk can be stratified ranging from 3.8 to 100%.

Comparison of outcomes using balloon-expandable versus self-expanding transcatheter prostheses according to the extent of aortic valve calcification.

Device landing zone (DLZ) calcification is an important determinant of procedural success in transcatheter aortic valve implantation (TAVI). To evaluate the impact of DLZ calcification on procedural outcome with different types of transcatheter heart valves (THVs). Aortic valve calcium density (AVCdens) was determined by non-contrast-enhanced computed tomography in 1232 patients undergoing transfemoral TAVI. We stratified the outcome data according to the extent of AVCdens (mild, moderate, severe) and compared balloon-expandable (BE) with self-expanding (SE) THV. Moreover, THVs were subdivided according to their radial force (BE: high; SEmod: moderate; SElow: low). With BE THV, PVR ≥2° (2.1 vs. 7.9%; p<0.001), post-dilatation (12.3 vs. 36.6%; p<0.001), malpositioning (8.4 vs. 13.0%; p=0.01), device embolization (0.4 vs. 2.6%; p=0.004), and the need for a second valve (1.2 vs. 3.6%; p=0.01) were less frequent than with SE devices, but mean transaortic gradients at discharge were higher [12.0mmHg (8.0-15.0) vs. 9.0mmHg (6.0-11.0); p<0.001], and aortic root injury was more frequent (2.7 vs. 0.8%; p =0.01). In cases of severe calcification, differences between BE and SE THV regarding PVR, post-dilatation, and hemodynamics were mostly pronounced, followed by patients with moderateAVCdens. In cases with low AVCdens, the best outcomes with respect to PVR, pacemaker implantation, and hemodynamics were achieved with SElow THV. In severe and moderate DLZ calcification, BE devices may have advantages, whereas in mild DLZ calcification, SElow THV showed the most favorable profile.

Transcatheter Aortic Valve Implantation With Different Valve Designs for Severe Device Landing Zone Calcification

Severe device landing zone calcification (DLZ-CA) predicted paravalvular leak (PVL) and post-dilatation (PD) after transcatheter aortic valve implantation (TAVI). The aim of this study was to determine the influence of DLZ-CA on PVL or PD rates after SAPIEN XT (XT) versus CoreValve (CV).We analyzed patients undergoing TAVI who had severe DLZ-CA. Severe DLZ-CA defined the upper left ventricular outflow tract calcification; the cross-sectional region 2 mm inferior to the annular plane. PVL was evaluated at 30days using transthoracic echocardiography. Overall, 133 patients had XT-TAVI and the remaining 41 patients had CV-TAVI. Two patients had annulus injury in the XT group (oversizing 20.2% and 20.5% for two XT cases). PD was less frequently performed in the XT group (34.1% versus 12.8%; P = 0.002), but PVL rates were similar between both groups (42.1% versus 41.5% for the XT and CV groups, respectively; P = 0.94). Importantly, excessive oversizing or the degree of filling volume was not associated with decreased PVL after XT-TAVI (P = non-significant for all). On multivariate analysis, CV-TAVI was found to be one of the independent predictors of need for PD (Odds ratio 3.63, 95% confidence interval 1.55 to 8.53, P = 0.003).In the setting of severe DLZ-CA, XT and CV have similar rates of PVL but XT had less need for PD. Excessive oversizing with XT carries a risk of root injury which could be further increased by DLZ-CA.

Device Landing Zone Calcification and Its Impact on Post Procedural Paravalvular Leakage after Transcatheter Aortic Valve Implantation with Two Generations of Balloon-expandable Transcatheter Heart Valves

Device Landing Zone Calcification and Its Impact on Post Procedural Paravalvular Leakage after Transcatheter Aortic Valve Implantation with Two Generations of Balloon-expandable Transcatheter Heart Valves

Impact of Device Landing Zone Calcification on Paravalvular Regurgitation after Transcatheter Aortic Valve Replacement: A Real-Time Three-Dimensional Transesophageal Echocardiographic Study

Determinants of paravalvular regurgitation after transcatheter aortic valve replacement (TAVR) remain unclear. The purpose of this study was to investigate the impact of aortic valve calcification (AVC) on paravalvular regurgitation after TAVR using real-time three-dimensional transesophageal echocardiography. A total of 227 patients with severe aortic stenosis who underwent TAVR using the Edwards SAPIEN or SAPIEN XT valve were retrospectively analyzed. Severity of AVC was assessed on a visual scale ranging from 0 to 3 at the aortic annulus, the leaflets near the nadir, and the commissure. The shape of calcification was assessed by measuring the radial and circumferential lengths of annular calcification and by focusing on the calcification protruding into the left ventricular outflow tract from the annular level. Severity of paravalvular regurgitation was determined by the sum of the cross-sectional area of the vena contracta from two-dimensional or three-dimensional color Doppler transesophageal echocardiographic data. Significant paravalvular regurgitation was defined as at least a moderate grade. After excluding 25 patients with inadequate image quality of three-dimensional and color Doppler data for analysis, AVC could be evaluated in 202 patients. Significant paravalvular regurgitation was occurred in 37 patients (18%). The sum of the AVC scale at the annulus was significantly correlated with the grade of paravalvular regurgitation, while those at the leaflets near the nadir and the commissure were not. As assessed by receiver operating characteristic curve analysis, the radial and circumferential length of the annular calcification had good discriminatory ability for significant paravalvular regurgitation, with areas under the curve of 0.91 and 0.81, respectively. On multivariate analysis, annular calcification with radial length ≥ 3.0 mm, circumferential length ≥ 8.0 mm, and calcification protruding into the left ventricular outflow tract were independently associated with significant paravalvular regurgitation. Assessment of AVC by real-time three-dimensional transesophageal echocardiography is feasible and has good discriminatory value for paravalvular regurgitation in patients who undergo TAVR. Significant paravalvular regurgitation after TAVR is associated with the location and size of calcification at the aortic annulus and left ventricular outflow tract, not with its severity.

Correlation of Device Landing Zone Calcification and Acute Procedural Success in Patients Undergoing Transcatheter Aortic Valve Implantations With the Self-Expanding CoreValve Prosthesis

The aim of this study was to assess the influence of amount and distribution of calcifications of the aortic valve and the left ventricular outflow tract on the acute procedural outcome of patients undergoing transcatheter aortic valve implantation (TAVI). Transcatheter aortic valve implantation is a new percutaneous technique especially for elderly, high-risk patients with significant aortic valve stenosis (AS). After TAVI, post-interventional paravalvular aortic regurgitations (PAR) can occur, which is believed to be related partially to valve calcifications. We prospectively analyzed 100 symptomatic patients with severe AS scheduled for TAVI with the CoreValve ReValving (Medtronic, Minneapolis, Minnesota) prosthesis. In all patients, a native and contrast-enhanced multislice cardiac computed tomography was performed pre-interventionally. Calcification load of the valve and the adjacent outflow tract was estimated by the Agatston Score (AgS), and the amount and distribution of calcification was semi-quantitatively assessed and graded on a 1 to 4 scale (device "landing zone" calcification score [DLZ-CS]). Aortography was performed to evaluate the PAR pre-interventionally, after initial device release (PAR0) and after termination of the procedure (PAR1). Transthoracic echocardiography was performed 2 weeks after implantation (PAR2). The AgS and DLZ-CS showed a significant correlation with the grade of PAR0 (AgS: r = 0.329, p = 0.001; DLZ-CS: r = 0.356, p < 0.001), PAR1 (AgS: r = 0.254, p = 0.011; DLZ-CS: r = 0.240, p = 0.016), and PAR2 (AgS: r = 0.341, p = 0.001; DLZ-CS: r = 0.300, p = 0.002). Both scores (AgS and DLZ-CS) showed a significant positive correlation (r = 0.858, p < 0.001). Calcification in the CoreValve device "landing zone" shows a significant positive correlation to PAR after TAVI. Furthermore, the need for "second maneuvers" (i.e., post-dilation after initial device release) can be predicted by these calcification scores (AgS and DLZ-CS).

Impact of Device Landing Zone Calcification in Transcatheter Aortic Valve Implantation – The Device Landing Zone Calcification Score

Impact of Device Landing Zone Calcification in Transcatheter Aortic Valve Implantation – The Device Landing Zone Calcification Score