High-risk Aortic Stenosis Research Articles

Comparison of invasive and non-invasive gradients before and after TAVI and their implications on clinical outcomes.

Transcatheter aortic valve implantation (TAVI) is recommended for treatment of high-risk aortic stenosis patients. While measuring mean transaortic valve gradient (MG) is crucial in evaluating procedural success, echocardiographic measurements often overestimate direct invasive measurements. This study aimed to examine the discordance between echocardiographic and invasive MGs in TAVI patients and assess their prognostic value on long-term outcomes. This prospective registry included consecutive TAVI patients at a tertiary university hospital. Transthoracic or transoesophageal echocardiography was performed pre-TAVI, at discharge, 1month, 1, and 5years with invasive MG measurements obtained peri-procedurally. The primary endpoints were 5-year all-cause mortality and major adverse cardiac events. Among 1353 patients from 2011 to 2023, non-invasive MGs exceeded invasive MGs pre- and post-implantation (43 [36, 52] mmHg vs. 40 [30, 50] mmHg, p < 0.001; 9 [6, 12] mmHg vs. 4 [2, 7] mmHg, p < 0.001) Pre-procedural MGs correlated better than post-procedural MGs (r = 0.70, p < 0.001 vs. r = 0.23, p < 0.001), particularly in self-expandable valves and smaller sinus of Valsalva diameter (SOVd) (r = 0.33, p < 0.001; r = 0.46, p < 0.001 vs R = 0.06, p = 0.701). Non-invasive MG remained stable from discharge (9 [6, 12] mmHg) to 5years (9 [7, 12] mmHg). While structural valve deterioration and patient-prosthesis mismatch showed no impact, extreme invasive MGs (< 3 or > 6mmHg) predicted worse outcomes (mortality hazard: 1.25 [1.06, 1.88] and 0.85 [0.8, 0.95], respectively), unlike non-invasive measurements. In conclusion, invasive as compared with non-invasive MGs correlated better before than after valve implantation, whereas invasive MGs were always lower than non-invasive MGs. Lower invasive MGs after TAVI appeared to be associated with favourable long-term outcomes.

Role of computed tomography as a preprocedural evaluation tool in transcatheter aortic valve replacement

Abstract Transcatheter aortic valve replacement (TAVR) is increasingly becoming the preferred innovative approach for high-risk aortic stenosis patients. However, before undergoing TAVR, it is crucial to undergo a noninvasive and accurate assessment for proper valve sizing and planning the access route. Computed tomography (CT) imaging plays a vital role in evaluating patients scheduled for transcatheter aortic valve implantation (TAVR). It offers comprehensive information about the aortic valve complex anatomy and the preferred access route, ensuring effective patient selection, and guiding the selection of the appropriate prosthesis. In addition, CT imaging aids in determining the fluoroscopic projection angle, leading to reduced procedural time and optimized use of contrast and radiation exposure.

Cost effectiveness of aortic valve therapies: a systematic review of the literature

&#x0D; Background: we performed a systematic review on the cost effectiveness of transcatheter aortic valve implantation (TAVI) to standard aortic valve replacement and medical management in high-risk elderly patients with severe aortic stenosis.&#x0D; Methods: in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses, a systematic review on current literature for cost-effectiveness of TAVI, standard aortic valve replacement, and medical management for elderly patients with high-risk severe aortic stenosis was performed. Incremental cost effectiveness ratio is used to measure effectiveness through life years gained or quality adjusted life years. Drummond checklist was used to further assess the quality of the included studies.&#x0D; Results: the systematic literature search identified 4 primary publications (derived from 52 citations) that fulfilled the inclusion criteria. Tremendous discrepancy in incremental cost effectiveness ratio is demonstrated with operable patients similar to Cohort A of the PARTNER trial (€ 749 416 and € 39 577). Inoperable patients similar to Cohort B of the PARTNER trial suggest notable differences in favour for transcatheter aortic valve implantation with an increase in quality adjusted life years (0.06 versus 1.6, respectively). With lifetime horizon to transcatheter aortic valve implantation there is a more comparable incremental cost effectiveness ratio in the literature (€ 38 260 and € 37 432). Lowest incremental cost effectiveness ratio witnessed in the technical inoperable group at € 26 482. Lifetime horizon of 10 years with transcatheter aortic valve implantation differ (€ 39 388 versus € 19 947). Overall, a review of the literature suggests TAVI usage in patients for severe aortic stenosis whom are not eligible for surgery. All the studies were overall judged of medium-high quality.&#x0D; Conclusions: transcatheter aortic valve replacement is more cost effective with a lifetime horizon for the treatment of patients with high-risk aortic stenosis compared with medical management considering those ineligible for standard aortic valve replacement. Further cost effectiveness research is needed in the stratifications of patient risk and patient co-morbidities for those candidates eligible for surgery. &#x0D;

Clinical outcomes of patients with hepatic insufficiency undergoing transcatheter aortic valve implantation: a systematic review and meta-analysis

BackgroundTranscatheter aortic valve implantation (TAVI) is currently a common treatment in high-risk aortic stenosis patients, but the impact of hepatic insufficiency on prognosis after TAVI is debatable and whether TAVI is superior to surgical aortic valve replacement (SAVR) in patients with hepatic insufficiency is uncertain.ObjectiveTo investigate the effect of abnormal liver function on the outcome and safety after TAVI and whether TAVI is superior to SAVR in patients with hepatic insufficiency.MethodsPubMed, Embase, the Cochrane Library and Web of Science were systematically searched from inception up to 26 November 2021. Studies were eligible if mortality and complications after TAVI in patients with and without hepatic insufficiency, or mortality and complications for TAVI versus SAVR in patients with hepatic insufficiency were reported. The Newcastle–Ottawa scale (NOS) was used to evaluate the quality of each study. This meta-analysis was registered with PROSPERO (CRD42021253423) and was carried out by using RevMan 5.3 and Stata 14.0.ResultsThis meta-analysis of 21 studies assessed a total of 222,694 patients. Hepatic insufficiency was associated with higher short-term (in-hospital or 30-day) mortality [OR = 1.62, 95% CI (1.18 to 2.21), P = 0.003] and 1–2 years mortality [HR = 1.64, 95% CI (1.42 to 1.89), P < 0.00001] after TAVI. Between TAVI and SAVR in patients with hepatic insufficiency, there was a statistically significant difference in in-hospital mortality [OR = 0.46, 95% CI (0.27 to 0.81), P = 0.007], the occurrence rate of blood transfusions [OR = 0.29, 95% CI (0.22 to 0.38), P < 0.00001] and the occurrence rate of acute kidney injury [OR = 0.55, 95% CI (0.33 to 0.91), P = 0.02].ConclusionsTAVI patients with hepatic insufficiency may have negative impact both on short-term (in-hospital or 30-day) and 1–2-years mortality. For patients with hepatic insufficiency, TAVI could be a better option than SAVR.

Understanding Repeat Hospitalizations in Intermediate- to High-Risk Aortic Stenosis Patients Following Transcatheter Aortic Valve Replacement

Understanding Repeat Hospitalizations in Intermediate- to High-Risk Aortic Stenosis Patients Following Transcatheter Aortic Valve Replacement

Single-center experience of 105-minimalistc transfemoral transcatheter aortic valve replacement and its outcome

IntroductionTranscatheter aortic valve replacement (TAVR) increases worldwide, and indications expand from high-risk aortic stenosis patients to low-risk aortic stenosis. Studies have shown that minimalistic TAVR done under conscious sedation is safe and effective. We report single-operator, the single-center outcome of 105 minimalist transfemoral, conscious sedation TAVR patients, analyzed retrospectively. MethodsAll patients underwent TAVR in cardiac catheterization lab via percutaneous transfemoral, conscious sedation approach. A dedicated cardiac anesthetist team delivered the conscious sedation with a standard protocol described in the main text. The outcomes were analyzed as per VARC-2 criteria and compared with the latest low-risk TAVR trials. ResultsA total of 105 patients underwent transcatheter aortic valve replacement between July 2016 to February 2020. The mean age of the population was 73 years, and the mean STS score was 3.99 ± 2.59. All patients underwent a percutaneous transfemoral approach. Self-expanding valve was used in 40% of cases and balloon-expandable valve in 60% (Sapien3™ in 31% and MyVal™ in 29%) of cases. One patient required conversion to surgical aortic valve replacement. The success rate was 99 percent. The outcomes were: all-cause mortality: 0.9%, stroke rate 1.9%, New pacemaker rate 5.7%, 87.6% had no paravalvular leak. The mild and moderate paravalvular leak was seen in 2.8% and 1.9%, respectively. The mean gradient decreased from 47.5 mmHg to 9 mmHg. The average ICU stay was 26.4 h, and the average hospital stay was 5.4 days. Our outcomes are comparable with the latest published low-risk trial. ConclusionMinimalist, conscious sedation, transfemoral transcatheter aortic valve replacement when done following a standard protocol is safe and effective.

Breaking down the silos: Transcatheter aortic valve implant versus open heart surgery.

Budget silos innate to hospital global funding schemes tend to inhibit the adoption of innovative clinical practices. In contrast, budget fluidity can encourage initiatives that align with the Quadruple Aim. This article calculated the budget impact of Surgical Aortic Valve Replacement (SAVR) and Transcatheter Valve Implant (TAVI) in high-risk aortic stenosis to demonstrate the value of a full-cost accounting approach. The budget impact of TAVI was $4,000 more than SAVR ($52,576 vs $48,578). However, the cost of managing SAVR adverse events was higher than TAVI ($17,718 vs. $11,754) over 1 year. A scenario analysis demonstrated that the total cost of care for a cohort of 100 patients at baseline ratio of 30% TAVI versus 70% SAVR was similar to a future scenario, with reverse proportions. While TAVI may seem expensive upfront, when considered as a surgical department budget item, the overall cost to the hospital is comparable to the SAVR.

Value of machine learning in predicting TAVI outcomes.

BackgroundTranscatheter aortic valve implantation (TAVI) has become a commonly applied procedure for high-risk aortic valve stenosis patients. However, for some patients, this procedure does not result in the expected benefits. Previous studies indicated that it is difficult to predict the beneficial effects for specific patients. We aim to study the accuracy of various traditional machine learning (ML) algorithms in the prediction of TAVI outcomes.Methods and resultsClinical and laboratory data from 1,478 TAVI patients from a single centre were collected. The outcome measures were improvement of dyspnoea and mortality. Three experiments were performed using (1) screening data, (2) laboratory data, and (3) the combination of both. Five well-established ML techniques were implemented, and the models were evaluated based on the area under the curve (AUC). Random forest classifier achieved the highest AUC (0.70) for predicting mortality. Logistic regression had the highest AUC (0.56) in predicting improvement of dyspnoea.ConclusionsIn our single-centre TAVI population, the tree-based models were slightly more accurate than others in predicting mortality. However, ML models performed poorly in predicting improvement of dyspnoea.Electronic supplementary materialThe online version of this article (10.1007/s12471-019-1285-7) contains supplementary material, which is available to authorized users.

Changes in left ventricular function in patients with aortic regurgitation 12 months after transapical transcatheter aortic valve implantation.

Transcatheter aortic valve implantation (TAVI) is an established treatment for high surgical risk aortic stenosis patients; in recent years, it has also been used in patients with pure/dominant aortic regurgitation (AR). This study aimed to determine the impact of transapical TAVI on left ventricle myocardial mechanics in AR patients. Thirty AR patients (70% men; mean age, 72.8 ± 4.3years) were enrolled. Conventional echocardiography was performed on all patients before and 12months after TAVI. Three-dimensional speckle tracking was accomplished in 20 AR patients for the evaluation of global longitudinal strain, global circumferential strain, twist, torsion, apical rotation and basal rotation. Preoperative left ventricular ejection fraction (LVEF), global longitudinal strain (GLS), global circumferential strain (GCS), twist, torsion and apical rotation were impaired in AR patients compared with controls. Mean left ventricular (LV) end-diastolic diameter (from 62.9 ± 7.3 to 52.0 ± 6.8mm, p < 0.001), LV end-diastolic volume (from 199.4 ± 55.0 to 130.1 ± 48.9mL, p < 0.001), and LV mass index (179.8 ± 52.2-134.4 ± 42.5g/m2, p = 0.001) decreased 12months after TAVI. Interestingly, GLS (from - 17.2 ± 3.2 to - 18.9 ± 3.7, p = 0.007) and GCS (from - 23.9 ± 4.9 to - 25.7 ± 5.0, p = 0.008) improved significantly, but LVEF did not significantly improve. In terms of the rotational mechanics, twist, rotation and basal rotation remained almost unchanged, whereas apical rotation (from 7.4 ± 4.0 to 5.5 ± 3.9, p = 0.009) was significantly impaired after transapical TAVI. Our results indicate that LV function was improved in terms of myocardial deformation but worsened in terms of apical rotation 12months after TAVI in AR patients. Three-dimensional speckle tracking echocardiography appears to be a sensitive method for detecting subtle cardiac remodeling after TAVI.

Transcatheter aortic valve replacement: current state of development

Transcatheter aortic valve replacement is a transformative technology for the treatment of severe aortic stenosis. It has allowed for the treatment of high-risk and inoperable aortic stenosis patients that would previously have not been able to undergo surgical aortic valve replacement. The safety and efficacy of transcatheter aortic valve replacement has been evaluated rigorously in multiple pivotal randomized clinical trials. Advancements in the technology with significant improvement in clinical outcomes and safety of the procedure have allowed for the extension to lower-risk groups. Future development will focus on continued refinement in the device and technique with expansion to low-risk patients and other clinical indications.

Transcatheter versus surgical aortic valve replacement in patients at low surgical risk: A meta-analysis of randomized trials and propensity score matched observational studies.

Although transcatheter aortic valve replacement (TAVR) is officially indicated for high risk aortic stenosis (AS) patients, the procedure is increasingly being performed in patients who are not at high surgical risk, including a substantial number of low risk patients. However, data on the benefit of TAVR in this patient population is limited. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies with propensity score matching (PSM) of TAVR versus surgical aortic valve replacement (SAVR) in patients who are at low surgical risk. The primary outcome was all-cause mortality. The secondary outcomes included stroke, myocardial infarction, bleeding, and various procedural complications. Six studies (2 RCTs and 4 PSM studies) totaling 3,484 patients were included. Follow-up ranged from 3 months to 3 years (median 2 years). The short-term mortality was similar with either TAVR or SAVR (2.2% for TAVR and 2.6% for SAVR, RR 0.89, 95% CI 0.56-1.41, P = 0.62), however, TAVR was associated with increased risk for intermediate-term mortality (17.2% for TAVR and 12.7% for SAVR, RR 1.45, 95% CI 1.11-1.89, P = 0.006). In terms of periprocedural complications, TAVR was associated with reduced risk for bleeding and renal failure and an increase in vascular complications and Pacemaker implantation. In patients who are at low surgical risk, TAVR seems to be associated with increased mortality risk. Until more data in this population is available, SAVR should remain the treatment of choice for these patients.

Эндоваскулярное лечение больных с критическим аортальным стенозом: сoвременное состояние проблемы и перспективы

The article contains the review of current understanding of the etiology and pathogenesis of degenerative aortic stenosis, approaches to surgical treatment depending on various factors, e. g. severity of defect and comorbidity, description of endovascular techniques (balloon valvuloplasty and transcatheter aortic valve implantation), and features of the selection of patients for these procedures. The authors also present assessment of results of operations performed from 2011 to 2016 in the city hospital № 2 in Saint-Petersburg. They analyze data from 72 high-risk aortic stenosis patients aged 81±6 years treated with transcatheter aortic valve implantation. In 68 out of 72 patients (94.4 %) clinical improvement was achieved with reduction of dilation of left ventricular cavity, decrease of functional class of heart failure, and decrease of mean pressure gradient across the aortic valve. A conclusion is made that these results confirm advantages and perspectives of the use of endovascular methods of treatment in this complicated group of patients.

Effectiveness of Rescue Percutaneous Balloon Aortic Valvuloplasty in Patients With Severe Aortic Stenosis and Acute Heart Failure

The prognosis of patients with cardiogenic shock (CS) or refractory pulmonary edema because of severe aortic stenosis remains poor. The purpose of this study was to assess the outcomes of rescue percutaneous balloon aortic valvuloplasty (PBAV) in the transcatheter aortic valve implantation (TAVI) era. Patients were consecutively included between 2008 and 2016. CS was defined as ≥1 sign of systemic hypoperfusion and need of catecholamines. Refractory pulmonary edema was defined as not controlled by optimal medical treatment. A total of 40 patients, 22 men (55%), aged 79 ± 9 years, were included: 17 with CS (42.5%), 23 with refractory pulmonary edema (57.5%). After PBAV, mean transaortic gradient decreased from 47 ± 16 mm Hg to 32 ± 10 mm Hg (p < 0.001), aortic valve area increased from 0.60 ± 0.18 cm2 to 0.88 ± 0.22 cm2 (p < 0.0001), left ventricular ejection fraction increased from 35 ± 15 to 37 ± 14% (p = 0.02), and systolic pulmonary artery pressure decreased from 61 ± 15 to 48 ± 12 mm Hg (p = 0.002). There was no procedural death. Early death occurred in 12 patients (30%). After PBAV, 16 of the 28 survivors (57%) were bridged to surgical aortic valve replacement (SAVR; n = 7) or TAVI (n = 9), and 12 (43%) were denied definitive therapy. The 2-year estimated survival rate was 71 ± 17% after SAVR, 36 ± 19% after TAVI, and 8 ± 8% after PBAV alone. In conclusion, rescue PBAV is safe in patients with CS and high-risk aortic stenosis or refractory pulmonary edema and may improve their dismal prognosis when followed by TAVI or SAVR.

GW28-e1195 The prognostic analysis of elderly high-risk severe aortic stenosis treated by different therapy procedure

GW28-e1195 The prognostic analysis of elderly high-risk severe aortic stenosis treated by different therapy procedure

Feasibility and applicability of static vascular outline roadmapping during transcatheter aortic valve implantation.

We investigated the application and feasibility of a novel software tool designed for the visualization of the aortic root during transcatheter aortic valve implantation (TAVI). The final positioning of the device prior deployment remains the most critical phase during TAVI. Philips "Vascular Outlining" prototype application was used during balloon expandable Edwards Lifesciences SapienXT valve deployment. It processes any angiographic sequences, extracting the static outline of vessels and projecting the two-dimensional vessel margins as a roadmap on live fluoroscopy. Preoperational planning, sizing and anatomical assessment of access routes were performed using computed tomography scans and the Philips "HeartNavigator" software. Fifteen high-risk aortic stenosis patients (mean age 82.0±6.6 years) underwent TAVI via transfemoral (N.=8), transapical (N.=4), and transaortic (N.=3) access routes. Mean logistic EuroSCOREs and STS-scores were 19.7±4.3% and 7.9±3.1%, respectively, mean aortic gradient was 66.3±18.3 mmHg. All valves were implanted successfully with none or trivial paravalvular regurgitation in 11 patients, mild in 3 patients, and moderate in 1 patient. TAVI was performed in all cases with only one aortic root contrast media injection during valve deployment. No major stroke or cardiovascular death occurred within 30 days. "Vascular Outlining"-guided implantation of the SapienXT valve is feasible. This new feature might increase the accuracy of valve placement and also may reduce the need for extra contrast media use during valve deployment. However, the lack of real-time motion compensation limits its wide application, as the overlay does not move together with respiratory and cardiac motion.

Transcutanous aortic valve replacement with Medtronic CoreValve in a publicprivate partnership hospital complex

Objective: The aim of this study was to assess the initial experience of transcutaneous aortic valve implantation (TAVI) in a high risk aortic stenosis population not suitable for conventional surgical valve replacement. Background: No data exist for TAVI with Medtronic CoreValve in South Africa and especially not in a public private partnership hospital complex. Methods: Retrospective data regarding severe aortic stenosis evaluation, risk stratifi cation and management were evaluated over a 24 month period. Results: A total of 106 patients were evaluated of whom 17 were accepted for surgical valve replacement (SVR) while TAVI was attempted in 25. The CoreValve was successfully implanted in 96% (24/25) of the cases. No procedural or peri-procedural deaths occurred. Three patients required permanent pacemaker insertion in the peri-procedural period and 2 patients had vascular access complications requiring blood transfusion only. Median hospital stay was 3.7days (range: 2 - 7). Aortic valve gradient showed a signifi cant reduction after valve implantation, which was sustained during follow-up (p<0.001). NYHA class symptomatology also improved from a median of 3.3 to 1.0 (p<0.001). During follow-up there were 4 late deaths, not related to the procedure, occurring after 78 to 193 days. Average cost for private and government patients were R268 000.00 and R163 000.00 respectively. Conclusions: The CoreValve can be implanted with a high success rate. Short term mortality and morbidity are acceptable. Signifi cant symptomatic improvement is gained at follow-up. The fi nancial implications are important.

CRT-800.25 Second Generation Versus First Generation Transcatheter Aortic Valve Replacement: A Meta-analysis

Transcatheter aortic valve replacement (TAVR) is increasingly being used for high and intermediate surgical risk aortic stenosis patients. Second generation TAVR valves (G2) with improved design have sought to address the drawbacks associated with first generation TAVR valves (G1). Electronic

Real-world 2-Year Outcomes from an Australasian High Risk Aortic Stenosis Service

Real-world 2-Year Outcomes from an Australasian High Risk Aortic Stenosis Service

Transaortic Aortic Valve Implantation in 100 Patients: Follow-up to 3 Years.

Transaortic aortic valve implantation (TAo-AVI) through the ascending aorta is a novel technique and is used as an alternative in patients with poor femoral access. Although early results have been promising, no midterm data have been published yet. To determine whether this approach is an acceptable treatment option, we analyzed the first 100 cases performed at our institution with a follow-up to 3 years. Between July 2011 and January 2015, a total of 100 patients with high-risk or inoperable aortic valve stenosis were treated with TAo-AVI. Preoperative patient data were collected and analyzed retrospectively. All surviving patients were seen for clinical and echocardiographic examination for follow-up. Median follow-up was 15 months. Device success was accomplished in 94 patients (94%). There were no access site complications. The 30-day mortality rate was 9%. Stroke occurred in a total of six patients (6%). Survival at 1-, 2-, and 3 years was 75%, 62%, and 58%, respectively. Our results show that TAo-AVI is a promising alternative to transapical implantation for treating severe inoperable aortic valve stenosis.

大動脈弁狭窄症に対するイノウエ・バルーンによる順行性大動脈弁拡張術 : 周術期および中期観察結果

大動脈弁狭窄症に対するイノウエ・バルーンによる順行性大動脈弁拡張術 : 周術期および中期観察結果