High-risk Transcatheter Aortic Valve Replacement Research Articles

Extracorporeal Membrane Oxygenation-Supported Patient Outcome Undergoing Transcatheter Aortic Valve Replacement.

The efficacy and safety of extracorporeal membrane oxygenation (ECMO) support during transcatheter aortic valve replacement (TAVR) remains unknown. We conducted a meta-analysis to compare benefit and risk of ECMO in TAVR patients. Bibliographic databases were searched from inception to January 1, 2024. Included studies involved patients ≥18 years old undergoing TAVR and using ECMO emergently or prophylactically. Mortality and procedure success were primary outcomes. Peri- or postoperative complications were the secondary outcomes. We identified 11 observational studies, including 2,275 participants (415 ECMO and 1,860 non-ECMO). The unadjusted mortality risk in ECMO-supported patient was higher than non-ECMO patients (odds ratio [OR] 1.73). The mortality unadjusted risk remained high (OR 3.89) and statistically significant for prophylactic ECMO. Prophylactic ECMO had lower mortality risk compared with emergent ECMO (OR 0.17). Extracorporeal membrane oxygenation-supported patients had lower procedural success rate (OR 0.10). Extracorporeal membrane oxygenation patients undergoing TAVR had significantly increased risk of bleeding (OR 3.32), renal failure (OR 2.38), postoperative myocardial infarction (OR 1.89), and stroke (OR 2.32) compared with non-ECMO patients. Clinical results are not improved by ECMO support in patients with high-risk TAVR. Prophylactic ECMO outperforms emergent. Overall, ECMO support increases mortality and postoperative complications. Transcatheter aortic valve replacement outcomes may improve with prophylactic ECMO in high-risk situations.

Impact of cerebral protection on observed versus predicted in-hospital stroke in a high stroke risk TAVR cohort

BackgroundDespite impressive improvements in the safety profile of Transcatheter aortic valve replacement (TAVR), the risk for peri-procedural stroke after TAVR has not declined substantially. In an effort to reduce periprocedural stroke, cerebral embolic protection (CEP) devices have been utilized but have yet to demonstrate benefit in all-comers. There is a paucity of data supporting the utilization of CEP in TAVR patients with an anticipated high risk for peri-procedural stroke.MethodsThe Transcatheter Aortic Valve Replacement In-Hospital Stroke (TASK) score is a clinical risk tool for predicting the in-hospital stroke risk of patients undergoing transfemoral TAVR. This score was used to identify high-risk patients and calculate the expected in-hospital stroke risk. This was a single-centre cohort study in all consecutive TAVR patients who had placement of CEP. The observed versus expected ratio for peri-procedural stroke was calculated. To obtain 95% credible intervals, we used 1000 bootstrapped samples of the original cohort sample size without replacement and recalculated the TASK predicted scores.ResultsThe study included 103 patients. The median age was 83 (IQR 78,89). 63 were male (61.1%) and 45 (43.69%) had a history of previous Stroke or TIA. Two patients had an in-hospital stroke after TAVR (1.94%). The expected risk of in-hospital stroke based on the TASK score was 3.39% (95% CI 3.07–3.73). The observed versus expected ratio was 0.57 (95% CI 0.52–0.64).ConclusionIn this single-center study, we found that in patients undergoing TAVR with high stroke risk, CEP reduced the in-hospital stroke risk by 43% when compared with the risk-score predicted rate.Clinical trial numberN/A.

Feasibility of standby ECMO with preset femoral vascular sheaths for high-risk transcatheter aortic valve replacement

Objective Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can provide temporary circulatory and respiratory support allowing hemodynamic stabilization during high-risk transcatheter aortic valve replacement (TAVR). However, the optimal timing of VA-ECMO use in high-risk TAVR remains controversial. We aimed to report our experience using a novel standby ECMO strategy during high-risk TAVR. Methods We retrospectively evaluated consecutive patients who received high-risk TAVR with standby ECMO between March 1,2023 and March 1,2024 at the Beijing Anzhen Hospital. Small, 5F or 6F sheaths were placed in ipsilateral femoral vein and artery before TAVR procedures. The primary outcome of this study was survival to hospital discharge with good neurological recovery defined as cerebral performance category (CPC) 1-2. Results A total of 24 patients undergoing high-risk TAVR with standby ECMO were included. Six (25.0%) of the 24 patients with standby ECMO suffered from cardiogenic shock or cardiac arrest and required emergency VA-ECMO institution. The median (IQR) cannulation time was 8 (6–11) minutes, and the median (IQR) ECMO duration was 35 (24–48) hours. All of the 24 patients underwent successful TAVR procedures and survival to hospital discharge with CPC1-2. Conclusions Standby ECMO with preset femoral vascular sheaths was feasible and effective for refractory cardiogenic shock and cardiac arrest during high-risk TAVR.

Utility of Photon Counting CT in Transcatheter Structural Heart Disease Interventions

Photon counting Computed Tomography (PCCT) is an innovative technology that utilizes a semiconductor detector and assigns x-ray photons to specific energy bins. PCCT features include ultra high-resolution, multi-energy binning, higher signal of iodine, lower artifacts, lower noise, and geometric radiation dose efficiency. These advantages may be highly beneficial in pre- and post-procedural assessment of transcatheter structural heart disease (SHD) interventions. Ultra-high resolution improves visualization of device structure and subtle findings such as hypoattenuated leaflet thickening, small vegetations and paravalvular leaks. High resolution also improves the evaluation of heavily calcified and stented coronary arteries, which are prevalent in high-risk transcatheter aortic valve replacement (TAVR) population. Visualization of heavily calcified coronary arteries and access vessels can also be improved by using multienergy calcium separation or high-energy virtual monoenergetic images (VMIs). PCCT allows use of low dose of iodinated contrast in severe renal dysfunction, due to inherent higher contrast-to-noise ratio of iodine, availability of a high-pitch helical mode and low-energy VMIs. High-energy VMIs can decrease artifacts including calcium blooming, beam hardening and metallic artifacts. Iodine maps enable quantification of extracellular volume without need for a non-contrast scan, facilitating the identification of cardiomyopathies like cardiac amyloidosis. Moreover, calcium score can be obtained from virtual non contrast (VNC) images derived from CT angiographic images. Additionally, VNC and iodine maps can characterize incidentally encountered lesions such as thrombus. In this article, we review the utility of PCCT in transcatheter SHD interventions.

Prevalence and Risk Factors Associated With Acute Kidney Injury After Transcatheter Aortic Valve Replacement at a Tertiary Hospital in Riyadh, Saudi Arabia.

Despite recent advancements in techniques, peri- and post-procedural complications still pose a significant challenge in the high-risk transcatheter aortic valve replacement (TAVR) patient population. This study aims to investigate and assess the prevalence of acute kidney injury (AKI) following TAVR, and to identify the risk factors associated with its occurrence. We conducted the study at King Abdulaziz Medical City, Riyadh, Saudi Arabia from January 2016 to December 2022. We extracted data from electronic medical records. We categorized and compared patientsbased on their diagnosis of AKI+ following TAVR, or their absence of AKI- after the procedure. The study included a total of 344 patients who underwent TAVR. The mean age of the patients was 77.8 ± 8.9 years, 61.8% were male, and the average body mass index was 30.5±7.0. In terms of comorbidities, 70.8% of the patients had diabetes mellitus, 80.5% had hypertension, 8.7% had hypothyroidism, 2.0% had hematological disorders, 23.6% had congestive heart disease, 20.4% had cerebrovascular disease, 4.1% had peripheral vascular disease, 7.3% had cancer, and 34.4% had other comorbidities. The prevalence of AKI was 60 (17.50%)following the procedure. Cerebrovascular diseases showed a significant association with AKI (OR= 3.381, 95% CI, 1.65-6.91, p = 0.001). Chronic kidney disease has a significant effect on AKI (OR = 2.56, 95%CI, 1.02-6.39, p = 0.044). The creatinine level on Day 0 has a significant association with AKI (OR = 1.01, 95%CI, 1.006-1.017, p = 0.0001). These findings highlight the importance of assessing and managing these risk factors (cerebrovascular diseases, chronic kidney disease, and creatinine level on Day 0) in TAVR patients to mitigate the occurrence and severity of AKI. By understanding and addressing these factors, healthcare providers can potentially improve patient outcomes and reduce the incidence of AKI-associated TAVR procedures.

In-Hospital and One-Year Outcomes of Transcatheter Aortic Valve Replacement in Patients Requiring Supplemental Home Oxygen Use.

There have been limited reports with inconsistent results on the impact of long-term use of oxygen therapry (LTOT) in patients treated with transcatheter aortic valve replacement (TAVR). We compared in-hospital and intermediate TAVR outcomes in 150 patients requiring LTOT (home O2 cohort) with 2,313 non-home O2 patients. Home O2 patients were younger, and had more comorbidities including chronic obstructive pulmonary disease (COPD), diabetes, carotid artery disease, lower forced expiratory volume (FEV1) (50.3±21.1% vs. 75.0±24.7%, P < 0.001), and lower diffusion capacity (DLCO, 48.6±19.2% vs. 74.6±22.4%, P < 0.001). These differences represented higher baseline Society of Thoracic Surgeons (STS) risk score (15.5±10.2% vs. 9.3±7.0%, P < 0.001) and lower pre-procedure Kansas City Cardiomyopathy Questionnaire (KCCQ-12) scores (32.5 ± 22.2 vs. 49.1 ± 25.4, P < 0.001). The home O2 cohort required higher use of alternative TAVR vascular access (24.0% vs. 12.8%, P = 0.002) and general anesthesia (51.3% vs. 36.0%, P < 0.001). Compared to non-home O2 patients, home O2 patients showed increased in-hospital mortality (5.3% vs. 1.6%, P = 0.001), procedural cardiac arrest (4.7% vs. 1.0%, P < 0.001), and postoperative atrial fibrillation (4.0% vs. 1.5%, P = 0.013). At 1-year follow-up, the home O2 cohort had a higher all-cause mortality (17.3% vs. 7.5%, P < 0.001) and lower KCCQ-12 scores (69.5 ± 23.8 vs. 82.1 ± 19.4, P < 0.001). Kaplan-Meir analysis revealed a lower survival rate in the home O2 cohort with an overall mean (95% confidence interval (CI)) survival time of 6.2 (5.9 - 6.5) years (P < 0.001). Home O2 patients represent a high-risk TAVR cohort with increased in-hospital morbidity and mortality, less improvement in 1-year KCCQ-12, and increased mortality at intermediate follow-up.

Prophylactic Awake Peripheral V-A ECMO during TAVR.

TAVR remains a complex procedure that may result in serious intraprocedural complications. In many of these circumstances, venoarterial extracorporeal membrane oxygenation (V-A ECMO) helps to manage complications, provides a hemodynamic back-up, and bridges to an emergency open heart surgery. The clinical outcomes of 27 patients who underwent prophylactic implantation of peripheral V-A ECMO (pV-A ECMO) during high-risk transcatheter aortic valve replacement (TAVR) cases are described. From June 2012 to October 2022, 590 consecutive patients underwent TAVR at our center. Of these, 27 patients (4.5%) underwent TAVR with pV-AECMO because they were deemed very high risk for periprocedural complications and formed the study population. There were no pV-A ECMO, hemodynamic or TAVR implantation complications. Decannulation of the ECMO system was performed in 92.6% of cases at the end of the procedure in the hybrid-operating theatre. The mean duration of pV-A ECMO for procedure support was 51.4 ± 10.3 min. There were no ECMO-related vascular or bleeding complications. This study shows that the prophylactic placement of awake peripheral V-A ECMO provides excellent temporary cardio-circulatory and pulmonary support during very high-risk TAVR procedures.

Assessment of Coronary Artery Obstruction Risk During Transcatheter Aortic Valve Replacement Utilising 3D-Printing

Current imaging techniques may inadequately rule out coronary artery obstruction (CAO), a potentially fatal complication during transcatheter aortic valve replacement (TAVR). Advancements in three-dimensional (3D)-printing allow the development of models capable of replicating cardiac anatomy and predicting CAO. We sought to simulate TAVR utilising 3D-printed cardiac models to improve CAO risk assessment and procedural safety. Thirteen (13) patients with aortic stenosis at high-risk of CAO during TAVR were selected for 3D-printed modelling. The relevant anatomy for TAVR was precisely reconstructed with Materialise Heart Print-Flex (Materialse, Leuven, Belgium) technology. An appropriately sized valve prosthesis was deployed in each 3D-model and coronary ostia assessed for obstruction. Model-derived results were compared to clinical outcomes in 13 cases. One high-risk case underwent TAVR resulting in left main obstruction and subsequent stenting. This outcome was accurately predicted by the 3D-model simulation. Two (2) high-risk TAVR cases were abandoned following transient CAO during balloon aortic valvuloplasty (BAV). The 3D-model simulations correlated with these findings, demonstrating CAO either by a calcium nodule or the native valve leaflet. In another two cases, BAV was uncertain, however the 3D-simulation demonstrated patency and successful TAVR was undertaken. In remaining cases, no obstruction was demonstrated in-vitro, and all underwent uncomplicated TAVR. In this proof-of-concept study, 3D-model TAVR simulation correlates well to clinical outcomes. 3D-models of patients at high-risk of CAO may be utilised in pre-procedural planning to accurately predict this complication. As lower-risk surgical cohorts are considered for TAVR, 3D-models may minimise complications leading to safer patient outcomes.

Cost-effectiveness analysis of a resource-intensive approach versus minimally invasive strategy for high-risk transcatheter aortic valve replacement patients.

Aortic stenosis has a high mortality rate in patients who do not receive aortic valve replacement. Previously, transcatheter aortic valve replacement (TAVR) was an intervention reserved for individuals deemed high-risk for surgery. Since that time, TAVR has increasingly been offered to lower risk patients, yet it is unclear whether TAVR will meet an acceptable cost-effectiveness threshold in this group. In this cost-effectiveness study, we employed a decision tree model with Monte Carlo probability sensitivity analysis to determine the incremental cost (in US$) per quality-adjusted life year (QALY) and life year (LY) of performing the TAVR procedure using the resource-intensive approach versus the minimally invasive strategy in high-risk surgical patients.

Evaluating the Association between Contrast Medium Dosage and Acute Kidney Injury in Transcatheter Aortic Valve Replacement Using Different Predictive Models.

Recent studies have suggested that contrast medium (CM) volume is associated with acute kidney injury (AKI) after transcatheter aortic valve replacement (TAVR). However, in a high-risk elderly TAVR population, the prognostic value and ideal threshold of CM dosage for AKI is unclear. Data of 532 successive TAVR patients (age 81.1 ± 6.8 years, EuroSCORE II 4.8% ± 6.0%) were therefore retrospectively analyzed. Based on a recently published formula, the renal function (preprocedural serum creatinine: SCr) corrected ratio of CM and body weight (CM*SCr/BW) was calculated to determine the risk of postprocedural contrast-associated AKI. AKI occurred in 94 patients (18.3%) and significantly increased 1-year all-cause mortality (23.4% vs. 13.1%; p = 0.001). A significant correlation between AKI and 30-day as well as 1-year all-cause mortality was observed (p = 0.001; p = 0.007). However, no association between CM dosage or the CM*SCr/BW ratio with the occurrence of AKI was seen (p = 0.968; p = 0.442). In our all-comers, all-access cohort, we found no relationship between CM dosage, or the established risk ratio model and the occurrence of postprocedural AKI. Further research needs to be directed towards different pathophysiological causes and preventive measures as AKI impairs short- and long-term survival.

Tricuspid regurgitation and in-hospital outcomes after transcatheter aortic valve replacement in high-risk patients.

BackgroundThe prognostic impact of tricuspid regurgitation (TR) following transcatheter aortic valve replacement (TAVR) is uncertain, and the management of patients with severe aortic stenosis and significant TR undergoing TAVR is unclear.MethodsRetrospective study investigating the role of TR severity on hospital outcomes in high risk patients with severe aortic stenosis undergoing TAVR.ResultsA total of 174 participants were included in the present study. The median age was 84 years and 48% were women. The median (IR) STS score was 7.3 (4.7–13.6). The pre-procedural mean (SD) aortic valve area (AVA) was 0.69 (0.2) cm2 and the average (SD) peak and mean gradients were 71 [23]/42 [15] mmHg. Pre TAVR, 28.7% of patients had significant (moderate or severe) TR. Significant TR pre-TAVR increased the risk of in-hospital cardiovascular (CV) and all-cause and mortality [adjusted relative risk (RR) (95% CI): 14.67 (1.35–159.51) and 5.09 (1.14–22.72), respectively], and those with severe TR post-TAVR had longer hospital stay [median (IR): 9.9 (2.9–17.0) days]. No improvement or worsened TR (greater than mild) post-TAVR was associated with higher CV and all-cause mortality [adjusted RR (95% CI): 21.5 (1.81–255.96) and 8.19 (1.67–40.29), respectively]. Right ventricular systolic pressure (RVSP) was independently associated with TR severity pre and post TAVR.ConclusionsSignificant TR was common among patients undergoing high risk TAVR, and is associated with increased in hospital mortality and longer hospital stay. Patients with elevated RVSP and persistent moderate or severe TR after TAVR are at higher risk of in hospital death.

Association of Right Ventricular Longitudinal Strain with Mortality in Patients Undergoing Transcatheter Aortic Valve Replacement

Conventional right ventricular (RV) echocardiographic measurements of systolic function (SF) have demonstrated conflicting results when their association with long-term outcomes after transcatheter aortic valve replacement (TAVR) is evaluated. RV free-wall (FW) longitudinal strain (LS) is a novel, single parameter to measure RV SF and may provide a better evaluation than fractional area change, tricuspid annular plane systolic excursion, and myocardial velocity (S'). The value of RV FW LS in patients undergoing TAVR and its association with 1-year mortality are unknown. The aim of this study was to test the hypothesis that RV FW LS would be associated with 1-year all-cause mortality in patients undergoing TAVR. Consecutive patients who underwent TAVR between 2007 and 2014 in whom RV FW LS was measurable were included; a subgroup that had 1-year follow-up echocardiographic evaluation of RV FW LS was analyzed. FW LS was derived from speckle-tracking analyses. The standard reference was determined as normal or impaired RV SF, the latter defined as the presence of ≥50% of tricuspid annular plane systolic excursion < 1.7cm, S' < 9.5cm/sec, and fractional area change < 35%. Cox proportional-hazards regression analysis was used to assess the association of RV FW LS with 1-year all-cause mortality. Of 612 patients, 334 were included for RV FW LS analysis on pre-TAVR echocardiography (feasibility 55%); exclusion criteria included atrial fibrillation (n=92 [15%]), pacemaker (n=73 [12%]), and poor image quality (n=113 [18%]). Baseline impaired RV SF was present in 19% of cases. RV FW LS did not change significantly at 1-year follow-up, in both the groups with baseline impaired and normal function. Cox regression analysis showed that RV FW LS was associated with all-cause mortality at 1year (hazard ratio, 1.06; 95% CI, 1.01-1.11). For each unit increase in RV FW LS, there was a 6% higher risk for 1-year mortality. In a high-risk TAVR population, RV FW LS should be considered a single echocardiographic parameter for the assessment of RV SF. When measurable, RV FW LS is associated with all-cause mortality at 1year after TAVR.

Comparative utility of frailty to a general prognostic score in identifying patients at risk for poor outcomes after aortic valve replacement

BackgroundCurrent guidelines recommend considering life expectancy before aortic valve replacement (AVR). We compared the performance of a general mortality index, the Lee index, to a frailty index.MethodsWe conducted a prospective cohort study of 246 older adults undergoing surgical (SAVR) or transcatheter aortic valve replacement (TAVR) at a single academic medical center. We compared performance of the Lee index to a deficit accumulation frailty index (FI). Logistic regression was used to assess the association of Lee index or FI with poor outcome, defined as death or functional decline with severe symptoms at 12 months. Discrimination was assessed using C-statistics.ResultsIn the overall cohort, 44 experienced poor outcome (31 deaths, 13 functional decline with severe symptoms). The risk of poor outcome by Lee index quartiles was 6.8% (reference), 17.9% (odds ratio [OR], 3.0; 95% confidence interval, [0.9–10.2]), 20.0% (OR 3.4; [1.0–11.4]), and 34.0% (OR 7.1; [2.2–22.6]) (p-for-trend = 0.001). Risk of poor outcome by FI quartiles was 3.6% (reference), 10.3% (OR 3.1; [0.6–15.8]), 25.0% (OR 8.8; [1.9–41.0]), and 37.3% (OR 15.8; [3.5–71.1]) (p-for-trend< 0.001). The Lee index predicted the risk of poor outcome in the SAVR cohort Lee index (quartiles 1–4: 2.1, 4.0, 15.4, and 20.0%; p-for-trend = 0.04), but not in the TAVR cohort (quartiles 1–4: 27.3, 29.0, 21.3, 35.4%; p-for-trend = 0.42). In contrast, the FI did not predict the risk of poor outcome well in the SAVR cohort (quartiles 1–4: 2.3, 4.4, 15.8, and 0%; p-for-trend = 0.24), however in the TAVR cohort (quartiles 1–4: 9.1, 14.3, 29.7, and 40.7%; p-for-trend = 0.004). Compared to the Lee index, an FI demonstrated higher C-statistics in the overall (Lee index versus FI: 0.680 versus 0.735; p = 0.03) and TAVR (0.560 versus 0.644; p = 0.03) cohorts, but not SAVR cohort (0.724 versus 0.766; p = 0.09).ConclusionsWhile a general mortality index Lee index predicted death or functional decline with severe symptoms at 12 months well among SAVR patients, the FI derived from a multi-domain geriatric assessment better informs risk-stratification for high-risk TAVR patients.

Use of Impella Support in Transcatheter Aortic Valve Replacement for a Patient With Severe Aortic Stenosis and Significantly Reduced Ejection Fraction

Abstract Transcatheter aortic valve replacement (TAVR) may be complicated by hemodynamic instability or circulatory collapse, especially in patients with severe left ventricular dysfunction. The Impella is a catheter-based ventricular assist device that is used in cardiogenic shock after myocardial infarction, high-risk percutaneous coronary intervention, and medically refractory heart failure. However, there is not a well-defined role for Impella in high-risk TAVR procedures. In this report, we describe the case of a patient with very low left ventricular ejection fraction undergoing TAVR with provisional Impella bailout use in the event of cardiovascular collapse during the procedure.

Abstract 156: Cost-Effectiveness Analysis of the Sentinel Cerebral Embolic Protection Device During Transcatheter Aortic Valve Replacement

Introduction: Transcatheter aortic valve replacement (TAVR) has been established as a standard of care for patients with severe aortic stenosis deemed at prohibitive or high risk for surgery. However, stroke remains an unpredictable and devastating complication after TAVR. The Sentinel cerebral embolic protection (CEP) device has been shown to collect thrombus and debris in 99% of patients during TAVR and possibly lowers risk of clinically-overt periprocedural stroke. Methods: We performed a cost-effectiveness analysis comparing CEP vs no CEP using a Markov model with 3 health states (stroke-free, post-stroke, death) and simulated an average 83-year old high-risk TAVR patient cohort. Risk of stroke and mortality at 30 days with and without CEP (5.6 vs 9.0 and 1.3 vs 1.8%, respectively) were based on the SENTINEL trial. U.S. healthcare costs, utilities, and long-term survival following TAVR with or without stroke were based on the PARTNER and CoreValve US Pivotal trials. Sentinel device costs were based on the manufacturer’s cost estimate ($2,400). We performed a probabilistic sensitivity analysis accounting for parameter uncertainty and calculated lifetime costs and quality-adjusted life years (QALYs) at a discount rate of 3%. Results: CEP increased QALYs of 3.81 by 0.16 (95% CI -0.04 to 0.54) and costs of $232,623 by $7,517 (95% CI $103 to 28,161), yielding an incremental cost-effectiveness ratio of $48,269 per QALY gained. The likelihood that CEP would be considered cost-effective at commonly used thresholds of $50-150k/QALY ranged from 45 to 86% ( Figure ). Results were influenced by procedural stroke risk and efficacy of the device. Conclusion: Our results suggest CEP may be considered a cost-effective strategy during TAVR.

LOWER DIASTOLIC BLOOD PRESSURE AFTER TRANSCATHETER OR SURGICAL AORTIC VALVE REPLACEMENT IS COMMON AND ASSOCIATED WITH INCREASED MORTALITY

Lower systolic blood pressure (SBP) after transcatheter aortic valve replacement (TAVR) has been associated with increased mortality, but the role of diastolic blood pressure (DBP) has not been carefully examined. Among patients enrolled in the Medtronic intermediate, high, and extreme risk TAVR

Assessment of Coronary Artery Obstruction Risk During Transcatheter Aortic Valve Replacement Utilising 3D Printing

Introduction: Current imaging techniques inadequately rule out coronary artery obstruction (CAO), a potentially fatal complication during transcatheter aortic valve replacement (TAVR). Advancements in 3D-printing may allow the development of models capable of replicating cardiac anatomy and predicting CAO. We sought to simulate TAVR utilising this 3D-technology to improve CAO risk assessment and procedural safety. Methodology: Eleven patients with aortic stenosis at high risk of CAO during TAVR were selected for 3D-printed modelling. The relevant anatomy to perform TAVR was precisely reconstructed from CT imaging with Materialise Heart Print-Flex technology. An appropriately sized valve prosthesis was deployed in vitro in each 3D-printed model and coronary ostia were assessed for obstruction. Results: Model-derived results were compared to clinical outcomes. Two high-risk TAVR cases were abandoned following transient CAO during balloon aortic valvuloplasty (BAV). In both cases, the 3D-model precisely simulated the clinical findings, demonstrating complete CAO either by a prominent calcium nodule or by the valve leaflet itself. In another case, the BAV outcome was uncertain, but the 3D-simulation demonstrated patency and successful TAVR implantation was undertaken with no obstruction. In other cases, no obstruction was demonstrated, and all underwent successful and uncomplicated TAVR. Conclusion: In this proof of concept study, model-derived TAVR simulation appears to correlate well to clinical outcomes. 3D-printed models of patients at high-risk of CAO may be utilised in pre-procedural planning to accurately predict this complication. 3D-models may help minimise TAVR complications leading to safer patient outcomes, especially as lower-risk surgical cohorts are considered in the future.

Ankle-brachial pressure index as a predictor of the 2-year outcome after transcatheter aortic valve replacement: data from the Japanese OCEAN-TAVI Registry.

Peripheral artery disease plays a pivotal role for access site selection in transcatheter aortic valve replacement (TAVR). Abnormal ankle-brachial index (ABI) is a generalized mortality marker in many cardiovascular scenarios. However, the long-term outcomes in high-risk TAVR populations remain unclear. We investigated the association between low ABI and 2-year outcome after TAVR. Of 1613 patients enrolled in the OCEAN-TAVI registry, 1458 (90.4%) who underwent ABI before TAVR were divided into groups: patients with (1) ABI≥0.9 in both legs and (2) ABI<0.9 in either leg. Primary endpoint was all-cause death within 2years. ABI<0.9 was noted in 304 patients (20.8%). ABI<0.9-group had more frequent and severe comorbidities. Primary endpoint in ABI<0.9-group was significantly higher than that in ABI≥0.9-group (15.8 vs. 8.7%, p<0.001). This trend continued in the transfemoral (TF)-approach (14.9 vs. 7.5%, p<0.001), but not in the alternative approach (17.2 vs. 15.8%, p=0.815). Within 30days, ABI<0.9-group had a higher cardiac death rate (3.1 vs. 1.0%, p=0.033), whereas between 31days and 2years, non-cardiovascular death was more frequently observed (9.2 vs. 5.1%, p=0.003). In ABI<0.9-group, in-hospital vascular complications (11.9 vs. 4.9%, p<0.001) and acute kidney injury (10.8 vs, 5.7%, p=0.009) were more frequently found when using the transfemoral-approach. In multivariate analysis, ABI<0.9 was an independent predictor of 2-year mortality (adjusted hazard ratio 1.495, 95% CI 1.007-2.220, p=0.046). Pre-procedure ABI<0.9 is a useful prognostic marker for all-cause mortality, even in high-risk TAVR populations.

Review of minimal access vs. transcatheter aortic valve replacement for patients with severe aortic stenosis

Transcatheter aortic valve replacement (TAVR) and minimally invasive aortic valve replacement (miniAVR) have become alternatives to surgical aortic valve replacement via median sternotomy (SAVR) to treat severe aortic stenosis (AS). Despite increased interest and utilization, few studies have directly compared TAVR and miniAVR. A review of the current literature shows TAVR to be an indispensable tool for inoperable, high-risk and perhaps intermediate-risk patients with severe AS. However, it is associated with a number of deleterious perioperative outcomes, such as valvular regurgitation and vascular complications. MiniAVR is associated with decreased intensive care unit (ICU) and hospital length of stay, a lower incidence of blood transfusions, decreased ventilation time and improved cosmetic results. MiniAVR maintains potential advantages over SAVR, including the implantation of a durable prosthesis and low rates of perioperative myocardial infarction and paravalvular leak. It is associated with longer aortic cross clamp and cardiopulmonary bypass (CPB) times; however, the use of sutureless valve implants can circumvent this. Studies comparing TAVR and miniAVR demonstrate decreased postoperative mortality, valvular regurgitation and incidence of stroke in the miniAVR cohorts. Few studies currently exist comparing TAVR and miniAVR, as it is hard to compare the typically low-risk miniAVR vs. high-risk TAVR patient populations. It is clear that both strategies will be cornerstones in the modern AVR era, but the situations in which to apply each strategy have not yet been clearly delineated. This highlights the need for surgeons to adopt these minimally invasive techniques. We believe there is a compelling role for miniAVR in low- and intermediate-risk patients, but due to the paucity of data, neither TAVR nor miniAVR should be discounted before a randomized, risk-stratified trial is performed. More studies are needed to compare TAVR and miniAVR in low- and intermediate-risk patients.

Review of minimal access versus transcatheter aortic valve replacement for patients with severe aortic stenosis.

Transcatheter aortic valve replacement (TAVR) and minimally invasive aortic valve replacement (miniAVR) have become alternatives to surgical aortic valve replacement via median sternotomy (SAVR) to treat severe aortic stenosis (AS). Despite increased interest and utilization, few studies have directly compared TAVR and miniAVR. A review of the current literature shows TAVR to be an indispensable tool for inoperable, high-risk, and perhaps intermediate-risk patients with severe AS. However, it is associated with a number of deleterious perioperative outcomes, such as valvular regurgitation and vascular complications. MiniAVR is associated with decreased intensive care unit (ICU) and hospital length of stay, a lower incidence of blood transfusions, decreased ventilation time, and improved cosmetic results. MiniAVR maintains potential advantages over SAVR, including the implantation of a durable prosthesis and low rates of perioperative myocardial infarction and paravalvular leak. It is associated with longer aortic cross clamp and cardiopulmonary bypass (CPB) times; however, the use of sutureless valve implants can circumvent this. Studies comparing TAVR and miniAVR demonstrate decreased postoperative mortality, valvular regurgitation, and incidence of stroke in the miniAVR cohorts. Few studies currently exist comparing TAVR and miniAVR, as it is hard to compare the typically low-risk miniAVR versus high-risk TAVR patient populations. It is clear that both strategies will be cornerstones in the modern AVR era, but the situations in which to apply each strategy have not yet been clearly delineated. This highlights the need for surgeons to adopt these minimally invasive techniques. We believe there is a compelling role for miniAVR in low- and intermediate-risk patients, but due to the paucity of data, neither TAVR nor miniAVR should be discounted before a randomized, risk-stratified trial is performed. More studies are needed to compare TAVR and miniAVR in low- and intermediate-risk patients.