Post TAVR Research Articles

HAEMODYNAMIC FORCES ANALYSIS IN PATIENTS WITH PARAVALVULAR REGURGITATION AFTER TAVR: A PROPENSITY–SCORE MATCHED RETROSPECTIVE STUDY

Abstract Background Paravalvular regurgitation (PVR) after TAVR is a frequent complication, but its direct quantification and grading with conventional echocardiography is still limited by several factors. LV remodeling has still a role in the evaluation of PVR and its pathophysiology. Hemodynamic forces (HDF) analysis has emerged as a new tool to evaluate LV cardiac function in addiction to ejection fraction (EF) and global longitudinal strain (GLS). Aim of the study: To evaluate the difference in pre– and post–TAVR HDF in patients with preserved EF, using a propensity–matched analysis comparing patients with more than mild PVR to patients with mild or no PVR. Medis Ultrasound Suite software has been used for the estimation of HDF in order to differentiate earlier LV function modification between the two groups and its relationship with clinical outcomes. Material and Methods 25 patients from two European high–volume centers with more than mild PVR and coupled pre– and post–TAVR echocardiographic evaluation available for HDF analysis were retrospectively included, paired 1:2 with 50 patients, matched for characteristics that may influence HDF analysis and with mild or none PVR. Clinical outcome was a composite of heart failure (HF) valve–related hospitalization and worsening HF at 1 year. Results No significative differences were found at baseline clinical and echocardiography evaluation between the two groups: median age was 83 years, mean LVEF was 61%. Post–procedural echocardiographic evaluation was performed at 34 days after TAVR (IQR 5 – 50). Patients with significant PVR had higher LV end–diastolic volume (p = 0.044), lower endocardial GLS (p = 0.07) and lower LV diastolic apex–base longitudinal forces (LVD Apex–Base) (p = 0.045). The difference between LVD Apex–base pre– and post–TAVR was significantly lower in the significant PVR group (–0.8 vs 0.3%, p = 0.021). At Cox regression analysis, LV longitudinal force (LVLF) Ratio turned out to be predictive of clinical outcome (HR 1.11, 95CI 1.02 – 1.20, p = 0.017) in the overall population. Conclusion HDF analysis seems to be superior to conventional echocardiographic values of left ventricular cardiac function to detect the early effects of LV volume overload in patients with significant PVR after TAVR. Furthermore, in the overall population, LVLF Ratio predicts clinical outcomes and could be a promising new index to better evaluate the development of heart failure in patients with AS undergoing TAVR.

Cardiac resynchronosation and left ventricular ejection fraction improvement with single ventricular conduction pacing system lead

Abstract Background Conduction system pacing is a new modality to obtain physiologic pacing (PP) and normal to near normal cardiac synchrony; they often obtain shorter QRS durations and they could replace the need of Bi-V (CRT) implants if LVEF improves as much with less leads implanted. Methods From our cohort of 340 physiologic pacing attempts (2019-2023), we extracted all patients (pts) with available ultrasounds before and after implants, aiming to describe the variation of Left Ventricular Ejection Fraction (LVEF) over time; all attempts, including failures were analyzed. Results A total of 146 pts completed follow-up LVEF evaluation. Pts were 36,8% females; median age was 79 +/- 8.5 years. Indications were: SSS 25%, AV block 41% (including 11 post TAVR), Pacemaker induced cardiomyopathy (PIMC) 27% and AV node ablation in 7%. Success to achieve cardiac resynchronisation (defined as a QRS shorter than 140ms and a LVAT shorter than 90ms, or 20% reduction in QRS width) was obtained in 82,6% of pts (higher success rate achieved with LBB-P: 88,4% vs 55,5% for His-P). Procedural time (pts in-out) was 88min (+/- 37min). Pts with a QRS larger than 150ms (CRT indication) were 49% of the cohort. Patients with a LVEF less than 50% accounted for 54,8% of the cohort. Mean QRS duration was 141,9ms (+/-36) pre-implant and 129,3ms (+/- 19) post implant. Mean LVEF was 43,6% (+/- 14) before implant and increased to 50,2% (+/-12) post implant for the entire cohort, in pts with CRT indication, variation persisted: mean LVEF improved from 33,2 to 43,8% and QRS duration from 172,9 to 136,8ms. Pts with less than 50% LVEF had a response rate of 75,5% (increase in LVEF from 4-41%), and 33% of patients increase their LEVF between 10-30% (deemed super responders), only one pt decrease 10% her LVEF (a His failure implant). Conclusion Cardiac resynchronisation is feasible with only one ventricular lead, potentially with longer duration of batteries and lesser costs. Response rate is similar to CRT historical controls but super responders are twice to three times higher than historical controls.

Abstract 17917: Effect of Transcatheter Aortic Valve Replacement (TAVR) on the Dicrotic Notch in Patients With Severe Aortic Stenosis

Background: The dicrotic notch in the aortic pressure waveform is seen around the time of closure of the aortic valve at the end of systole and the beginning of diastole. We aim to study the change in the dicrotic notch post TAVR in patients with severe AS and its impact on clinical outcomes. Methods: We included patients with severe AS who underwent TAVR consecutively between 2019-2020. Central aortic pressure waveforms were reviewed from the SyngoDynamics imaging software (Siemens Healthcare, Malvern, PA) for the invasive hemodynamic data obtained during TAVR. Heights of the systolic, diastolic blood pressure and dicrotic notch waveforms are measured. Dicrotic notch index (DNI) is calculated as the difference between the SBP and dicrotic notch divided by the pulse pressure (see figure 1). The invasive hemodynamics are compared between pre and post TAVR using independent samples t test. Statistical significance was defined as two-tailed p-value less than 0.05. Survival analysis is performed using cox regression. Results: A total of 724 patients (1448 studies) were evaluated. There is significant increase in dicrotic notch pressure (p<0.001) and DNI (p<0.001) post-TAVR in the overall population. Women (n=310) had a higher pre-TAVR and post-TAVR DNI (p<0.001 and p<0.01 respectively). Figure 1 shows hemodynamic characteristics of before and after TAVR. Heart failure hospitalization (HFH) or mortality at 3 years (composite outcome) was present in 146 patients (20.1%). DNI was lower in patients reaching composite outcomes compared to patients surviving without HFH (p<0.001). Conclusion: Higher DNI after TAVR is associated with lower HFH and mortality after TAVR. Simple measurement of DNI offer substantial prognostic value to patients with severe AS undergoing TAVR.

Abstract 14082: Evans Syndrome Post Transcatheter Aortic Valve Replacement: A Rare Presentation

Description of Case: Evans Syndrome is a rare hematologic condition. Here we present a patient who developed Evans Syndrome post TAVR. A 63-year-old male with history of HFrEF and aortic stenosis presented with 2-week history of worsening shortness of breath and bilateral lower extremity swelling. He was found to be in cardiogenic shock. TTE showed (LFLG) aortic stenosis (AS). Due to concomitant cardiogenic shock and tachyarrhythmias, we were unable to perform dobutamine stress echo. A cardiac CT was performed which revealed an aortic valve calcium score of 2761 (Figure 1). The diagnosis of severe AS was confirmed, and patient underwent TAVR. Postprocedural TTE showed significant improvement in EF. Patient’s complete blood count on admission was remarkable for Hgb of 12.5 g/dL and PLT of 148 k/mm 3 . Both Hgb and PLT began to drop significantly following TAVR. We ruled out vascular access site bleeding, mechanical complication from paravalvular leak, nutritional deficiencies, disseminated intravascular coagulation, heparin-induced thrombocytopenia, thrombotic thrombocytopenic purpura, myelodysplastic syndrome, HIV, hepatitis C. Autoimmune hemolytic anemia was identified given elevated lactate dehydrogenase, low haptoglobin, and positive IgG direct antiglobulin test. We started steroids and treat the case as Evans syndrome. PLT count improved from 67 to 117 k/mm 3 within 2 days of steroids initiation. The bone marrow biopsy was deferred to outpatient follow up given the response to steroids. Patient was discharged on oral prednisone. Three-month follow up showed Hgb and PLT with normal limits. Discussion: Anemia and thrombocytopenia are common complications post TAVR. Both anemia and thrombocytopenia are suggested to be excellent markers for clinical outcomes, morbidity and mortality after TAVR. It is crucial to keep a broad differential for post TAVR anemia and thrombocytopenia. Less common causes should be evaluated and addressed to improve prognosis.

Immediate hemodynamic effects of transcatheter aortic valve replacement on left ventricular stroke volume and carotid artery blood flow

IntroductionTranscatheter aortic valve replacement (TAVR) is performed in selected patients with severe aortic valve stenosis, leading to immediate relief of left ventricular outflow obstruction. The purpose of this study was to evaluate the immediate hemodynamic effects of TAVR on left ventricular stroke volume (SVLVOT) and common carotid artery stroke volume (SVCCA). Material and methodsTwenty-five TAVR patients were included in this prospective observational study. Patients were treated under either local, or general anesthesia. Echocardiographic, and carotid ultrasound measurements were performed in the operating room pre (T1), and post (T2) TAVR. Changes in SVLVOT, SVCCA, carotid peak systolic velocity (PSV), pulsatility index (PI) and other carotid Doppler parameters were evaluated. ResultsFollowing TAVR, the aortic valve area (AVA) increased from 0.8 [0.6–0.9] to 1.9 [1.6–2.3] cm2 (p < 0.001), and the peak transvalvular gradient (PGAV) decreased from 70 [65–81] to 15 [11-18] mm Hg (p < 0.001) from T1 to T2. SVLVOT increased from 58 ± 17 to 69 ± 24 ml, p < 0.01, whereas SVCCA remained unchanged (from 10 [7-11] to 10 [8-11] ml, p = 0.50). Δ SVLVOT was 19 [7–31] % and Δ SVCCA was 1 [-7-20] %, p < 0.05. PSV increased from 68 ± 17 to 81 ± 17 cm/s, p < 0.001, and PI increased from 1.7 [1.5–2.2] to 2.2 [1.7–2.6], p < 0.001. ConclusionSuccessful TAVR resulted in immediate improvement of left ventricular stroke volume, whereas carotid stroke volume remained unchanged.

PO-03-111 PACEMAKER DEPENDENCY AND IMPACT ON MORTALITY FOLLOWING TRANSCATHETER AORTIC VALVE REPLACEMENT

Conduction abnormalities requiring permanent pacemaker (PPM) are a frequent complication following TAVR. Few studies have evaluated chronic pacemaker dependency after TAVR. To evaluate post-TAVR pacemaker dependency and impact on mortality at one year. 626 patients with severe aortic stenosis who underwent TAVR between 01/01/2012 and 12/31/2019 were identified. Those with pre-TAVR pacemaker were excluded. Patients underwent post TAVR PPM if found to have high grade AV block,> 5seconds pause or symptomatic bradycardia < 50 bpm. Patients who underwent TAVR without PPM implant represented the control arm. PPM dependency was defined as > 50% pacing during 1 and 30 days post implantation. All-cause mortality was reported at one year. Of 357 patients, 16% required PPM with no difference in either balloon expandable or self-expandable valve types (14.6% vs 17.6%; P=0.471). The mean age was 80 + 8.2 years, and 52.7% were male. The median time to PPM implantation was 2 days. The main indications were complete AV block (67%) and symptomatic bradycardia (8.8%). 56.1% received a dual chamber, 24.6% a single chamber and 8.8% received a biventricular PPM. At day 1 and 30 days following implant 73.7% and 78.9% of patient fulfilled criteria for PPM dependency. There were no difference in mortality between the cohorts at one year (Fig. 1). 78% of patients requiring PPM post TAVR were pace dependent at 30 days. PPM implantation did not have an impact on mortality at 1 year. Indications for acute pacing predicted PPM dependency at 30 days and support the selection criteria used for PPM implantation in this cohort.

Abstract 11271: Post TAVR Outcomes Among Patient With Amyloidosis and Aortic Stenosis: A Meta Analysis

Introduction: Aortic stenosis (AS) is one of the most prevalent valvular heart diseases globally. As many as 16% of AS patients have underlying cardiac amyloidosis (CA). To date, there is a paucity of data on outcomes among AS with concomitant CA patients post-TAVR. Hypothesis: This study aimed to evaluate the clinical outcomes post TAVR among patients with CA. Methods: We performed a systematic literature search of databases for relevant articles from inception until June 01, 2022. Unadjusted odds ratios (OR) were pooled using a random-effect model, and a p-value of &lt;0.05 was considered statistically significant. Results: 5 studies with 1,488 patients were involved in the final analysis. The mean age of patients among CA+AS and AS alone was (85 vs 80) years. The number of males affected with dual pathology was higher compared to AS alone (71% vs 59%). 29% of patients were having a right bundle branch block in the CA+AS group, while 12% were among AS alone. Mean IV Septal Thickness (1.53 vs 1.33), mean relative wall thickness (0.60 vs 0.40) and mean LA dimensions (5.19 vs 4.8) were higher among the CA+AS group compared with AS alone. At the mean follow up of 12 months the odds of in-hospital mortality (OR, 2.09(95% CI: 0.77-5.63), P = 0.15), stroke (OR, 0.46(95%CI: 0.06-3.60), P = 0.46), and vascular complication (OR, 0.19(95% CI: 0.01-3.40), P = 0.26) were comparable between both group. In contrast, the incidence of acute kidney injury (OR, 3.09(95% CI: 2.02-4.71), P&lt;0.001), and major bleeding (OR, 1.74(95% CI: 1.02-2.98), P = 0.04) were significantly higher among CA+AS group compared to AS group following TAVR. Conclusions: TAVR appeared to be a safe procedure among patients diagnosed with amyloidosis in aortic stenosis with a similar mortality rate between both groups of patients. Further studies should aim at determining the optimal valve replacement strategy in AS patients with concomitant CA.

Abstract 12115: TAVR Endocarditis Complicated by Aortic Root Pseudoaneurysm

Case Presentation: An 83-year-old man with hypertension, hyperlipidemia, atrial fibrillation, non-obstructive CAD, and severe AS status post TAVR 4 months prior was transferred from an outside hospital with reported persistent fever for one week. He had no other procedure recently including dental work. He was found to have staphylococcus epidermidis bacteremia in multiple blood cultures. His outside hospital TEE showed pulsatility of the non-coronary sinus with possible vegetations on the noncoronary cusp of the TAVR. On physical examination, he was afebrile, normotensive, and well appearing. His cardiovascular examination, laboratory tests, and chest radiograph were unremarkable, and he denied any chest pain or shortness of breath. His ECG revealed rate-controlled atrial fibrillation. A cardiac CTA revealed a 6 mm mobile hypodense thickening of the non-coronary prosthetic cusp, suspicious for vegetation and a contrast opacifying outpouching in the aortic root near the aorto-mitral curtain, suspicious for pseudoaneurysm. The patient underwent TAVR explantation, pseudoaneurysm exclusion, and AVR using a 23 mm bioprosthesis (Figure). He was discharged 8 days later on antibiotic treatment. At follow-up, the patient felt well with no complaints. Discussion: TAVR endocarditis with resulting aortic root pseudoaneurysm is an immensely rare entity, where there is lack of clinical data with regards to management. Guidelines of prosthetic valve endocarditis (for both TAVR and SAVR) recommend surgical treatment in such cases, although this recommendation was mostly based on the SAVR literature and many patients who undergo TAVR are at higher surgical risk at baseline. Recent studies on TAVR explantation showcase the risky nature of surgery in these patients, with high mortality rates, making treatment decisions less clear. Careful multidisciplinary discussion of risk and benefits is vital to guide clinical decision making in these complex patients.

Predictors of high-degree atrioventricular block in patients with new-onset left bundle branch block following transcatheter aortic valve replacement.

The development of new left bundle branch block (LBBB) is frequently seen post TAVR and is a known risk factor for progression to high degree AV block. The timing and likelihood of progression into complete heart block is variable and can develop after hospital discharge. We sought to determine predictors for the development of high degree AV block in patients who developed LBBB following TAVR. All patients between 2014 and 2019 underwent electrophysiology study after developing LBBB post TAVR. Data on these patients including baseline characteristics, echo parameters, EKG variables, HV interval, and the need for subsequent pacemaker implantation were extracted. A prolonged HV interval was defined as ≥ 65ms. Clinically significant conduction abnormality was defined as development of high-degree AV block or clinically significant complete heart block. Thirty-four patients were included in our study of which 10 (29.4%) developed clinically significant heart block, while 24 (70.6%) did not. The mean HV interval for patients with clinically significant heart block was 70.1ms vs 57.8ms for those who did not (p = 0.022). Pre-existing first-degree heart block prior to TAVR (p = 0.026), history of AFib (p = 0.05) in addition to STS score (p = 0.037) were predictors of development of high-degree AV block in our patient population. In patients who develop LBBB following TAVR, HV interval, pre-existing first-degree heart block, and STS score predict progression to high-degree AV block. Performance of a routine electrophysiology study should be considered for high-risk patients who develop LBBB following TAVR.

The native aortic valve reduces paravalvular leak in TAVR patients.

Background: Paravalvular leak (PVL) is a frequent TAVR complication. Prospective identification of patients who are likely to develop PVL after TAVR would likely lead to improved outcomes. Prior studies have used geometric characteristics to predict the likelihood of PVL development, but prediction and quantification has not been done. One of the reasons is that it is difficult to predict the mechanical deformation of the native diseased aortic valve prior to implantation of the prosthetic valve, as existing calcifications likely contribute to the seal between the prosthetic valve and the aortic annulus. However, the relatively amount the native valve plays in preventing PVL is unknown. Methods: A retrospective chart review was conducted identifying patients with mild or greater PVL. One patient who had substantial PVL was identified and a 3D printed (pre-TAVR) aortic root was created. Balloon-expandable TAVR stent frames were implanted within the 3D printed root and a new model was created. Using this geometry, computational fluid dynamics (CFD) simulations were done to quantify PVL. The PVL flow path was iteratively decreased to simulate the space occupied by a crushed native aortic valve and PVL was quantified. Results: PVL was found to decrease as the space occupying the PVL area increased, demonstrating that the native aortic valve contributes to reducing regurgitation. CFD simulations demonstrated that within the patient analyzed, the native valve occupies between 3–40% of the PVL pathway. Conclusion: A priori techniques that predict the development of post TAVR PVL should account for the native diseased valve as our simulations demonstrate that it plays a role in reducing PVL.

Alternative Application Technique for the MANTA Vascular Closure Device for Percutaneous Large-Bore Arterial Access Closure: The Fluoroscopic DOT Technique

Background: Vascular complications are a cause of increased morbidity and mortality when performing percutaneous procedures requiring large-bore arterial access. MANTA vascular closure device (VCD) is currently the only large-bore VCD using an intraluminal foot plate and an extraluminal collagen plug. The traditional depth locator approach might be compromised in; emergent cases without the required measurements, cases of hematoma formation, or other patient, procedure, or operator-specific variables. Furthermore, this technique can be used for postclosure in cases without the required measurement of depth. We describe vascular outcomes using fluoroscopy (fluoroscopic DOT technique) rather than traditional depth locator approach for vascular closure with the MANTA VCD. Methods: Fifty patients who underwent transcatheter aortic valve implantation (TAVI) were retrospectively analyzed using fluoroscopic DOT technique with 18F MANTA VCD between May and August 2021. All patients >18 years of age who qualified for transfemoral TAVI were included. Access was obtained with ultrasound guidance with vessel diameter of at least > 6 mm and free from anterior vessel wall calcification. Patient related factors and primary outcomes of access site bleeding and acute flow-limited limb ischemia requiring intervention were prospectively analyzed. Furthermore, 1 patient who failed hemostasis with suture-mediated VCD had successful hemostasis with fluoroscopic DOT technique as dry postclosure after balloon aortic valvuloplasty. Results: In total, 50 patients were analyzed with a mean age of 81 years and majority were male (56%). Majority had comorbidities of hypertension (88%) and hyperlipidemia (94%), 24% had peripheral arterial disease, 38% coronary artery disease, and 58% were former smokers. Importantly, 40% were obese with an average body mass index (BMI) of 29 kg/m2. There were no bleeding or ischemic limb complications post MANTA VCD deployment using the fluoroscopic DOT technique. Furthermore, none of the patients required peripheral intervention from index procedure to 1 month post verified during their 1-month post TAVR follow-up. Conclusion: Fluoroscopic DOT technique using the MANTA VCD is highly reproducible and allows hemostasis in a predictable manner for procedures requiring large-bore arterial access in the absence of MANTA depth measurement.

Infective endocarditis post-transcatheter aortic valve replacement: a systematic review of epidemiology, clinical findings and prognosis

Abstract Funding Acknowledgements Type of funding sources: None. Background Transcatheter aortic valve replacement (TAVR) is a minimally invasive, catheter-based procedure to replace calcified narrow aortic valves. Available data on prosthetic valve endocarditis (PVE) post TAVR is limited to small subject populations in the form of case reports and case series. This systematic review aims to evaluate first the incidence of infective endocarditis post TAVR, second the microorganism profile and clinical findings, and third associated mortality/morbidity. Methods By adhering to the 2020 PRISMA statement guidelines, a systematic search was conducted to identify studies reporting the incidence of PVE post TAVR. An analysis of patient data including baseline characteristics, clinical findings, and outcomes was conducted. The following keywords were used by applying the BOOLEAN (and/or) logic: infective endocarditis, prosthetic endocarditis, transcatheter aortic valve replacement. Results In total, 18 studies were included, comprising 63,604 patients who underwent TAVR. All included studies were observational, i.e., seven multicenter registries, five retrospective studies, three cohort studies, two single-center observational studies, and one prospective study. The analysis yielded that 2.9% (1891) of the included patients suffered from post-TAVR infective endocarditis (IE). The patients with post-TAVR IE had a mean age of 79.2 ± 3.5 years, and 59.6% were males. Nine studies reported theuse of antibiotics for prophylaxis, with β-lactams being the most commonly used. Seventeen studies reported the type of bacteria isolated in cultures; all studies found enterococcus and staphylococcus species, whereas Streptococcus was isolated in 7 of the 18 studies. Only 3% (60) of the patients had a prior history of IE. Of the reported complications post-TAVR, heart failure was the leading complication, with 0.2% of patients experiencing neurological symptoms, including stroke. The overall mortality rate ofpost-TAVR IE, estimated to be 23%, was alarmingly high. Conclusion This synthesis collates a low (2.9%) incidence of infective endocarditis post-TAVR, however high mortality and morbidity by means of heart failure and stroke is documented. Ultimately, appropriate medical care ought to be taken to reduce post-TAVR complications, with cautious and warranted measures of antibiotics prophylaxis to avoid valve complications.

Transcatheter aortic valve replacement in the developing world: Lessons learnt and its implications for practice

BackrgroundTranscatheter aortic valve replacement (TAVR) has become an accepted modality of treatment in intermediate and high surgical risk patients of symptomatic severe calcific aortic stenosis (AS). We herein report Indian data of 84 intermediate and high-risk patients who underwent TAVR at two Armed Forces cardiac centres. MethodsMost of the patients underwent TAVR in cardiac catheterization lab by percutaneous transfemoral approach, under conscious sedation. Patients were followed up and echocardiographic parameters were assessed after six months of procedure. ResultsTotal of 84 intermediate and high-risk patients underwent TAVR between Jan 2017 and June 2021. Mean age of population was 71.5 ± 8.4 years; 28.5% of patients had bicuspid aortic valve and Mean STS score was 6.34 ± 2.08. Majority (92.8%) patients underwent the procedure under conscious sedation. Self-expanding valves were used in 72.6% and balloon expandable in 27.4% of patients. Predilatation was done in 64% patients while 13% cases underwent post dilatation. Procedural mortality was 2.3%. Rate of permanent pacemaker implantation was 4.9%. Ischemic stroke occurred in 1.1% of patents. There was no case of severe paravalvular leak. Emergency surgical aortic valve replacement was done in 2.4% patients. Procedural success in this study was 97.6%. All-cause mortality was 9.5% at 6 months. ConclusionsTAVR is an effective treatment modality in intermediate and high-risk Indian patients with severe aortic stenosis. Patients with bicuspid or previous bio prosthetic aortic valves also have a good outcome post TAVR.

Permanent pacemaker implantation post transcatheter aortic valve replacement- the role of pacing burden

Abstract Introduction Previous studies have provided inconsistent results regarding the clinical impact of new permanent pacemaker (PPM) post TAVR. Our aim is to evaluate whether new PPM post TAVR is associated with higher 1-year mortality and/or heart failure hospitalizations and whether pacing burden is related to adverse outcomes. Results Overall, 1245 patients underwent TAVR between the years 2008–2019 and were included in our analysis with a median follow up of 2.3 years (IQR 1–4). 191 (15%) had a new PPM implantation during index admission. Compared to patients without PPM those implanted had significantly higher 1-year mortality rate (18% vs 11%, p-0.007) as well has higher combined outcome of mortality and HF hospitalizations. There was no difference in pacing burden between survivors and non survivors in all models examined: first and last clinic visit, maximal pacing during the first-year post implantation and the difference in pacing trend between visits. Older age, peripheral artery disease (PAD) and previous myocardial infarction (MI) were independently associated with mortality or combined outcome of mortality and HF hospitalizations. Conclusion New pacemaker implantation post TAVR is associated with higher 1-year mortality and HF hospitalization, however pacing burden isn't associated with adverse clinical course. Funding Acknowledgement Type of funding sources: None.

Outcomes of transfemoral-transcatheter aortic valve replacement with Sapien-3 valve in liver cirrhosis patients

Abstract Background Little is known about the outcomes of liver cirrhosis patients with severe aortic stenosis (AS) who undergo transcatheter aortic valve replacement (TAVR). Methods We undertook a retrospective analysis of consecutive patients with severe symptomatic AS who underwent transfemoral-TAVR with Sapien-3 valve at our Clinic between April 2015 and December 2018, yielding 32 patients with liver cirrhosis on imaging including ultrasound and/or computed tomography. Their baseline characteristics, procedural and long-term outcomes after TAVR with the non-cirrhotic group were compared, along with their management strategies as per the hepatology team. Results Among 1028 patients, 32 were assigned to the cirrhosis, and 996 were assigned to the non-cirrhosis (control) group. Compared with the control group cirrhotic patients were slightly younger in age (74.5 vs 81.2 years), had a slightly higher BMI (31.3 vs 29.3), and had a higher incidence of prior history of myocardial infarction (38% vs 33%). Baseline variables including the history of smoking, hypertension, diabetes, and atrial fibrillation were comparable in both groups. Among cirrhotic patients (n=32), the most common etiologies were non-alcoholic steatohepatitis (NASH) (37.5%), Alcoholism (18.75%), and Hepatitis C (12.5%). The mean MELD-NA score was 11.8 and 67% of patients were Child PUGH Class A and 33% were Child PUGH Class B and all patients had a Child PUGH score of ≥5. 53% of patients (n=17) in the cirrhosis group were evaluated by Hepatology and 12.5% (n=4) were evaluated for a liver transplant but only 1 patient had a liver transplant post-TAVR. Compared with the control group cirrhotic patients had similar 1-year mortality (12% vs 12%, p=1), had a lower rate of 30-day new pacemaker post tavr (6% vs 9% p=0.85), had a higher rate of 1-year readmission for heart failure (12% vs 5% p=0.12) and similar 1-year major adverse cardiac and cerebrovascular event (MACCE) rate (15% vs 14% p=0.98) Conclusion Patients with severe AS undergoing TAVR with concomitant liver cirrhosis demonstrate comparable outcomes compared with their non- cirrhotic counterparts. NASH followed by alcoholic cirrhosis was found to be most common etiology. Funding Acknowledgement Type of funding sources: None. Figure 1Figure 2

Comparing predictors of permanent pacemaker insertion after TAVR in new-generation versus early generation heart valves

Abstract Introduction Transcatheter Aortic Valve Replacement (TAVR) has emerged as the standard of care for patient with severe aortic stenosis. Conduction abnormalities leading to permanent pacemaker (PPM) implantation is one of the most common complication after TAVR. Newer generation valves (NGV) such as Sapien S3, XT and Evolut are widely being used in real time practice. The aim of this analysis is to compare the predictors associated with increased risk of PPM implantation after TAVR in newer generation valves (NGV) as compared to older generation valves (OGV). Methods A comprehensive literature search was performed in PubMed, Embase, and Cochrane to identify relevant trials. Summary effects were calculated using a DerSimonian and Laird random-effects model as odds ratio with 95% confidence intervals for all the clinical endpoints. Results 18 observational studies with 16,004 patients were identified. The incidence of PPM implantation after TAVR in our analysis was 8.9%. For the NGV, right bundle branch block (RBBB) and atrioventricular (AV) block were independent predictors of PPM insertion after TAVR. Baseline heart rate, presence of atrial fibrillation, and baseline intraventricular conduction delay were not significant predictors. However, for the OGV, risk of PPM implantation after TAVR was higher in presence of RBBB, depth of implant, valve size/annulus size, presence of atrial fibrillation and post-procedure AV block. Conclusions Our analysis identified 2 factors that were significantly associated with increased risk of PPM insertion after TAVR in NGV compared to 6 factors with OGV. With the increasing physician expertise with TAVI and use of NGV, the incidence of post TAVR PPM insertion has reduced but baseline RBBB and AV conduction block still continue to be significant predictors of increased PPM insertion after TAVR. Funding Acknowledgement Type of funding sources: None.

Perioperative serious complications in patients undergoing transcatheter aortic valve replacement: a single-center experience

Objective: To observe the incidence of perioperative severe complications in aortic stenosis (AS) patients undergoing transcatheter aortic valve implantation (TAVR), and to explore the influence of the accumulated experience of the operators on the incidence of complications. Methods: This is a single-center retrospective study. Patients with AS who underwent TAVR from May 2016 to November 2020 in General Hospital of Northern Theater Command were included. The occurrence of severe complications during perioperative period was recorded. Severe complications included all-cause death, surgical transfer to thoracotomy, coronary artery occlusion, peripheral vascular approach complications, severe cerebrovascular events, moderate or above perivalvular leakage, valve displacement (implanted valve middle valve), pacemaker implantation, etc. In order to observe the influence of the accumulated experience of the operators on the occurrence of postoperative complications, the complications in each stage of the patients were counted and the bar chart was drawn with interval of every 30 patients. Results: A total of 119 patients were included, including 64 males and 55 females, the mean age was (73.9±6.9) years. The valve implantation was unsuccessful in 3 out of 119 patients (2.5%). There were 39 cases of severe complications during perioperative period, including 1 death (0.8%), 2 cases of thoracotomy (1.7%), 2 cases of coronary artery occlusion (1.7%), 8 cases of peripheral vascular approach complications (6.7%), and 1 case of new severe cerebrovascular event (0.8%), 3 cases of moderate or higher perivalvular leakage (2.5%), 8 cases of valve displacement leads to midvalvular implantation (6.7%), 14 cases of permanent pacemaker implantation due to new atrioventricular block (11.8%). The bar chart showed that the incidence of permanent pacemaker implantation and in-valve implantation did not significantly decrease with the accumulation of experience, while the incidence of other complications showed a decreasing trend after 30 cases. Conclusions: Most serious complications occurred in the early stage of TAVR in our center. The incidence of all cause death, coronary artery occlusion and peripheral vascular approach complications in the perioperative period post TAVR could be reduced in the TAVR center in the learning stage through the accumulation of procedure-related experience, but the incidence of pacemaker placement and the implanted valve within the valve dose not significantly decrease over time.

Impact on outcome of different etiologies, baseline degree and improvement of mitral regurgitation in patients with aortic stenosis who underwent transcatheter aortic valve replacement

Abstract Funding Acknowledgements Type of funding sources: None. Background - Mitral regurgitation (MR) is a frequent finding in patients with aortic stenosis (AS). Moderate or severe MR is present in up to one-third of pts undergoing TAVR and it is a negative prognostic factor as well as the presence of residual MR after TAVR. However, whether different etiologies/mechanisms of MR have different effects on outcome and MR degree changes after TAVR is yet unknown. Aim – The aim of the study is to evaluate the prognostic impact of baseline MR degree and its changes after TAVR procedures according to different etiologies of MR in patients who underwent TAVR. Methods - We performed a retrospective observational study on a cohort of patients who underwent TAVR between January 2015 and December 2019. During the index period 947 pts underwent TAVR. To better characterize the mechanism of MR only pts with pre-procedural 3D transesophageal echocardiographic and at least one follow-up available study were included. The final study population consisted of 224 pts. MR severity was evaluated by multiparametric approach and classified in 4 degrees. The study population was further divided in 4 groups: Group I: fibro-calcific degeneration of the leaflets (78.6% pts); 2. Group II: prolapse or flail (4.4% pts); Group III: functional MR (FMR) due to leaflets tethering (5.6% pts); Group IV: FMR due to annular dysfunction or dilatation (11.3% pts). Primary outcome was all-cause of death. Results and Discussion – MR was absent in 15 pts (6.7%), mild in 79 pts (35.7%), mild-to-moderate in 109 in pts (49.3%), moderate-to-severe in 7 pts (3.1%) and severe in 11 pts (4.9%). Patients with &amp;gt; moderate MR degree at baseline had a worse outcome than patients with &amp;lt; moderate MR degree (p log rank = 0.029). FMR (groups III and IV) was associated with better outcome than organic MR (groups I and II) (p log rank = 0.035). Moreover, group IV showed a better outcome compared groups I (p log rank = 0.047) and II (p log rank = 0.038). Patients who showed improvement of MR of at least 1 degree post TAVR showed better outcome compared to patients without improvement (p log rank = 0.04). At multivariate analysis, including pre procedural MR &amp;gt; 2+, pre procedural TR &amp;gt; 2+, organic vs functional etiology and MR improvement after TAVR as covariates, only baseline MR &amp;gt; moderate was an independent predictor of mortality (HR 6.3; 95% CI 1.4 -27.0; p &amp;lt; 0.001). Conclusion - This study confirms the prognostic role of the baseline degree of MR in patients with AS undergoing TAVR. Moreover, this is the first study demonstrating that FMR due to annular dilatation but not due to leaflet tethering is associated with better outcome compared to organic etiologies.

Acute kidney injury and Acute kidney recovery following TAVR: Conflicting results with regards to earlier studies

Acute kidney injury (AKI) remains associated with a dismal prognosis in TAVR. Acute kidney recovery (AKR), a phenomenon reverse to AKI has recently been associated with better outcomes. Between November 2012 to May 2018, we explored consecutive patients referred to our Heart Valve Center for TAVR. AKI was defined according to the VARC-2 definition. Mirroring the VARC-2 definition of AKI, AKR was defined as a decrease in serum creatinine (≥ 50%) or ≥ 25% improvement in GFR up to 72 hours after TAVR. AKI and AKR were respectively observed in 8.3 and 15.7% of the 574 patients included. AKI and AKR patients were associated to more advanced kidney disease at baseline. At a median follow-up of 608 days (range 355–893), AKI and AKR patients experienced an increased cardiovascular mortality compared to unchanged renal function patients (14.6% and 17.8% respectively, vs. 8.1%, CI 95%, P < 0.022). Chronic kidney disease, (HR: 3.9; 95% CI 1.7–9.2; P < 0.001) was the strongest independent factor associated with AKI similarly as baseline creatinine level (HR: 1; 95% CI 1 to 1.1 P < 0.001) for AKR. 72-hours post procedural AKR (HR: 2.26; 95% CI 1.14 to 4.88; P = 0.021) was the strongest independent predictor of CV mortality ( Fig. 1 ). 72-hours post procedural AKR patients are a subgroup of patients at high risk of post TAVR cardiovascular complications

Effect of concomitant aortic regurgitation on early hypoattenuated leaflet thickening after transcatheter aortic valve replacement in patients with symptomatic severe aortic stenosis

Identification of hypoattenuated leaflet thickening (HALT) and subacute leaflet thrombosis has become widely recognized. Patients with anatomical changes associated with moderate or greater aortic regurgitation (larger sinus of Valsalva and eccentric left ventricular remodeling) appear to have less HALT early postprocedure compared with those without. Further research on the risk factors including anatomical and hemodynamic variables should further our knowledge of these entities so we can better manage patient both pre and post TAVR.