Post Transcatheter Aortic Valve Replacement Research Articles

Efficacy and outcomes of antiplatelet therapy versus oral anticoagulants in patients undergoing transcatheter aortic valve replacement: a systematic review and meta-analysis.

Recent guidelines suggest that antiplatelet therapy (APT) is the standard of care in the absence of long-term oral anticoagulation (OAC) indications in patients post-transcatheter aortic valve replacement (TAVR). The superiority of one method over the other remains controversial. Several databases, including MEDLINE, Google Scholar, and EMBASE, were electronically searched. The primary endpoint was the all-cause mortality (ACM) rate. Secondary endpoints included cardiovascular death, myocardial infarction (MI), stroke/TIA, haemorrhagic stroke, bleeding events, systemic embolism, and valve thrombosis in post-TAVR patients receiving APT and oral anticoagulants (OACs). Forest plots were generated using Review Manager version 5.4, with a p value less than 0.05 indicating statistical significance. Subgroup analysis was performed to explore potential sources of heterogeneity. Twelve studies were selected. No significant differences were observed in APT and OAC group for ACM [risk ratio (RR): 0.67; 95% CI:0.45-1.01; P=0.05], cardiovascular death [RR:0.91; 95% CI:0.73-1.14; P=0.42], MI [RR:1.69; 95% CI:0.43-6.72; P=0.46], Stroke/TIA [RR:0.79; 95% CI:0.58-1.06; P=0.12], ischaemic stroke [RR:0.83; 95% CI:0.50-1.37; P=0.47], haemorrhagic stroke [RR:1.08; 95% CI: 0.23-5.15; P=0.92], major bleeding [RR:0.79; 95% CI:0.51-1.21; P=0.28], minor bleeding [RR:1.09; 95% CI: 0.80-1.47; P=0.58], life-threatening bleeding [RR:0.85; 95% CI:0.55-1.30; P=0.45], any bleeding [RR:0.98; 95% CI:0.83-1.15; P=0.78], and systemic embolism [RR:0.87; 95% CI:0.44-1.70; P=0.68]. The risk of valve thrombosis was higher in patients receiving APT than in those receiving OAC [RR:2.61; 95% CI:1.56-4.36; P =0.0002]. Although the risk of valve thrombosis increased in patients receiving APT, the risk of other endpoints was comparable between the two groups.

E-3 | Impact of Prior Stroke or TIA on Post-Transcatheter Aortic Valve Replacement Outcomes: A Meta-analysis of Prospective Studies

E-3 | Impact of Prior Stroke or TIA on Post-Transcatheter Aortic Valve Replacement Outcomes: A Meta-analysis of Prospective Studies

Emergency department imaging utilization post-transcatheter aortic valve replacement: single institution 7-year experience.

This study aims to highlight presentations, acute findings and imaging phenotypes of patients presenting to the emergency department (ED) within 30 days of a transcatheter aortic valve replacement (TAVR). A retrospective review of patients diagnosed with aortic valve disease who underwent a TAVR between Jan 2015 and Nov 2021 at a large academic medical center was completed. From an initial 1271 patients, 146 were included based on their presentation to the ED within 30 days post-TAVR procedure. Patient data, including ED presentation details and imaging results, were recorded and de-identified. Of the 146 post-TAVR patients, there were 168 ED visits within 30 days. The median time to ED after TAVR was 12 days. Respiratory symptoms were the most common complaint (27%). Neurological (23%) and cardiovascular symptoms (18%) followed. Cross-sectional imaging was conducted 250 times across visits, with an average of 1.7 scans per patient. CTs were most frequently used, followed by ultrasounds, especially echocardiograms and duplex extremity vasculature ultrasounds. 30.1% of patients had acute findings from imaging. Specific findings included heart failure (5.5%), access site complications (5.5%), pneumonia (5.5%), intracranial pathologies (3.4% for strokes and 0.7% for hematoma), and pleural effusion (3.4%). Echocardiograms and CTA chest were most associated with significant acute findings. Our study highlights the vital role of early and accurate imaging in post-TAVR patients within 30 days post-procedure. As transcatheter approaches rise in popularity, emergency radiologists become instrumental in diagnosing common post-procedural presentations. Continued research is essential to devise post-discharge strategies to curtail readmissions and related costs. Proper imaging ensures prompt, effective care, enhancing overall patient outcomes.

Computed Tomography Geometry of Extremely Undersized SAPIEN 3 Transcatheter Aortic Valves With Balloon Overfilling

Overfilling the balloon-expandable Sapien 3/Ultra (S3) transcatheter heart valves in undersized aortic valve anatomies is associated with favorable outcomes. The expansion of S3 valves beyond nominal values is feasible on benchtop testing. Still, a dearth of information exists on the actual valve area achieved when these valves are filled beyond nominal volumes. We herein assess post-transcatheter aortic valve replacement (TAVR) computed tomography (CT) derived geometry of overfilled, extremely undersized balloon-expandable transcatheter heart valves. A total of 23 patients (mean age 76±7.2 years, 17.4% female) treated had annular undersizing: 10.3±2.0% for 23mm, 7.8±4.8% for 26mm and 12.3±6.3% for 29mm. The mean volumes added to 23mm, 26mm, and 29mm S3 valves were 1.9±0.3 mL, 2.2±0.7mL, 3.2 ±1.3 mL, respectively. CT analysis at 30 days found that no valve achieved an expansion index >1 at the mid-frame portion, i.e., greater than the respective valve’s nominal valve area, but 29mm S3 had an expansion index >1 at inflow and outflow. Aortic valve gradients were favourable, and there was no moderate/severe PVL or transvalvular regurgitation at 30-day follow-up. We hypothesize that the approach of undersizing for annular anatomies and overfilling the balloon may achieve more optimal valve expansion.

Diagnostic Accuracy of Pre-Transcatheter Aortic Valve Replacement Nitroglycerin-Free Fractional Flow Reserve-Computed Tomography-Based Physiological Assessment in Patients With Severe Aortic Stenosis for Predicting Post-Transcatheter Aortic Valve Replacement Ischemia.

Fractional flow reserve-computed tomography (FFRCT) has not been validated in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) for coronary artery disease due to theoretical difficulties in using nitroglycerin for such patients.Methods and Results: In this single-center study, we prospectively enrolled 21 patients (34 vessels) and performed pre-TAVR FFRCTwithout nitroglycerin, pre-TAVR invasive instantaneous wave-free ratio (iFR) measurements, and post-TAVR FFR measurements using a pressure wire. The diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of pre-TAVR FFRCT≤0.80 to predict post-TAVR invasive FFR ≤0.80 were 82%, 83%, 82%, 71%, and 90%, respectively. A receiver operating characteristic analysis demonstrated an optimal cutoff of 0.78 for pre-TAVR FFRCTto indicate post-TAVR FFR ≤0.80, with an area under the curve (AUC) of 0.84, and the counterpart cutoff of pre-TAVR iFR was 0.89 with an AUC of 0.86. FFRCTwithout nitroglycerin could be a useful non-invasive imaging modality for assessing the severity of coronary artery lesions in patients with severe AS.

Female showed favorable left ventricle hypertrophy regression during post-TAVR follow-up.

Transcatheter aortic valve replacement (TAVR) is a well-established procedure using a catheter-introduced valve prosthesis for patients with severe aortic stenosis (AS). This retrospective study investigated sex-related differences in pre- and post-TAVR clinical and hemodynamic outcomes and analyzed data of the first 100 cases at Kaohsiung Medical University Chung-Ho Memorial Hospital (KMUH) between December 2013 and December 2021. Baseline characteristics, procedural outcomes, mortality rates, and echocardiographic parameters were analyzed and compared between sexes. Among the 100 patients, male (46%) and female (54%) were of similar age (mean age, male 86.0 years vs. female 84.5 years) and of the same severity of AS (mean pressure gradient, male 47.5 mmHg vs. female 45.7 mmHg) at the time receiving the TAVR procedure. Women had smaller aortic valve areas calculated by continuity equation (0.8 ± 0.3 cm2 vs. 0.7 ± 0.2 cm2, p < 0.001). In addition, women had better left ventricle ejection fraction (59.6 ± 14.0% vs. men 54.7 ± 17.2%, p < 0.01). In the post-TAVR follow-up, regression of left ventricle mass and dimension was better in women than in men. None of the patient died within 30 days after the procedure, and women tended to have a more favorable survival than men (2-year mortality and overall mortality rate in 8.3 year, women 9.1% and 22.2% vs. men 22.2% and 34.8%; p = 0.6385 and 0.1277, respectively). In conclusion, the sex-based difference in post-TAVR regression of LV remodeling suggests a need for sex-based evaluation for patients with severe AS and their post TAVR follow-up.

Survival outcomes of TAVR and self-expanding versus balloon-expandable valves in patients with advanced cardiac dysfunction.

There is a growing body of literature on long-term outcomes post-transcatheter aortic valve replacement (TAVR), but to our knowledge, few research have focused on patients with advanced cardiac dysfunction. This challenging category of patients was excluded from the Partner 3 clinical trial. There are no data to guide the choice of valve type in patients with severely depressed ejection fraction. This study evaluates the safety, efficacy, and outcomes of TAVR in patients with severe aortic stenosis and left ventricular ejection fraction (LVEF)≤35%. It compares post-TAVR survival outcomes with self-expanding (SEV) versus balloon-expandable (BEV) valves in the context of cardiac dysfunction. A retrospective cohort was conducted on 977 patients who underwent TAVR at Toulouse University Hospital between January 2016 and December 2020. The study population included two groups: LVEF≤35% (N=157) and LVEF≥50% (N=820). The group of LVEF≤35% was divided into two subgroups according to the type of implanted device: self-expanding (N=66) versus balloon-expandable (N=91). The living status of each of study's participants was observed in December 2022. Patients with low ejection fraction were younger (82 vs. 84.6years) and commonly males (71.3% vs. 45.6%). Procedural success was almost 98% in both study groups (97.5% vs. 97.9%). The prevalence of all in-hospital post-TAVR complications [acute kidney injury (3.8% vs. 2.2%), major bleeding events (2.5% vs. 3.2%), stroke (1.3% vs. 1.6%), pacemaker implantation (10.2% vs. 10.7%), major vascular complication (4.5% vs. 4.5%), new onset atrial fibrillation (3.2% vs. 3.4%), and in-hospital death (3.2% vs. 2.8%)] were similar between groups (LVEF≤35% vs. LVEF≥50%). No difference in long-term survival has been revealed over 3.4years (P=0.268). In patients with LVEF≤35%, except for post-TAVR mean aortic gradient (7.8±4.2 vs. 10.2±3.6), baseline and procedural characteristics were comparable between SEV versus BEV subgroups. An early improvement in LVEF (from 29.2±5.5 to 37.4±10.8) was observed. In patients with LVEF≤35%, the all-cause mortality rate was significantly higher in BEV than that in SEV subgroups, respectively (40.7% vs. 22.7%, P=0.018). Kaplan-Meier curve showed better survival outcomes after SEV implantation (P=0.032). A Cox regression identified BEV as independent predictor of mortality [HR=3.276, 95% CI (1.520-7.060), P=0.002]. In the setting of low LVEF, TAVR remains a safe and effective procedure not associated with an increased risk of complications and mortality. SEV implantation may likely result in superior survival outcomes in patients with advanced cardiac dysfunction.

The utility and impact of outpatient telemetry monitoring in post-transcatheter aortic valve replacement patients

BackgroundConduction disturbances are a common complication of transcatheter aortic valve replacement (TAVR). Mobile Cardiac Telemetry (MCT) allows for continuous monitoring with near “real time” alerts and has allowed for timely detection of conduction abnormalities and pacemaker placement in small trials. A standardized, systematic approach utilizing MCT devices post TAVR has not been widely implemented, leading to variation in use across hospital systems. ObjectivesOur aim was to evaluate the utility of a standardized, systematic approach utilizing routine MCT to facilitate safe and earlier discharge by identifying conduction disturbances requiring permanent pacemaker (PPM) placement. We also sought to assess the occurrence of actionable arrhythmias in post-TAVR patients. MethodsUsing guidance from the JACC Scientific Expert Panel, a protocol was implemented starting in December 2019 to guide PPM placement post-TAVR across our health system. All patients who underwent TAVR from December 2019 to June 2021 across four hospitals within Northwell Health, who did not receive or have a pre-existing PPM received an MCT device at discharge and were monitored for 30 days. Clinical and follow-up data were collected and compared to pre initiative patients. ResultsDuring the initiative 693 patients were monitored with MCT upon discharge, 21 of whom required PPM placement. Eight of these patients had no conduction abnormality on initial or discharge ECG. 59 (8.6 %) patients were found to have new atrial fibrillation or flutter via MCT monitoring. There were no adverse events in the initiative group. Prior to the initiative, 1281 patients underwent TAVR over a one-year period. The initiative group had significantly shorter length of stay than pre-initiative patients (2.5 ± 4.5 vs 3.0 ± 3.8 days, p < 0.001) and lower overall PPM placement rate within 30 days post-TAVR (16 % vs 20.5 %, P = 0.0125). ConclusionsIn our study, implementation of a standardized, systematic approach utilizing MCT in post-TAVR patients was safe and allowed for timely detection of conduction abnormalities requiring pacemaker placement. This strategy also detected new atrial fibrillation and flutter. Reduction in post TAVR pacemaker rate and length of stay were also noted although this effect is multifactorial.

Tricuspid regurgitation burden following transcatheter aortic valve replacement requiring early pacemaker implantation

Background Conduction abnormality requiring the implantation of a permanent pacemaker (PPM) is a well-known and clinically important complication of transcatheter aortic valve replacement (TAVR). However, PPM implantation may result in lead-associated tricuspid valve regurgitation (TR). This study sought to determine the incidence and progression of TR following PPM implantation after TAVR. Methods This was a retrospective review of all echocardiograms of patients who underwent PPM following TAVR at the Baylor Scott & White hospitals from 2012 to 2021. The primary endpoint was TR progression at 30 days and 1 year. A subanalysis comparing the change in TR progression between small and large TAVR devices was also conducted. Secondary outcomes included all-cause death at 30 days and 1 year. Results Out of the 2744 patients who underwent TAVR between April 2012 and August 2021, 177 patients (6.5%) subsequently received a new PPM. There was a statistically significant progression of TR at 1-year follow-up (McNemar’s P value = 0.02). TR progression rates were comparable between the small and large valve groups at 1-year follow-up (4% vs 11%, P = 0.09, respectively). Conclusion In this single healthcare system study, we demonstrated a significant progression of TR in patients with PPM post TAVR at 1 year.

Neo-Commissural Alignment by Withdrawing and Readvancing the Delivery System during Transcatheter Aortic Valve Replacement with Self-Expanding Prosthesis.

To investigate the feasibility of obtaining neo-commissural alignment by withdrawing and readvancing the delivery system during transcatheter aortic valve replacement (TAVR) with self-expanding prosthesis. TAVR was performed in five patients with severe aortic valve stenosis by the femoral approach. The delivery catheter was withdrawn and readvanced with the opposite orientation when the Venus-A plus transcatheter heart valve (THV) centre marker was found to be overlapped with or close to the left marker at the aortic annulus level on the fluoroscopic image at the projection of the right and left coronary cusps superimposing. Neo-commissural alignment was evaluated by comparing the aortic computed tomography before TAVR with it after TAVR. The THV centre marker was overlapped with or close to the right marker at the aortic annulus level on the fluoroscopic image at the projection of the right and left coronary cusps superimposed in all the present five patients after withdrawing and readvancing the delivery system. The commissural angle deviation before vs. post TAVR was 12.3° ± 7.0°. Three of five patients had neo-commissural alignment. Two of the five patients had mild neo-commissural misalignment. It is possible to obtain the neo-commissural alignment by controlling delivery catheter insertion orientation using the markers on the inflow of the Venus-A plus valve.

Cusp-overlap view reduces conduction disturbances and permanent pacemaker implantation after transcatheter aortic valve replacement even with balloon-expandable and mechanically-expandable heart valves.

Conduction disturbances demanding permanent pacemaker implantation (PPI) remain a common complication after transcatheter aortic valve replacement (TAVR). Optimization of the implantation depth (ID) by introducing the cusp-overlap projection (COP) technique led to a reduced rate of PPI when self-expanding valves were used. The aim of the present study was to determine if using the novel COP view is applicable for all types of TAVR prosthesis and results in a higher ID and reduced incidence of new conduction disturbances and PPI. In this prospective case-control study 586 consecutive patients undergoing TAVR with either balloon-expandable Edwards SAPIEN S3 (n = 280; 47.8%), or mechanically expandable Boston LOTUS Edge heart valve prostheses (n = 306; 52.2%) were included. ID as well as rates of periprocedural PPI and left bundle branch block (LBBB) were compared between the conventional three-cusp coplanar (TCC) projection and the COP view for implantation. Of 586 patients, 282 (48.1%) underwent TAVR using COP, whereas in 304 patients (51.9%) the TCC view was applied. Using COP a significantly higher ID was achieved in Edwards SAPIEN S3 TAVR procedures (ID mean difference -1.0 mm, 95%-CI -1.9 to -0.1 mm; P = 0.029), whereas the final platform position did not differ significantly between both techniques when a Boston LOTUS Edge valve was used (ID mean difference -0.1 mm, 95%-CI -1.1 to +0.9 mm; P = 0.890). In Edwards SAPIEN S3 valves, higher ID was associated with a numerically lower post-procedural PPI incidence (4.9% vs. 7.3%; P = 0.464). Moreover, ID was significantly deeper in patients requiring PPI post TAVR compared to those without PPI [8.7 mm (6.8-10.6 mm) vs. 6.5 mm (6.1-7.0 mm); P = 0.005]. In Boston LOTUS Edge devices, COP view significantly decreased the incidence of LBBB post procedure (28.1% vs. 47.9%; P < 0.001), while PPI rates were similar in both groups (21.6% vs. 25.7%; P = 0.396). The present study demonstrates the safety, efficacy and reproducibility of the cusp-overlap view even in balloon-expandable and mechanically-expandable TAVR procedures. Application of COP leads to significantly less LBBB in repositionable Boston LOTUS Edge valves and a numerically lower PPI rate in Edwards SAPIEN S3 valves post TAVR compared to the standard TCC projection. The results should encourage to apply the COP view more widely in clinical practice.

Impact of platelet reactivity on subclinical valve thrombosis in patients treated with TAVR

Abstract Background and introduction High residual platelet reactivity (HPR) in patients undergoing percutaneous coronary intervention with dual antiplatelet therapy (DAPT) is associated with an increased risk of thrombotic events. The relationship between HPR and the presence of subclinical valve thrombosis (SVT) following transcatheter aortic valve replacement (TAVR) is unknown. Purpose The aim of this study was to determine whether HPR is associated with the occurrence of SVT in patients undergoing TAVR treated with DAPT and to determine independent predictors of SVT. Methods This is a prospective, multicentre study. Patients with symptomatic aortic stenosis successfully treated with TAVR followed by DAPT (aspirin + clopidogrel) for 3 months were included. Patients with monotherapy, oral anticoagulation, or severe renal impairment were excluded. For the purpose of the study, platelet reactivity was measured either with Multiplate analyzer or VerifyNow point-of-care assay at baseline, at 1-2 days post, and 1-3 months post-TAVR. HPR was defined as ≥ 468AU, or ≥208PRU, respectively. The primary endpoint was the incidence of SVT measured by multi-slice CT at 3-months post TAVR in relation to HPR. Secondary objectives included the relationship between HPR following TAVR and the incidence of major adverse cardiac and cerebral clinical events (MACCE), to determine whether a pro-thrombotic inflammatory response is associated with the appearance of SVT and to evaluate factors associated with the occurrence of SVT. Results A total of 169 patients were included, the mean age was 81.5±5 and 51% were female. The overall rate of SVT was 22%. Patients with HPR demonstrated a similar incidence of SVT to those without (23,7% vs 33,6%: p=0,29). The overall bleeding rate was 4,9%. No differences in the rate of stroke at 1-year follow-up were observed (no SVT group 1.5% vs SVT group 2.6%: p=0.6). Independent predictors of SVT, were: dyslipemia OR 0,38 (0,15-0,96) p=0,039, creatinine clearance 0.98 (0.96.1.0, p=0.04), self-expandable valve OR 3,57 (1,40-9,06); p=0,006 and prosthesis size 0,78 (0,64-0,96): p=0,009. Patients with SVT expressed increased inflammatory parameters at 6 months compared to those without SVT CD14+ CD16-: 76,6±9,9 vs 70,7±13,9: p=0.02. Conclusion In contrast to coronary interventions, for the first time we have demonstrated that HPR does not appear to be associated with the development of SVT in TAVR patients treated with DAPT.

The efficacy and safety of novel oral anticoagulants versus vitamin k antagonist in transcatheter aortic valve replacement patients with indications for anticoagulation

Abstract Introduction Thrombotic events from atrial fibrillation, clinical and subclinical leaflet thromboses continue to be a major concern in Transcatheter Aortic Valve Replacement (TAVR) patients despite technological advancement and operator expertise. The proportion of TAVR patients who have or eventually develop indications for anticoagulation is not negligible and thus may warrant oral anticoagulants. However, the choice of anticoagulation is this select patients remained debatable. Thus, this study was conducted to determine whether current collective data support the efficacy and safety of novel oral anticoagulants (NOACS) versus vitamin K antagonists (VKAs). Purpose Oral anticoagulation (OAC) is necessary but the patients who needed it the most have baseline high bleeding risks. Anticoagulation carries a high bleeding risk especially among majority of a typical post TAVR patients with indications for anticoagulation. The paucity of data among asian TAVR patients were propensity to bleed are prevailing issues with anticoagulation owing perhaps to genetic or race predisposition and lower body weights or BMI compared to non-Asian counterparts. Currently the high court is still out to settle the optimum choice of anti-thrombotic therapy after TAVR. With TAVR now being performed in our local setting, we find this a relevant issue, hence we conducted a meta-analysis. Methods A literature search from Pubmed, Embase, and Cochrane databases for relevant RCTs and observational studies published until February 2022 were conducted. The pooled estimates of all-cause mortality, stroke and major bleeding events were measured using RevMan version 5.4.1 software. Results Eleven eligible studies (9 observational studies and 2 RCTs) allocated 29,156 TAVR patients with indications for anticoagulation either to receive NOACS (n = 11,718) or VKAs (n = 17,468). The effect estimate using random effects model showed no significant differences in all-cause mortality (RR 0.79, 95% CI 0.42–2.25, p = 0.07), stroke (RR 0.96, 95% CI 0.54–2.79, p = 0.70), and major bleeding events (RR 0.82, 95% CI 0.48–1.44, p = 0.08) between the NOACs and VKAs treatment arms. Conclusion NOACs demonstrated non-inferiority over VKA in reducing all-cause mortality, stroke and major or life-threatening bleeding events in TAVR patients with indications for anticoagulation.

Abstract 16858: QRS/T Ratio With Progression of Left Bundle Branch Block From New to Old: Is Voltage-Time-Integral Better Than Amplitude in Discriminating of Chronicity of Block?

Introduction: Discriminating acute versus chronic left bundle branch block (LBBB) has well known and important clinical implications. QRS/T vector magnitude ratio, and ratio of deepest S to tallest T in precordial leads, have been shown to discriminate new vs old LBBB. We sought to evaluate how QRS/T voltage-time-integral (VTI) ratio, as opposed to QRS/T amplitude ratio changes with progression of LBBB from new to old. Hypothesis: We proposed that QRS/T VTI ratio would be equivalent to QRS/T amplitude ratio in distinguishing new from old LBBB. Methods: We analyzed ECGs of patients with known chronic LBBB (n=385, 53.5% female, age 70.6±12) against ECGs of patients with acute LBBB (n=79, 53.6% female, age 77.7±9.5) one day post transcatheter aortic valve replacement (TAVR) and at 1 month post TAVR utilizing VTI of 3D QRS and 3D T-wave ratio. Orthogonal X, Y, Z leads were reconstructed from 12-lead ECG using Kors’s matrix. VTI X, Y ,Z and VTI 3D were obtained from temporal integration of voltage in X, Y, Z and root-mean-squared (3D) ECGs respectively. We compared changes in QRS/T amplitude, VTI ratios, and maximum precordial S/T magnitude ratio 1 month after versus day 1 of new LBBB using pairwise t-tests. Results: We found acute post-TAVR LBBB was best distinguished utilizing VTI of 3D QRS (3.37±1.27, p &lt;0.0005) compared to 3D T-wave ratio (2.90±1.00, p &lt;0.003). We also found LBBB post TAVR at one month is best distinguished by the 3D QRS/T-wave VTI ratio (1.53±0.32, p &lt; 0.0001) and less so by the 3D amplitude ratio (3.27±1.37, p 0.003) Acute max precordial S/T magnitude was not able to differentiate chronic from acute LBBB ( p 0.1). At one month follow up, acute LBBB TAVR QRS-T amplitude ratios were found to return to their baseline values (3.37±1.27 for acute and 3.27±1.37 with p 0.5). Conclusions: Between VTI of 3D QRS and 3D T wave ratio, VTI 3D QRS proved to be more reliable for distinguishing acute versus chronic LBBB. Chronicity of LBBB was not predicted by maximum precordial S/T magnitude.

Abstract 14768: Elevated Baseline Serum High Sensitivity Cardiac Troponin Levels and Mortality Post Transcatheter Aortic Valve Replacement: A Meta-Analysis

Introduction: High-sensitive cardiac troponins (hs-cTn) have been associated with worse prognosis and increased mortality post transcatheter aortic valve replacement (post-TAVR). However, limited data on the association prompted us to perform a meta-analysis for further understanding. Methods: PubMed, SCOPUS and Google Scholar were searched until May 2023 using relevant keywords. A random effects model was employed to estimate the odds of pooled pre-procedural hs-cTn levels and post-TAVR mortality. Inter-study heterogeneity was assessed using I2 statistics, and leave-one-out sensitivity analysis was performed with a significance level of p&lt;0.05 Results: The final analysis included six studies (n=4672) with a mean age of 82.7±5.6 and 46% female participants. There are 2 retrospective and 3 prospective studies with median follow up of 1 year. The population exhibited a high prevalence of hypertension, hyperlipidemia, and diabetes. All individuals who underwent TAVR had aortic valve area measuring &lt;1cm2. The combined mean logistic EuroSCORE was calculated as 20.91%±12.88. An increase in pre-procedural hs-cTn levels was associated with significantly higher unadjusted (OR 2.29, 95% CI 1.85-2.84, p&lt;0.01, I2=61.34%) and adjusted odds (aOR 2.01, 95%CI 1.62-2.50, p&lt;0.01, I2=52.81 %) of post-TAVR mortality (Fig. 1). Subgroup analysis revealed elevated mortality risk in both retrospective (OR 1.86, 95% CI: 1.33-2.60, p&lt;0.01) and prospective (OR 2.21, 95% CI: 1.62-3.01, p&lt;0.01) studies (Fig. 1). Furthermore, increased mortality risk persisted during both short-term (less than 2 years; OR 1.86, 95% CI: 1.33-2.60, p&lt;0.01) and long-term (more than 2 years; OR 2.21, 95% CI: 1.62-3.01,p&lt;0.01) follow-up (Fig. 1). Leave-one out sensitivity analysis confirmed the robustness of findings. Conclusion: This meta-analysis provides compelling evidence that elevated pre-procedural levels of hs-cTn serve as a significant predictor of post-TAVR 1-year mortality.

Management of Postprocedural Conduction Disturbances Using a Prespecified Algorithm in the Optimize PRO Study

BackgroundLack of standardization in posttranscatheter aortic valve replacement (TAVR) conduction disturbance (CD) identification and treatment may affect permanent pacemaker implantation (PPI) rates and clinical outcomes. The safety and efficacy of a standardized TAVR CD algorithm has not been analyzed. This study analyzes the Optimize PRO post-TAVR CD management algorithm with Evolut PRO/PRO+ valves. MethodsOptimize PRO is a prospective, postmarket study implementing 2 strategies to reduce pacemaker rates: TAVR with cusp overlap technique and a post-TAVR CD algorithm. The 2-hour postprocedural electrocardiogram (ECG) stratified patients to early discharge in the absence of new ECG changes or to CD algorithms for (1) ECG changes with preexisting right or left bundle branch block (LBBB), interventricular conduction delay or first-degree atrioventricular block, (2) new LBBB, or (3) high-degree atrioventricular block (HAVB). ResultsThe interim analysis of the CD cohort consisted of 125/400 TAVR recipients. In the CD cohort, the 30-day new PPI rate was higher (28.1% vs 1.5%; P <.001), and 60 (48%) patients were discharged with a 30-day continuous ECG monitor. At 30 days, 90% of patients discharged with a monitor did not require PPI. Clinical outcomes, including mortality, stroke, bleeding, and reintervention, were similar in patients with and without CDs. No patient experienced sudden cardiac death. ConclusionsEffective management of CDs using a standard algorithm following Evolut TAVR provides similar 30-day safety outcomes to patients without CDs who undergo routine next day discharge. The CD algorithm may provide an effective strategy to recognize arrhythmias early, improve PPI utilization, and facilitate safe monitoring of patients after discharge.

Prevalence and Clinical Outcomes of Noncardiac Surgery After Transcatheter Aortic Valve Replacement

BackgroundAortic stenosis (AS) is a prevalent valvular heart disease, especially among the elderly. They often coexist with other comorbidities, and noncardiac surgery carries a higher risk due to the underlying valve condition. Despite the growing concern about the safety and optimal management of non-cardiac surgery post-transcatheter aortic valve replacement (TAVR), there is limited evidence on this matter. This study aims to assess the clinical outcomes of non-cardiac surgeries following TAVR. Methods and ResultsThis retrospective study included 718 patients who underwent TAVR. Of these, 36 patients underwent non-cardiac surgery after TAVR. The primary endpoint was the incidence of cardiovascular adverse events post-TAVR and the secondary endpoint was the incidence of structural valve deterioration (SVD). Composite endpoints included disabling stroke, heart failure requiring hospitalization, and cardiac death as defined by VARC3. Most of these surgeries were orthopedic and classified as intermediate risk. All non-cardiac surgeries were performed without perioperative adverse events. There was no observed SVD, and the incidence of composite endpoints did not significantly differ between the surgical and non-surgical groups during the follow-up period. ConclusionNon-cardiac surgery after TAVR can be performed safely and does not have a negative impact on prognosis. Further studies are warranted to determine the optimal strategy for non-cardiac surgery post-TAVR.

Prognostic Value of Patient-Reported Outcomes in Predicting Long-Term Mortality After Transcatheter Aortic Valve Replacement.

Background Patient-reported outcome measures have been shown to have important prognostic value after various cardiac interventions. We assessed the association between the change in Kansas City Cardiomyopathy Questionnaire 12 (KCCQ-12) score after transcatheter aortic valve replacement and mortality. Methods and Results We included patients who underwent transcatheter aortic valve replacement at Mayo Clinic between February 2012 to June 2022 and who completed a KCCQ-12 before and 30 to 45 days after the procedure. Patients were categorized into 3 groups: those who experienced significant (>+19 points; group 1), modest (1-19 points; group 2), and no (≤0 points; group 3) improvement. A total of 1124 patients were included: 60.8% men; 97.6% White. Mean age was 79.4±8.3 years, baseline KCCQ-12 score was 53.9±24.5, and median Society of Thoracic Surgeons score was 4.9% (interquartile range, 3.1-8.0). At 45 days, the mean change in KCCQ-12 score was 19±24 points; 46.3% (n=520) of patients had a significant improvement in their KCCQ-12 score, while 33.4% (n=375) and 20.4% (n=229) had modest and no improvement, respectively. Median survival was higher in group 1 (5.7±0.2 years) compared with groups 2 and 3 (5.1±0.3 and 4.1±0.4 years, respectively; P<0.001). Compared with patients in group 1, those in groups 2 and 3 had higher long-term risk-adjusted mortality (adjusted hazard ratios, 1.54 [95% CI, 1.20-1.96], and 2.30 [95% CI, 1.74-3.04], respectively). Conclusions Patients who experience modest or no improvement in KCCQ-12 score after transcatheter aortic valve replacement have substantially higher long-term mortality. Delta KCCQ-12 is a cost-effective, efficient tool that can identify patients at increased risk of death at long-term follow-up post-transcatheter aortic valve replacement.

[Safety and efficacy of transcatheter aortic valve replacement using the "All in One" single artery/vessel technique].

Objective: To explore the safety and efficacy of transcatheter aortic valve replacement (TAVR) using the "All in One" single-artery/vessel technique. Methods: This is a retrospective study. A total of 30 consecutive patients underwent TAVR using the single artery/vascular technique in Beijing Anzhen Hospital from August to December 2021 were included. Baseline clinical data, operative situation, postoperative outcomes, and incidence of adverse events during hospitalization and at one month post TAVR were analyzed. Results: Mean age was (72.6±9.7) years, 16 were male patients, STS score was (4.73±3.12)%. Four patients were diagnosed as isolated aortic regurgitation (all with tricuspid aortic valves), and 26 patients were diagnosed as aortic stenosis (AS), 10 of whom with tricuspid aortic valves and 16 of whom with bicuspid aortic valves. The single-vessel technique was applied in 3 aortic stenosis cases; the single-artery technique was applied in 27 cases. Echocardiography was performed immediately after procedure and results showed no or trace perivalvular leak in 27 cases and small perivalvular leak in 3 cases; the mean aortic transvalvular gradient of 26 AS patients decreased from (50.4±16.0) mmHg (1 mmHg=0.133 kPa) to (9.4±3.2) mmHg (P<0.001). The procedure time was (64.8±18.9) min. There were no intraoperative death, valve displacement, conversion to surgery, coronary artery occlusion in all 30 patients. There were no major cardiac adverse events such as myocardial infarction or stroke occurred during hospitalization or at follow-up. One-month follow-up echocardiography indicated prosthesis works well. The symptoms were significantly alleviated, and the Kansas City Cardiomyopathy Score (KCCQ score) of all patients increased from 48.1±18.4 to 73.5±17.6 (P<0.001). Conclusions: TAVR using the single artery/vessel technique is safe and feasible. This technique is related to reduced access complications and worthy of wide application.

Restoration of von Willebrand factor after transcatheter aortic valve replacement-A possible cause for posttranscatheter aortic valve replacement thrombocytopenia?

The aim of the current study was to analyze the clinical and procedural predictors of thrombocytopenia and the relationship between the decrease in platelet count (DPC) and change in vWF function (ΔvWF) after transcatheter aortic valve replacement (TAVR). TAVR often causes temporary thrombocytopenia. At the same time, TAVR leads to a restoration of von Willebrand factor (vWF) function. One hundred and forty-one patients with severe aortic stenosis undergoing TAVR were included in the study. Platelet count and vWF function (vWF:Ac/Ag ratio) were assessed at baseline and 6 h after TAVR. Thrombocytopenia was defined as platelet count <150/nL. Median platelet count at baseline was 214/nL (interquartile range [IQR]: 176-261) and decreased significantly to 184/nL (IQR: 145-222) 6 h after TAVR. The number of patients with thrombocytopenia increased from 12.8% at baseline to 29.1% after 6 h. DPC 6 h after TAVR showed a significant correlation with ΔvWF (r = - 0.254, p = 0.002). Patients with DPC > 20% had significantly higher ΔvWF (10.9% vs. 6.5%, p = 0.021). Obese patients showed a significantly lower DPC (11.8% vs. 19.9%, p = 0.001). In multivariate analysis, ΔvWF 6 h after TAVR was the only significant predictor for DPC > 20% (p = 0.017). The restoration of vWF after TAVR is a significant predictor for DPC after TAVR. An increased platelet consumption due to vWF restoration could play a key role in the development of thrombocytopenia after TAVR.