Postprocedural Aortic Regurgitation Research Articles

Review of Te Whatu Ora – Counties Manukau Patients Receiving Transcatheter Aortic Valve Implantation

Transcatheter aortic valve implantation (TAVI) procedures are increasingly being offered in this community, but little is known of local outcomes. The clinical notes of 100 consecutive patients from Counties Manukau and who received TAVI between January 2018 and March 2022 were retrospectively reviewed. The majority (90%) were European/others, 52% were male, the mean age was 80 years (range 20–95 years), and the predominant diagnosis was aortic stenosis (93%). Present symptoms included dyspnoea (90%), chest pain (25%), and syncope (9%). Pre-existing coronary artery disease was present in 81% of patients. The majority had a transfemoral approach (99%), with an Edwards Sapien 3 valve used in 78% of cases. After the procedure 3% were not on antiplatelets or anticoagulants; 86% reported improved symptoms and 26% had post-procedural aortic regurgitation (mild to moderate). It was identified that 25% had a cardiac admission (some multiple) and 66% had a non-cardiac admission over at least 1 year of follow-up. Pacemakers were implanted in 9% pre-TAVI and 9% post-TAVI, with 8% other significant post-procedural complications identified. In the follow-up period there were 13% deaths with a mean time from TAVI to death of 20 months (6–42 months). Transcatheter aortic valve implantation provided symptomatic benefit to most who received this procedure from the Counties Manukau area. However, it should be noted that TAVI is associated with important clinical complications. Equity issues are apparent and need to be considered.

Transcatheter Aortic Valve Implantation Outcomes and Challenges in Asia: A Systematic Review and Meta-Analysis.

Aortic stenosis (AS) is the world's most prevalent heart valve disease. Transcatheter aortic valve replacement (TAVR) or Implantation (TAVI) is widely available yet adopting this procedure in Asia has been slow due to high device cost, the need for specific training programs, and the lack of specialized heart teams and dedicated infrastructures. The limited number of randomized controlled trials describing TAVI outcomes among the Asian population hampered the approval for medical reimbursements as well as acceptance among surgeons and operators in some Asian countries. A comprehensive medical literature search on TAVI and/or TAVR performed in Asian countries published between January 2015 and June 2022 was done through MEDLINE and manual searches of bibliographies. The full text of eligible articles was obtained and evaluated for final analysis. The event rates for key efficacy and safety outcomes were calculated using the data from the registries and randomized controlled trials. A total of 15,297 patients were included from 20 eligible studies. The mean patient age was 82.88 9.94 years, with over half being females (62.01%). All but one study reported Society of Thoracic Surgeons (STS) scores averaging an intermediate risk score of 6.28 1.06%. The mean logistic European Systems for Cardiac Operations Risk Evaluation (EuroSCORE) was 14.85. The mean baseline transaortic gradient and mean aortic valve area were 50.93 3.70 mmHg and 0.64 0.07 , respectively. The mean procedural success rate was 95.28 1.51%. The weighted mean 30-day and 1-year all-cause mortality rate was 1.66 1.21% and 8.79 2.3%, respectively. The mean average for stroke was 1.98 1.49%. The acute kidney injury (AKI) rate was 6.88 5.71%. The overall major vascular complication rate was 2.58 2.54%; the overall major bleeding rate was 3.88 3.74%. Paravalvular aortic regurgitation rate was 15.07 9.58%. The overall rate of pacemaker insertion was 7.76 4.6%. Compared to Americans and Europeans, Asian patients who underwent TAVI had lower all-cause mortality, bleeding, and vascular complications, however, had a higher rate of postprocedural aortic regurgitation. More studies with greater sample sizes are needed among Asian patients for a more robust comparison.

Reduction of permanent pacemaker implantation by using the cusp overlap technique in transcatheter aortic valve replacement: a meta-analysis

BackgroundThe need for permanent pacemaker (PPM) implantation is a common complication after transcatheter aortic valve replacement (TAVR). Deep implantation position is a risk factor for PPM implantation. Thus, in the field of self-expandable (SE) transcatheter heart valves (THV) cusp overlap projection (COP) technique was implemented to reduce parallax, allowing a more precise guidance of implantation depth.AimsThis meta-analysis aims to report the outcome of patients undergoing TAVR with SE THV using COP versus conventional implantation technique (CIT).MethodsSystematical search in MEDLINE and EMBASE yielded five observational controlled studies comparing both implantation techniques for the SE Evolut prosthesis (Medtronic Intern. Ltd., CA, USA) and fulfilling the inclusion criteria for meta-analysis.ResultsTotally, 1227 patients were included, comprising 641 who underwent COP and 586 CIT TAVR. Incidence of post-procedural need for PPM implantation was significantly lower in COP group (9.8% vs 20.6%; OR = 0.43; p < 0.00001). This was accompanied by significantly higher implantation position in COP group (mean difference distance from distal end of the intraventricular portion of the THV to the non-coronary cusp (NCC): − 1.03 mm; p = 0.00001). Incidence of new-onset left bundle branch block did not differ. Regarding procedural and 30-day mortality, technical success, post-procedural aortic regurgitation, and rates of multiple device implantation, no difference between COP and CIT was found.ConclusionCOP is an effective and safe implantation technique to reduce the need for a permanent pacemaker implantation during TAVR with SE Evolut prosthesis.Graphical abstract

Comparison of outcomes of trans-subclavian versus trans-apical approaches in transcatheter aortic valve implantation

BackgroundMany patients are unsuitable for conventional femoral transcatheter aortic valve implantation (TAVI) but there is limited evidence as to which alternative approach has the best outcomes. We compared clinical outcomes in patients undergoing trans-subclavian (TS) or trans-apical (TA) TAVI.MethodsThis was a national retrospective observational study of patients undergoing surgical TAVI in Scotland between January 2013 and March 2020. The pre-operative patient characteristics, intraoperative details and post-operative outcomes were compared between TS and TA cohorts using data from the National Institute of Cardiovascular Outcomes Research (NICOR) registry.ResultsAmong 1055 patients who underwent TAVI, TS or TA access was used in 50 (4.7%) and 90 (8.5%) patients respectively. Self-expanding Medtronic Evolut R valves were used in 84% of TS procedures, while balloon-expandable Edwards SAPIEN valves were used in all TA procedures. The TS group had a lower mean logistic EuroSCORE than the TA group (27.31 ± 19.44% vs 34.92 ± 19.61% p = 0.029). The TS approach was associated with a higher incidence of moderate postprocedural aortic regurgitation (12.5% vs 2.4%, p = 0.025). There was no significant difference in 30-day, 1-year or overall all-cause mortality.ConclusionsBoth trans-subclavian and trans-apical access are viable approaches for patients requiring non-transfemoral TAVI. Differences in peri-procedural indices reflect the disparate patient populations and factors governing prosthesis choice, and short- and long-term mortality was similar.

Outcomes of permanent pacemaker insertion after TAVR: a systematic review and meta-analysis

Abstract Background/Introduction Conduction abnormalities are frequently encountered after transcatheter aortic valve replacement (TAVR) performed for severe aortic stenosis, leading to post-procedure permanent pacemaker (PPM) insertion. Although the predictors of- and factors leading to post-TAVR PPM have been studied extensively, its short-term and long-term outcomes have not been established. Purpose PPM placement can lead to significant changes in outcomes in post-TAVR patients, which remain unclear. With this analysis, we aim to evaluate the differences between outcomes of patients requiring PPM and those not requiring PPM post-TAVR. Methods A comprehensive literature search was performed in PubMed, EMBASE, and Cochrane to identify relevant trials. Outcomes were compared between the two groups of patients- those requiring post-TAVR PPM and those not requiring post-TAVR PPM. Summary effects were calculated using a DerSimonian and Laird random-effects model as odds ratio (OD) with 95% confidence intervals (CI) for all the clinical endpoints. Results 34 studies, including observational and prospective studies, met our inclusion criteria, with a total of 76,402 patients undergoing TAVR and 10,381 requiring post-TAVR PPM. There were no significant differences between 30-days (OR 1.04; 95% CI 0.96–1.13) and 1-year (OR 1.09; 95% CI 0.72–1.03) all-cause mortality rates, and 30-days (OR 0.86; 95% CI 0.72–1.03) and 1-year (OR 0.85; 95% CI 0.70–1.04) cardiovascular deaths among the two groups. Incidence of heart failure was higher in the post-TAVR PPM group at 30 days (OR 1.26; 95% CI 1.05–1.51) but not at 1 year (OR 1.21; 95% CI 0.93–1.57). No significant difference was noted between the two groups in 30-days or 1-year stroke, 30-days or 1-year myocardial infarction, 30-days or 1-year atrial fibrillation, 30-days or 1-year major bleeding, or 30-days and 1-year readmission rate. Other outcomes, including post-procedure aortic regurgitation, major vascular complications, minor bleeding, valve migration, and device success, also did not have any statistically significant difference in the two patient groups (Figure 1). Of all the patients who received post-TAVR PPM, an average of 46.4% and 58.5% patients had &amp;gt;40% ventricular pacing, and 48.9% and 41.4% had &amp;lt;40% ventricular pacing at 1-month, and 1-year follow up respectively. Conclusions Although there were no differences in the outcomes between the two groups at 30-days and 1-year follow-ups (except the higher incidence of heart failure at 30 days in the post-TAVR PPM group), long-term follow-up studies would be needed to identify any possible adverse events after one year. Also, a significant number of patients requiring post-TAVR PPM had &amp;lt;40% ventricular pacing at 1-month and even at 1-year intervals, which might suggest adopting an alternate approach of closely monitoring any conduction disturbances and avoiding early PPM implantation in post-TAVR patients, if possible. Funding Acknowledgement Type of funding sources: None. Forest plot of differences in outcomes

Influence of Left Ventricular Function on the "Aortic Regurgitation Index" Proposed for the Hemodynamic Assessment of Postprocedural Aortic Regurgitation.

The aortic regurgitation (AR) index, proposed as an objective indicator of postprocedural AR, decreases in proportion to AR severity, besides reportedly providing additional prognostic information. Meanwhile, left ventricular (LV) function has also been considered an essential prognostic factor. This study aimed to clarify whether LV function affected the AR index using cardiac catheterization data.A retrospective study was performed in patients whose LV function was evaluated using a micromanometer-tipped catheter. Patients with grade 2 or higher AR were excluded to explore non-AR factors affecting the AR index value. The AR index was calculated as a ratio of the gradient between the aortic diastolic blood pressure (DBP) and the LV end-diastolic pressure (EDP) to the aortic systolic blood pressure (SBP): AR Index = [ (DBP - LVEDP) / SBP] × 100.A total of 64 patients [age, 62 (interquartile range: 48-70) years; LV ejection fraction, 19% (16%-26%) ] were examined. AR index values ranged from 18.3 to 68.6. Despite having no AR, two patients displayed an AR index < 25, indicating significant AR. Multiple-regression analysis revealed that LV diastolic stiffness (β = -0.750, P < 0.001), LV max dP/dt (β = -0.296, P = 0.006), and heart rate (β = 0.284, P = 0.011) were independent determinants of the AR index value.Patients with impaired LV diastolic function and preserved systolic function had low AR index values. The additional prognostic information of the AR index may be related to LV diastolic function.

Quantitative assessment of aortic regurgitation following transcatheter aortic valve replacement

ABSTRACT Introduction: Transcatheter aortic valve replacement (TAVR) is expanding to lower risk and younger patients with severe symptomatic aortic valve disease. Despite clinical and technological improvements, post-procedural aortic regurgitation (AR) remains a limitation of TAVR, particularly when compared to surgical aortic valve replacement. Although several methods for AR quantification after TAVR are currently available, its exact graduation in everyday clinical practice remains challenging. Areas covered: This review describes the currently available evaluation methods of AR after TAVR, with a special emphasis on the quantitative assessment using videodensitometric angiography, echocardiography and cardiac magnetic resonance imaging. Expert opinion: In the majority of clinical scenarios, satisfactory evaluation of post-TAVR AR can be achieved with a combination of post-procedural angiography, hemodynamic indices and transthoracic echocardiography. Nevertheless, some TAVR patients show ‘intermediate’ forms of post-procedural AR, in which quantitative evaluation is mandatory for prognostic purposes and further decision-making. Notably, interpretation of quantitative measures early post-TAVR is challenging because of the lack of left ventricular enlargement. Video-densitometric angiography is an emerging method that appears to be clinically attractive for immediate post-TAVR assessment, but requires further validation in everyday clinical practice.

The Effect Of Calcium Score On Aortic Regurgitation Post Transcatheter Aortic Valve Replacement

Introduction: As transcatheter aortic valve replacements (TAVR) becomes more common in lower risk populations, the importance of even mild post-procedural paravalvular aortic regurgitation (AR) becomes more important. A very high Agatson calcium score (CS) of the aortic valve has been shown to be an independent prognostic factor for ≥ moderate aortic regurgitation post TAVR, however, the predictive value of CS for mild AR is not known. Furthermore, the evidence mainly refers to older TAVR valve models; new TAVR valve models have much lower rates of AR, and the evidence of calcium scoring to predict AR in these devices is limited. Our aim was to study the relationship of valve calcium and paravalvular AR in the current generation of devices.

Non-contrast transoesophageal echo-guided transapical transcatheter aortic valve replacement: 10-year experience of a renoprotective strategy

This study aims to evaluate the efficacy, safety and long-term outcomes of a renoprotective non-contrast, transoesophageal echocardiography-guided transapical (TA) transcatheter aortic valve replacement (TAVR) strategy with a balloon-expandable prosthesis, as well as to determine its impact on renal function. Between 2009 and 2019, 200 consecutive patients underwent a non-contrast, transoesophageal echocardiography-guided TA TAVR with a balloon-expandable prosthesis. The device success rate was 95.5%. Transoesophageal echocardiography-guided deployment demonstrated a low rate of procedure-related complications: 9.5% of acute kidney injury, 8% postoperative bleeding, 6% low-cardiac output, 4.5% postprocedural aortic regurgitation ≥+2, 4% implantation of permanent pacemaker and 2% stroke. There were no significant differences between preoperative and on discharge estimated glomerular filtration rate (53.9 ± 22.2 vs 54.3 ± 22.9 ml/min/1.73 m2, P = 0.60). Logistic regression analysis confirmed postoperative bleeding as an independent predictor for acute kidney injury (odds ratio (OR) 11.148, 95% confidence interval 3.537-35.140, P < 0.001). In-hospital mortality was 7.5%. The mean follow-up was 48.5 ± 39.9 months. Renal function and patient's chronic kidney disease stage did not significantly vary during follow-up. Long-term cumulative survival at 1, 5 and 10 years was 84.2 ± 0.027%, 42.9 ± 0.038% and 32.5 ± 0.044%, respectively. Renal function affected on neither in-hospital mortality nor long-term survival. Non-contrast, transoesophageal echocardiography-guided TA TAVR is a safe and reproducible technique with a low incidence of periprocedural complications that avoids the use of contrast and mitigates the incidence of acute kidney injury.

Baseline, procedural and outcome features of patients undergoing transcatheter aortic valve implantation according to different body mass index categories.

Transcatheter aortic valve implantation (TAVI) has become first-line treatment for severe aortic valve stenosis in patients with moderate, high or prohibitive surgical risk. However, access site complications may occur more frequently in extreme body mass index (BMI) categories. The aim of this study was to describe the features and outcomes of patients undergoing TAVI in a comprehensive Italian prospective clinical registry, focusing on BMI classes. A national prospective database was queried for baseline, procedural, and outcome details of patients undergoing TAVI according to established BMI categories: underweight (BMI <18.5 kg/m2), normal weight (BMI 18.5-24.9 kg/m2), overweight (BMI 25.0-29.9 kg/m2), and obese (BMI≥30 kg/m2). Short- and long-term outcomes, including major adverse events (MAE), i.e. the composite of death, stroke, myocardial infarction, major vascular complication, major bleeding, or renal failure, were appraised with bivariate and multivariable analyses. A total of 3075 subjects were included, 64 (2.1%) were underweight, 1319 (42.9%) were normal weight, 1152 (37.4%) were overweight, and 540 (17.6%) were obese. Several baseline differences were evident, including gender, diabetes mellitus, renal function, chronic obstructive pulmonary disease, surgical scores, and left ventricular ejection fraction (LVEF) (all P<0.05). Several procedural differences were also evident, including percutaneous approach, predilation, prosthesis type and size (all P<0.05), with postprocedural aortic regurgitation >2+ significantly more common in underweight patients (P<0.05). Nonetheless, unadjusted analysis for one-month outcomes showed similar rates for fatal and non-fatal outcomes, including MAE (all P>0.05), with the notable exception of permanent pacemaker implantation, which was more common in higher BMI classes (P=0.010) Unadjusted analysis for long-term events showed an increased rate of death in underweight patients (P=0.024). Multivariable adjusted analysis confirmed the increased risk of permanent pacemaker implantation in obese patients (P=0.015 when comparing obese vs. normal weight subjects), but disproved differences in long-term mortality and other outcomes (P>0.05 for all comparisons). Irrespective of BMI class, TAVI is associated with favorable outcomes in surgical high-risk risk patients, with the notable exclusion of permanent pacemaker implantation, which is significantly more common in obese subjects.

A systematic review and meta-analysis of the clinical outcomes of TAVI versus SAVR in the octogenarian population.

Surgical aortic valve replacement (SAVR) has shown safe, robust results in elderly populations, and up until recently, was the gold standard for management of severe aortic stenosis. The approach to severe aortic stenosis in high-risk populations, such as octogenarians, has been challenged with the development of transcatheter-based strategies. We sought to systematically analyse outcomes between surgical and transcatheter aortic valve replacement (TAVI) in octogenarians. Electronic databases were searched from their inception until November 2018 for studies comparing SAVR to TAVI in octogenarians, according to a predefined search criterion. The primary end point was mortality, and secondary end points included post-procedural complications. The review yielded four observational studies. The total number of patients included was 1221 including 395 who underwent TAVI and 826 SAVR. On average, patients from both subgroups carried a high number of cardiac risk factors, and STS-PROM scoring yielded mean values equating to high-risk population groups, with significantly higher values for TAVI patients across the board. The presence of post-procedural moderate aortic regurgitation was noted only in the TAVI population (OR = 8.88; 95% CI (1.47-53.64), χ2 = 1.22; p = 0.02; I 2= 0%). Otherwise, there were no significant differences when accounting for mortality (OR = 0.68; 95% CI (0.44-1.05), χ2 = 1.88; p = 0.60; I 2= 0%), permanent pacemaker implantation groups (OR = 0.45; 95% CI (0.44-1.49), χ2 = 0.11; p = 0.19; I 2= 0%), and neurological events (OR = 0.72; 95% CI (0.42-1.23), χ2 = 2.57; p = 0.23; I 2= 22%). The analysed data on TAVI versus SAVR in the octogenarian population show that TAVI shows similar outcomes with relation to mortality and inpatient admission times, in a population with significantly higher risk profiles than their SAVR counterparts. TAVI has higher occurrences of post-procedural AR. TAVI still does not have robust long-term data to ensure its efficacy and rate of complications, but is showing promising results nonetheless.

Distinct pressure half-time values by transthoracic echocardiography for grading of paravalvular regurgitation after transcatheter aortic valve replacement

Postprocedural aortic regurgitation (AR) has negative impact on patient outcome after transcatheter aortic valve replacement (TAVR). Standard assessment of AR severity by echocardiography is hampered after TAVR. Measurement of pressure half-time (PHT) by echocardiography is not limited in these patients but it may be affected by concomitant left ventricular hypertrophy (LVH). This study sought to evaluate distinct cut-off values of PHT differentiating between patients without and with more than mild LVH for grading of AR after TAVR with cardiac magnetic resonance (CMR) as the reference method for comparison. 71 patients (age 81 ± 6 years) with severe aortic stenosis undergoing TAVR were included into the study. Transthoracic echocardiography (TTE) and CMR were performed after TAVR. Left ventricular mass index was calculated by TTE. PHT was measured by continuous-wave Doppler echocardiography of aortic regurgitation jet. In 18 patients (25%) PHT could not be obtained due to no or very faint Doppler signal. Aortic regurgitant volume and regurgitant fraction were calculated by CMR by flow analysis of the ascending aorta. In 14 of 53 patients (26%) AR after TAVR was moderate or severe as categorized by CMR analysis. More than mild LVH was present in 27 of 53 patients (51%). PHT correlated inversely less to regurgitant fraction by CMR analysis in patients with LVH (r = −0.293; p = 0.138) than in patients without LVH (r = −0.455; p = 0.020). In patients without relevant LVH accuracy of PHT to predict moderate or severe paravalvular regurgitation AUC was 0.813 using a cut-off value of 347 ms and AUC was 0.729 in patients with more than mild LVH using a cut-off value of 420 ms. Analysis of PHT by TTE with distinct cut-off values for patients without and with more than mild LVH allows detection of moderate or severe AR after TAVR as defined by CMR. In none of the patients in which PHT could not be measured AR was categorized as more than trace by CMR analysis.

Periprocedural Dynamics of Aortic Regurgitation in Patients Supported With an Impella Left Ventricular Assist Device

To determine the presence of and periprocedural changes caused by aortic regurgitation (AR) in patients supported with an Impella (Abiomed, Danvers, MA) left ventricular assist device. Retrospective. Tertiary academic medical center. Patients who underwent insertion of an Impella device at Allegheny General Hospital from January 2015 to December 2018. Analysis of patient electronic medical records. Demographic information; comorbidities; duration of support; and the presence and severity of AR pre-procedure and post-procedure, as reported by echocardiography, were analyzed. The electronic medical records of 69 patients were included in the present study. Before placement of the Impella device, 25 (35%) patients showed detectable AR, with 18 (26%) showing mild AR and 7 (10%) showing moderate AR. After the removal of the Impella device, AR remained steady or increased in 61 patients. Fifteen patients (22%) demonstrated mild AR, 6 (8.7%) demonstrated moderate AR, and 2 (2.9%) demonstrated severe AR. An increase in severity of AR was noted in 9 patients (14.7%), and 52 patients (85%) had no change in the severity of AR. The duration of support with the Impella device, demographic variables, and comorbidities were not associated with a statistically significant risk for increased severity of post-procedural AR in multiple multivariable logistic regression analyses. The presented data suggest that after Impella device support, a significant proportion of patients may show evidence of increased AR. Additional studies are needed to understand the etiology and significance of this observation.

Predictors and Risk Calculator of Early Unplanned Hospital Readmission Following Contemporary Self-Expanding Transcatheter Aortic Valve Replacement from the STS/ACC TVT Registry

BackgroundPredictors of hospital readmissions and tools to predict readmissions after TAVR are scarce. Our objective was to identify predictors of early hospital readmission following TAVR in contemporary clinical practice and develop a risk calculator. MethodsPatients with a contemporary self-expanding TAVR between 2015 and 2017 in the STS/ACC/TVT Registry™ database were included. Patients were divided into a derivation and validation cohort (2:1). A risk score was calculated using the derivation cohort based on multivariable predictors of 30-day unplanned readmissions and applied to the validation cohort. ResultsA total of 10,345 TAVR patients at 350 centers were included. Unplanned 30-day hospital readmission was 9.2%. Patients with an early readmission had higher 30-day rates for mortality (2.3% vs. 0.8%, p ≪ 0.001), stroke (4.1% vs. 2.7% p = 0.009), major vascular complications (2.0% vs. 1.0%, p = 0.003) and new pacemaker implantation (25.7% vs. 18.6%, p ≪ 0.001). Multivariable predictors of 30-day readmission included diabetes, atrial fibrillation, advanced heart failure symptoms, home oxygen, decreased 5-m gait speed or the inability to walk, serum creatinine ≫1.6 mg/dL, index hospitalization length of stay ≫5 days, major vascular complication and ≥ moderate post-procedure aortic or mitral valve regurgitation. Based on these predictors, we stratified 30-day readmission risk into low-, moderate- and high-risk subsets. There was a 2.5× difference in readmission rates between the low- (5.8%) and high-risk subsets (14.6%). ConclusionWe stratified the risk of early hospital readmission after TAVR based on a simple scoring system. This score may improve discharge planning centered on the individual's readmission risk. SummaryUnplanned readmissions in the United States are prevalent and costly accounting for $41.3 billion in annual hospital payments and are associated with adverse clinical outcomes. We found that diabetes, atrial fibrillation, advanced heart failure symptoms, home oxygen, frailty, acute kidney injury, prolonged hospitalization, major vascular complications, and moderate or worse post-procedure aortic or mitral valve regurgitation predicted of 30-day readmission following self-expanding TAVR. This information may improve discharge planning centered on each patient's readmission risk.

Update on the clinical impact of mild aortic regurgitation after transcatheter aortic valve implantation: Insights from the Japanese multicenter OCEAN‐TAVI registry

This study aimed to compare the clinical impact of mild postprocedural aortic regurgitation (post-AR) to that of none-trivial post-AR after transcatheter aortic valve implantation (TAVI) and to identify the vulnerability factors to mild post-AR. Moderate-severe post-AR, associated with increased mortality, is an important issue. However, the clinical impact of mild post-AR remains controversial. We analyzed data from 1,572 consecutive patients (1,026 of none-trivial post-AR and 546 of mild post-AR) obtained from the Optimized transCathEter vAlvular Intervention (OCEAN-TAVI) Japanese multicenter registry. We evaluated the 1-year cumulative cardiovascular death and re-hospitalization rates for heart failure (HF) after TAVI according to the degree of post-AR. Kaplan-Meier curves showed no significant difference between "none-trivial post-AR" and "mild post-AR" in terms of cardiovascular death, but a significant difference was noted in the cumulative incidence of re-hospitalization for HF between the two groups (hazard ratio 1.57, 95% confidence interval 1.02-2.41, p = .04). In the stratified analysis, only in patients with not more than 50% of left ventricular ejection fraction (LVEF), concentric left ventricular hypertrophy (LVH), and none-trivial pre-procedural aortic regurgitation (pre-AR), mild post-AR resulted in a higher incidence of re-hospitalization for HF. In this study, the clinical impact of mild post-AR compared to none-trivial post-AR tended to be augmented in the presence of reduced LVEF, concentric LVH, and none-trivial pre-AR. Pre-procedure echocardiographic findings including LVEF, left ventricular geometry, and pre-AR may help to judge the necessity of postdilatation in case of mild post-AR just after the bioprosthesis deployment.

Hospital readmission following transcatheter aortic valve implantation in the real world

BackgroundThere is limited data on hospital readmissions following transcatheter aortic valve implantation (TAVI). The aim of this study was to investigate hospital readmissions post-TAVI. MethodsData from the Optimized transCathEter vAlvular iNtervention (OCEAN-TAVI) multicenter registry (registration no. UMIN000020423) were collected from 1215 patients who underwent TAVI. Incidence, timing, causes, and predictors of readmission in addition to the impact on patient outcomes were analyzed. ResultsOf 1215 patients, 223 (18.4%) were readmitted within 1 year post-TAVI. Early readmission (≤30 days) occurred in 42 patients, while late readmission (>30 days) occurred in 181 patients. Readmissions were due to cardiac disorders, such as heart failure and arrhythmia, in 77 patients and non-cardiac disorders, such as respiratory disorders, infections, and cerebrovascular events, in 146 patients. Kaplan-Meier analysis revealed that early readmission was associated with a lower 1-year survival compared to non-early readmission (72.4% vs. 89.0%, p < 0.05). Multivariate Cox regression analysis showed that acute kidney injury (hazard ratio [HR], 2.27; p = 0.03) was an independent predictor of early readmission, while anemia (HR, 2.21; p < 0.01), hypoalbuminemia (HR, 1.37; p = 0.04), atrial fibrillation (HR, 1.70; p < 0.01), and more than mild postprocedural aortic regurgitation (HR, 1.62; p < 0.01) were independent predictors of late readmission. ConclusionReadmission occurred in approximately one-fifth of patients post-TAVI and was associated with poor patient outcomes. Early readmission was mainly due to procedural complications, while late readmission was mainly determined by baseline comorbidities including a frailty criterion. Measures should be taken to reduce hospital readmissions and improve patient outcomes post-TAVI.

Readmission for Acute Decompensated Heart Failure among Patients Successfully Treated with Transcatheter Aortic Valve Replacement: A PARTNER-1 Substudy

ABSTRACTBackground: Readmission for acute decompensated heart failure (ADHF) following transcatheter aortic valve replacement (TAVR) is common and linked with mortality. However, time course of ADHF readmissions, their risk factors, and their association with long-term outcomes are not well understood. Our objectives were to identify the temporal pattern of readmission for ADHF following TAVR, which patients are at high risk, and the association of readmission for ADHF and subsequent mortality.Methods: We evaluated 2467 patients successfully treated and discharged in the PARTNER-1 trial, and followed for 5 years. Baseline and discharge clinical, pharmacologic, procedure, and echocardiographic characteristics were considered. The likelihood and temporal pattern of ADHF readmission after accounting for the competing risk of death were assessed using nested competing-risk methodology for repeating time-related events. Risk factors were identified by unsupervised bootstrap-aggregation machine learning.Results: Admission for ADHF following TAVR was associated with an increased risk of subsequent readmission. Accounting for baseline, procedure, and discharge characteristics, we identified greater severity of post-procedure mitral and aortic regurgitation, both lower- and higher-gradient aortic stenosis, oxygen-dependent COPD, baseline calcium channel blocker and long-acting nitrate use, and longer index hospitalization length of stay as risk factors for readmission for ADHF.Conclusion: Early readmission for ADHF following TAVR was associated with clinical, pharmacologic, and echocardiographic characteristics. The resulting models may be used to identify patients at high risk for early readmission following TAVR and to suggest future prospective trials, particularly to treat combined mitral regurgitation associated with aortic stenosis.

Transcatheter aortic valve implantation in bicuspid anatomy: procedural results with two different types of valves

It is well known that bicuspid valve stenosis can be treated with transcatheter aortic valve implantation (TAVI) even if specific issues can cause problems: dilatation of ascending aorta, possible aorthopathy, eccentricity of the valve and calcium distribution in leaflets and in commissures. We classified Bicuspid aortic valve (BAV) in type 0 (2 cusps and no raphe), and type 1 (2 cusps and one or more raphes). The aim of the present study was to report the results of two types of valve (CoreValve from 2009 to 2016 and Lotus valve from 2014 to 2017) in a consecutive series of BAV patients treated in 2 Italian centers. A total of 30 patients with BAV underwent TAVI from September 2009 to March 2017. Mean age was 78±8 years, 54.5% were males and 7.4% had peripheral vasculopathy, 6.5% previous stroke or TIA, 15.6% previous PCI and 9.4% previous coronary artery bypass grafting. Ten patients (30.3%) had a type 1; mean aortic valvular gradient was 57.7±17.7 mmHg; aortic valvular area was 0.7±0.2 mm2, left ventricular ejection fraction was 51.4±10.0% and ascending aorta was 41.0±5.6 mm. Among these 30 patients, 16 of them (group 1) undergone CoreValve implantation and 14 (group 2) undergone Lotus valve implantation. Patients in the first group had a higher Logistic Euroscore (P<0.001) and higher AVA (P=0.026) and valve area CT (P=0.003). Device size in group1 was more often bigger than in group 2 (P<0.001) and postdilatation was never used in the last group. Group 1 had a significant more frequent aortic regurgitation ≥2 assessed with angiography (28.6% vs. 0%; P=0.05). A non-statistically significant higher rate of second valve implantation (6.2% vs. 0%; P=1.00) was also observed. New permanent pacemaker implantation (40.0% vs. 35.7%; P=0.812) was equal in both valves. Postprocedural aortic regurgitation is still an issue in BAV undergone TAVI when: 1) the annulus is big; 2) when we are using self-expandable valves; and 3) in type 0 valves. Lotus valve, with a higher radial force put in a small annuls seems associated to better procedural outcomes in this subset of patients.

Outcomes following transcatheter aortic valve replacement in patients with native aortic valve regurgitation.

Due to the absence of annular calcification for device anchoring, it is presumed that transcatheter aortic valve replacement (TAVR) is not suitable for the treatment of native aortic valve regurgitation (NAVR) resulting in very limited data and experience concerning its safety and efficacy. We sought to review published data on the safety and efficacy of TAVR in high-risk patients with NAVR. Studies including case reports, case series and original articles published between 2002 and 2016 on TAVR in patients with NAVR were identified with a systematic electronic search using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Only studies reporting data on demographic and procedural characteristics, management and follow up outcomes were analyzed. A total of 30 publications describing 182 patients were identified. Most patients (54%) were men, with a mean age of 70.1±2.6 years, mean logistic European System for Cardiac Operative Risk Evaluation score (EuroSCORE) of 21.8%±4.5% and mean Society of Thoracic Surgeons (STS) score of 8%±1.8% for mortality. The majority (87%) of patients had severe NAVR with no valvular calcification. TAVR was mostly performed through the femoral (58.8%) and apical (33.1%) approach. Device success, defined by VARC-2, was achieved in 86.3% of our study population. A second valve was required in 17 patients (9.3%) during the index procedure for residual aortic regurgitation or malposition. Post-procedure aortic regurgitation of grade 1 or less was present in 80 patients (81%). Pacemaker implantation was required post procedure in 17 patients (9.3%). The 30-day and 1-year mortality was 11.9% and 16.2%, respectively. TAVR is associated with favorable pacemaker implantation and 1-year mortality rates with a high 30-day mortality among selected patients with NAVR.

Association of postprocedural aortic regurgitation with mitral regurgitation worsened after transcatheter aortic valve replacement.

There is a paucity of investigation which demonstrates a predictor of mitral regurgitation (MR) worsened after aortic valve replacement (TAVR). The aim of this study was to identify the predictor of worsened MR after transcatheter TAVR. We retrospectively studied a total of 209 patients with mild or less MR at baseline who underwent TAVR for the treatment of severe aortic stenosis with the balloon-expandable device. We found the presence of MR worsened after TAVR in 6% (12 patients) of all patients. Moderate or more postprocedural aortic regurgitation (AR) (odds ratio, 8.104; 95% confidence interval, 1.78-36.87; P=.007) was identified as a predictor of MR worsening after TAVR. In-hospital outcomes indicated that patients within whom MR worsened suffered congestive heart failure more than those with unchanged or improved MR after TAVR (P<.05). Significant postprocedural AR was associated with MR worsened from mild or less to moderate or more after TAVR. Worsened MR might affect in-hospital congestive heart failure.