Post-procedural Paravalvular Leak Research Articles

German Experience with a Novel Balloon-Expandable Heart Valve Prosthesis for Transcatheter Aortic Valve Implantation-Outcomes of the MYLAND (MYvaL germAN stuDy) Study.

Background: The primary objective of this study was to evaluate the initial experience in Germany with the Meril Myval™ (MM) transcatheter heart valve (THV) system for the treatment of severe symptomatic aortic valve stenosis. The MM THV is a novel balloon-expandable valve with an expanded sizing matrix. Contemporary patients undergoing TAVI with the established Edwards Sapien™ (ES) THV served as the comparator group. Methods: Between 1st March and 31 August 2020 a total of 134 patients (33% female, 80.1 ± 6.7 years; EuroScore II 4.7 ± 4.8) underwent TAVI with an MM (95% transfemoral) for severe aortic stenosis at six German tertiary care centers. Results: Correct positioning of the THV was achieved in 98.5% (n = 132). Mean aortic gradients (MPG) were reduced from 42 ± 14 mmHg to 11 ± 5 mmHg. Mild postprocedural paravalvular leak (PVL) was observed in 62% (n = 82) patients, whereas only one patient had more than mild PVL. New permanent pacemaker implantation (PPI) was indicated in 15 patients (11%). Major vascular complications occurred in 6.7% (n = 9) patients. The in-hospital combined incidence of all-cause death and stroke was 4.5% (n = 6). In the comparator group that included 268 patients, the 30-day incidences of PPI, major vascular complications, and the composite of all-cause death and stroke were 16%, 1.9%, and 7.1%, respectively; MPGs were reduced from 44 ± 15 mmHg to 12.8 ± 4.6 mmHg and the more than mild PVL occurred in 0.7%. Conclusions: The MM is a promising novel THV system, with performance comparable to the established ES THVs. These findings await confirmation by ongoing randomized trials.

Meta-Analysis on the Clinical Outcomes of Transcatheter Aortic Valve Implantation in Low-Surgical Risk Patients With Bicuspid Aortic Valves

Transcatheter aortic valve implantation (TAVI) has been widely considered for patients with aortic stenosis (AS) across all surgical risk spectra.1 Bicuspid aortic valve (BAV) is the most common congenital heart defect and can progress to moderate to severe AS in about 12% to 37% of affected patients.2 Patients with BAV have traditionally been excluded from trials comparing TAVI and surgical aortic valve replacement, mainly due to their complex valvular anatomy and higher incidence of postprocedural paravalvular leak (PVL).

Generational Differences in Outcomes of Self-Expanding Valves for Transcatheter Aortic Valve Replacement.

The Medtronic Evolut Pro valve (EPV) is a new-generation self-expanding valve (SEV), particularly designed to reduce paravalvular leak (PVL) rates in transcatheter aortic valve replacement (TAVR). We aimed to compare the safety and efficacy of EPV with older-generation SEVs, in particular, postprocedural PVL and permanent pacemaker (PPM) implantation rates. We performed a retrospective, multicenter, propensity-matched analysis of the Israeli TAVR registry between September 2008 and June 2019. Two independent propensity score-matched comparisons were performed comparing EPV with the first-generation CoreValve (CV), and comparing EPV with the second-generation Evolut R valve (ERV). The registry included 2591 patients who were propensity-matched into 3 cohorts: EPV (n = 222), CV (n = 212), and ERV (n = 213). Moderate and above PVL rates were lower for EPV (angiographic PVL [aPVL], 0.6%; echocardiographic PVL [ePVL], 3.0%) as compared with CV (aPVL, 7.8% [P<.001] and ePVL, 11.6% [P<.01]), but not as compared with ERV (aPVL, 6.4% [P<.01] and ePVL, 4.4% [P=.57]). Lower rates of PPM were noted for EPV (16.3%) as compared with both CV (33.5%; P<.001) and ERV (24.4%; hazard ratio, 0.61; 95% confidence interval, 0.37-0.995; P=.046). Other safety and efficacy outcome rates were excellent, with significant improvements as compared with older-generation SEVs. The EPV demonstrates excellent procedural safety and efficacy outcomes. Moderate and above PVL rates were significantly reduced in comparison with CV; however, not significantly reduced as compared with ERV. The need for PPM implantation was lower as compared with both older-generation valves.

Transcatheter Aortic Valve Replacement in Nonagenarians: A Systematic Review and Meta-Analysis.

Nonagenarians represent only a small proportion of patients included in large transcatheter aortic valve replacement (TAVR) trials, but will become a relevant future population in need of treatment due to demographic change. Thus, this study sought to evaluate outcomes of TAVR for the treatment of severe aortic stenosis (AS) in nonagenarian patients. We screened Medline/Pubmed for studies that stated specific outcomes for nonagenarians undergoing TAVR. A weighted meta-analysis was conducted, calculating pooled estimate rates using a binary random-effects model for dichotomous variables, and comparing non-dichotomous outcomes with a continuous random-effects model. Data from 23 studies including 16,094 nonagenarians were merged; 53.4% were women. Despite reasonable rates of comorbidities, Society of Thoracic Surgeons mortality risk score was 10.2 ± 5.4. Pooled estimate rate of procedural success was 94.1% (95% confidence interval [CI], 91.7-96.6), with major vascular complications occurring in 6.3% (95% CI, 2.7-9.8) and at least moderate postprocedural paravalvular leak in 7.5% (95% CI, 4.4-10.6). The rate of periprocedural stroke or transient ischemic attack was 2.6% (95% CI, 2.0-3.2). At 30 days, the pooled estimate of mortality was 6.1% (95% CI, 4.7-7.4) and a permanent pacemaker was implanted in 12.6% (95% CI, 7.6-17.6). After 1 year, the mortality rate was 20.5% (95% CI, 15.9-25.1). TAVR in nonagenarians is an effective and safe procedure, with encouraging outcomes given the general life expectancy of these patients. Currently, only selected nonagenarians are undergoing TAVR, but their number will grow as life expectancy continues to increase in the developed world. Specific research to identify ideal candidates and techniques in this cohort is needed.

302 Impact of right ventricular pacing in patients with TAVI underwent permanent pacemaker implantation: the Pace-TAVI International Multicentre Study

Abstract Aims Permanent pacemaker implantation after transcatheter aortic valve implantation (TAVI) has emerged as a relevant issue, being more frequent than after surgery and the progressive shift towards low-risk patients stressed the importance to reduce the risk of complications that could impact patient’s long-term prognosis. Long-term right ventricular pacing has been related to an increased risk of electromechanical asynchrony, negative left-ventricular remodelling, atrial fibrillation and heart failure, but there is a lack of evidence regarding the prognostic impact on TAVI patients. The aim of this international multicentre study is to assess the impact of right ventricular pacing on prognosis of TAVI patients undergone pacemaker implantation after the procedure due to conduction disorders. Methods and results All the consecutive patients with severe aortic stenosis treated with TAVI and subsequently underwent pacemaker implantation in each participating centre were enrolled. Patients were divided into two subgroups according to the percentage of ventricular pacing (VP cut-off: 40%) at pacemaker interrogation. The primary endpoint was the composite of cardiovascular mortality and hospitalization for heart failure in subgroups based on the percentage of ventricular stimulation. All cause and cardiovascular mortality in the subgroups according to the percentage of ventricular pacing were the secondary endpoints. In total, 427 patients were enrolled, 153 patients with VP &amp;lt; 40% and 274 with a with VP ≥ 40%. Patients with VP ≥ 40% were older (81.16 ± 6.4 years vs. 80.51 ± 6.8 years), with higher NYHA class, a lower EF (55.26 ± 12.2 vs. 57.99 ± 11.3 P = 0.03), an increased end diastolic ventricular volume (112.11 ± 47.6 vs. 96.60 ± 40.4, P = 0.005) and diameter (48.89 ± 9.7 vs. 45.84 ± 7.5 P = 0.01). A higher incidence of moderate post-procedural paravalvular leak was observed in patients with VP ≥ 40% (37.5% vs. 26.85%, P = 0.03). Ventricular pacing ≥40% was associated with a higher incidence of the composite primary endpoint of CV mortality and HF hospitalization (p at log rank test = 0.006, adjusted HR: 2.41; 95% CI: 1.03–5.6; P = 0.04). Patients with ventricular pacing ≥ 40% had also a higher risk of all-cause (p at log rank test = 0.03, adjusted HR = 1.57; 95% CI: 1.03–2.38; P = 0.03) and cardiovascular (p at log ank test =0.008, adjusted HR: 3.77; CI: 1.32–10.78; P = 0.006) mortality compared to patients with a VP &amp;lt; 40%. Conclusions TAVI Patients underwent permanent pacemaker implantation after the procedure due to conduction disorders and with a VP ≥ 40% at follow-up are at increased risk of cardiovascular death and HF hospitalizations and of all-cause mortality compared to patients with a VP &amp;lt; 40%. It is mandatory to reduce the percentage of ventricular pacing at follow-up when possible or consider left ventricular branch pacing and biventricular pacing in TAVI patients.

860 Outcomes of First 500 Cases of Transcatheter Aortic Valve Implantation at a High-Volume Australian Private Hospital

Transcatheter aortic valve implantation (TAVI) was first performed in Australia in 2008 and grown to 42 implanting centres nationwide. There is limited published data on outcomes from Australian centres, especially private hospitals. We describe outcomes of the first 500 cases at Queensland’s first TAVI implanting private hospital. From July 2015-March 2020, 500 patients with severe, symptomatic aortic stenosis underwent TAVI at our centre. A multidisciplinary heart-team assessed all patients as suitable. Computed tomography (CT) TAVI assessment was mandatory for procedural planning. Mean age was 85 years old, 57% were male, mean STS score 4.0%, 49% had NYHA Class III/IV, 24% previous CABG, 14% peripheral vascular disease and 4.7% renal impairment. At 30 days mortality was 1.2%, stroke 1.0%, myocardial infarction (MI) 0.2%, major vascular complication 2.5% and new permanent pacemaker (PPM) requirement was 8.4%. Post-procedural paravalvular leak was none or trace in 82.7% mild in 16.8% and ≥moderate in 0.4%. At 1year, mortality was 4.3%, stroke 1.4%, no life-threatening bleeding and PPM 10.1%. Between patients 1-300, 301-400, and 401-500, we observed improvements in major adverse cardiac/cerebrovascular events (4.8%, 4.6%, 2.0%) and post-procedural paravalvular leak of none/trace (80%, 81%, 89%) respectively. Excellent TAVI clinical outcomes can be achieved in the Australian private hospital setting. Expert Heart Team assessment and CT guided procedural planning are key to these outcomes. Cumulative volume experience appears linked to achieving sustained excellent results.

Incremental Value of Aortomitral Continuity Calcification for Risk Assessment after Transcatheter Aortic Valve Replacement.

To investigate the association of aortomitral continuity calcification (AMCC) with all-cause mortality, postprocedural paravalvular leak (PVL), and prolonged hospital stay in patients undergoing transcatheter aortic valve replacement (TAVR). The authors retrospectively evaluated 329 patients who underwent TAVR between March 2013 and March 2016. AMCC, aortic valve calcification (AVC), and coronary artery calcification (CAC) were quantified by using preprocedural CT. Pre-procedural Society of Thoracic Surgeons (STS) score was recorded. Associations between baseline AMCC, AVC, and CAC and 1-year mortality, PVL, and hospital stay longer than 7 days were analyzed. The median follow-up was 415 days (interquartiles, 344-727 days). After 1 year, 46 of the 329 patients (14%) died and 52 (16%) were hospitalized for more than 7 days. Of the 326 patients who underwent postprocedural echocardiography, 147 (45%) had postprocedural PVL. The CAC score (hazard ratio: 1.11 per 500 points) and AMCC mass (hazard ratio: 1.13 per 500 mg) were associated with 1-year mortality. AVC mass (odds ratio: 1.93 per 100 mg) was associated with postprocedural PVL. Only the STS score was associated with prolonged hospital stay (odds ratio: 1.19 per point). AMCC is associated with mortality within 1 year after TAVR and substantially improves individual risk classification when added to a model consisting of STS score and AVC mass only.Supplemental material is available for this article.© RSNA, 2019See also the commentary by Brown and Leipsic in this issue.

Safety and effectiveness of a transaortic approach for TAVI: procedural and midterm outcomes of 265 consecutive patients in a single centre.

Transcatheter aortic valve implantation with a transaortic approach (TAo-TAVI) is an alternative to transapical or femoral access. We studied the procedural and midterm efficacy and safety of TAo-TAVI with Edwards Sapien XT and Medtronic CoreValve devices. Among 901 patients receiving TAVI since 2006, 265 consecutive patients underwent TAo-TAVI between January 2011 and September 2014. Procedural and midterm results were evaluated according to Valve Academic Research Consortium-2 criteria. The mean age was 83 ± 5 years. Sapien XT and CoreValve were used in 191 (72.1%) and 74 (27.9%) patients, respectively. Full sternotomy made elective concomitant off-pump coronary artery bypass grafting possible in 38 patients (14.3%) with severe coronary artery disease unsuitable for percutaneous coronary intervention. The device success rate was 95.5%. Postprocedural paravalvular leak ≥2/4 was observed in 16 patients (6.4%). Emergency open chest surgery was required in 10 patients (3.8%) (3 aortic dissections, 3 valve embolizations, 2 LMCA occlusions, 1 aortic annulus rupture and 1 aortic rupture). Cerebrovascular accidents occurred in 3 patients (1.1%). Transfusions ≥4 units were required in 36 patients (13.6%). New pacemakers were implanted in 26 patients (9.8%). Thirty-day and 1-year mortality were 8.7% and 16.2%, respectively. Mean follow-up duration was 24 ± 6 months. At 3 years, freedom from all-cause death was 80% ± 4%. New York Heart Association class <III included 81% (n = 172) of patients alive and without prosthetic echocardiographic dysfunction at follow-up (mean gradient 10.5 ± 5.6 mmHg). The TAo-TAVI approach confirms its safety and effectiveness with satisfactory procedural and midterm outcomes with both currently available devices.

Comparative survival and role of STS score in aortic paravalvular leak after SAVR or TAVR: a retrospective study from the USA

ObjectiveThe presence of aortic paravalvular leak (PVL) is associated with lower survival, but a direct comparison of its impact after transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement...

Impact of CoreValve size selection based on multi-slice computed tomography on paravalvular leak after transcatheter aortic valve implantation.

Paravalvular leak (PVL) has significant impact on long-term outcomes in patients after transcatheter aortic valve implantation (TAVI). This study sought to determine whether multi-slice computed tomography (MSCT)-guided valve selection reduces PVL after CoreValve implantation. The analysis encompassed 69 patients implanted with CoreValve and were divided into two groups. In Group I (30 patients), valve selection was based on standard procedures, in Group II (39 patients), on MSCT measurements. Paravalvular leak was assessed with angiography and echocardiography. Multi-slice computed tomography results influenced a change of decision as to the size of the implanted valve in 12 (30.9%) patients in Group II and would have caused the decision to change in 9 (37.5%) patients in Group I. The degree of oversizing in Group I and II was 12.8% ± ± 7.6% vs. 18.6% ± 5.1% (p = 0.0006), respectively. The oversizing among the patients with leak degree of 0-1 and ≥ 2 was 18.1% ± 6.0% and 12.8% ± 7.4% (p = 0.0036). Angiographic assessment indicated post-procedural PVL ≥ 2 in 50% of patients in Group I and 20.5% in Group II (p = 0.01), while echocardiographic assessment indicated the same in 73.3% of patients in Group I and 45.6% in Group II (p = 0.0136). The composite endpoint occurred in 26.6% (8/30) patients in Group I vs. 5.1% (2/39) patients in Group II (p = 0.0118). Selecting the CoreValve device based on MSCT resulted in smaller rates of PVL and less frequent composite endpoint. In 1/3 of patients MSCT led to a change of the valve size. The degree of oversizing had a significant impact on PVL.

Does pre-existing aortic regurgitation protect from death in patients who develop paravalvular leak after TAVI?

ObjectiveThe aim of this study was to investigate interactions among pre-procedural aortic regurgitation (AR), post-procedural paravalvular leak (PVL) and long-term clinical outcomes. Methods and resultsWe analyzed data prospectively collected in the Italian Transcatheter balloon-Expandable Registry (ITER) on aortic stenosis (AS) patients. The degree of pre-procedural AR and post-procedural PVL was stratified as: absent/trivial, mild, and moderate/severe. VARC definitions were applied to outcomes. Of 1708 patients, preoperatively, AR was absent/trivial in 40% of the patients, mild in 42%, and moderate in 18%. Postoperatively, PVL was moderate–severe in 5%, mild in 32% of patients, and absent/trivial in 63%. Clinical follow-up, median 821days (IQR 585.75), was performed in 99.7% of patients. PVL, but not preoperative AR, was a major predictor of adverse outcome (HR 1.33, CI 95% 0.9–2.05, p=0.012 for mild PVL, HR 1.36, CI 95% 0.9–2.05, p<0.001 for PVL≥moderate and OR 1.04, p=0.97 respectively). Patients with moderate–severe PVL and preoperative left ventricle (LV) dilatation (LVEDVi>75ml/m2) showed better survival than those without dilatation (HR 8.63, p=0.001). ConclusionsIn patients with severe AS treated with balloon-expandable TAVI, the presence of PVL, but not pre-procedural AR, was a major predictor of adverse outcome. Preoperative LV dilatation seemed to offer some clinical advantages.

Abstract 15926: Impact of Small Body Surface Area on Para-valvular Leak After Balloon-expandable Transcatheter Aortic Valve Replacement

Aims: The efficacy and safety of balloon-expandable transcatheter aortic valve replacement (TAVR) in patients of small body surface is not well understood. The aim of this study was to evaluate that the efficacy and safety and association between small BSA (S-BSA) and para-valvular leak (PVL) after balloon-expandable TAVR. Methods: Between January 2013 and April 2015, a total of consecutive 379 patients with severe aortic stenosis underwent balloon-expandable TAVR (SAPIEN =82 or XT =297) and had suitable contrast cardiac CT. Patients with S-BSA were defined as &lt;1.75cm2. The S-BSA group included 149 patients and the remaining 230 patients were included in the large BSA (L-BSA) group. Major adverse cerebro-cardiac vascular events (MACCE) at 30-days were recorded. Post procedural PVL and mean pressure gradient were also evaluated by transthoracic echocardiography at 30-days. Results: Mean aortic annulus area in the S-BSA group was significantly smaller than in the L-BSA group (412.7 ± 70.8 cm2 vs. 498.5 ± 88.8 cm2; p&lt; 0.001) but degree of device oversizing was similar between groups (16.6% vs 17.0%, p=0.74). MACCE were similar between both groups (6.7% vs. 6.1%; p =0.483), however major vascular events were significant higher in S-BSA (15.4% vs. 7.0%; p=0.007). There was one patient with aortic annulus injury in the S-BSA group. Similar post-procedural mean pressure gradient was achieved in both groups (10.2 ± 4.1 mmHg vs. 9.6 ± 3.9 mmHg; p=0.17). S-BSA was significantly associated with the incidence of PVL (PVL ≤mild: 41.6% vs. 23.5%; p&lt;0.001; moderate PVL ≤; 12.1% vs. 5.0%; p=0.009). Post-dilatation was higher in S-BSA (14.8% vs. 7.4%; p=0.017). Multivariate analysis demonstrated that aortic valve calcium was an independent strong predictor of PVL (Odds ratio (OR): 1.002; 95% confidence interval (CI) 1.001-1.003; p=0.001). S-BSA was found to be independently protective for PVL (OR: 0.38; 95% CI 0.24-0.61; p&lt;0.001). Conclusions: TAVR in patients with S-BSA was associated with similar MACCE overall but with higher incidence of major vascular events compared to L-BSA. S-BSA was found to be independently protective for post procedural PVL at 30-days in patients that underwent balloon-expandable TAVR. This appeared independent to the degree of oversizing.

TCT-663 Anatomic and Procedural Predictors of Paravalvular Leak following Transcatheter Aortic Valve Replacement with a Self-expanding Prosthesis at a High Volume Center Including a Novel Variable of Inflow Expansion

Transcatheter Aortic Valve Replacement (TAVR) is frequently used to treat patients with symptomatic, severe aortic stenosis in whom surgery is considered to be high-risk or contraindicated. Post-procedural para-valvular leak (PVL) remains a significant issue with a complex etiology. Our objective

Can we predict postprocedural paravalvular leak after Edwards SAPIEN transcatheter aortic valve implantation?

Postprocedural paravalvular leak (PVL) ≥ 2 has been shown to be associated with worse outcomes after transcatheter aortic valve implantation (TAVI). This study sought to identify predictive factors of postprocedural PVL ≥ 2 after TAVI with the Edwards valve. A total of 176 patients with Edwards TAVI (aged 83.4 ± 7.4 years, Logistic EuroSCORE [the Logistic European System for Cardiac Operative Risk Evaluation] 18.8 ± 12.0, transfemoral 54.5%) who had preprocedural multidetector computed tomography (MDCT) were studied. A PVL ≥ 2 was observed in 12.5% of cases. By multivariate analysis, only the valve calcification index (VCI) defined as aortic root calcification volume/body surface area (odds ratio [OR] = 1.002, 95% confidence interval [CI] = 1.001-1.004, P = 0.006) and the valve diameter/the calculated average annulus diameter (CAAD) by MDCT (OR = 0.683, 95% CI = 0.474-0.984, P = 0.041) were identified as independent predictors of postprocedural PVL ≥ 2. A score predicting postprocedural PVL ≥ 2 (PVL score) was determined by allotting one point when the valve diameter/CAAD ratio was <1.055 and one point when VCI was >418.4 mm(3) /m(2) , and summing all points accrued. Area under receiver-operator characteristic curves of PVL score was 0.71 (95% CI = 0.59-0.83, P < 0.01). The incidence of PVL ≥ 2 was 5.3% in patients with a PVL score of 0, 11.8% for a PVL score of 1 and 37.5% for a PVL score of 2. The only predictors of PVL ≥ 2 after Edwards valve implantation are the valve diameter/CAAD and VCI. The PVL score could prove to be an excellent tool for predicting the risk of PVL.

Successful repair of aortic annulus rupture during transcatheter aortic valve replacement using extracorporeal membrane oxygenation support

Aortic annular rupture is a rare and much dreaded complication of transcatheter aortic valve replacement. Device oversizing to prevent post-procedural paravalvular leak is the most commonly identified cause of this complication. However, mechanical stress in a heavily calcified non-compliant vessel can also lead to annular rupture in this older population. We describe a case of aortic annular rupture with involvement of right coronary artery ostium leading to cardiac tamponade and cardiac arrest, successfully managed by extracorporeal membrane oxygenation support, open drainage of the pericardial space, pericardial patching of the defect and bypass of the affected vessel with excellent post-procedural results.

Sutureless aortic valve replacement as an alternative treatment for patients belonging to the “gray zone” between transcatheter aortic valve implantation and conventional surgery: A propensity-matched, multicenter analysis

The aim of this propensity-matched, multicenter study was to compare early clinical and echocardiographic outcomes of patients undergoing transapical aortic valve implantation (TA-TAVI) versus patients undergoing sutureless aortic valve replacement (SU-AVR) for severe symptomatic aortic valve stenosis. We reviewed 468 TA-TAVIs performed in 20 centers from April 2008 to May 2011, and 51 SU-AVRs performed in 3 centers from March to September 2011. Based on a propensity score analysis, 2 groups with 38 matched pairs were created. Variables used in the propensity analysis were age, sex, body surface area, New York Heart Association class, logistic EuroSCORE, peripheral vascular disease, chronic obstructive pulmonary disease, aortic valve area, mitral regurgitation, and left ventricular ejection fraction. Preoperative characteristics of the 2 groups were comparable. Hospital mortality was 5.3% and 0% in the TA-TAVI and SU-AVR groups, respectively (P = .49). We did not observe stroke or acute myocardial infarction in the 2 groups. Permanent pacemaker implantation was needed in 2 patients of each group (5.3%, P = 1.0). Dialysis was required in 2 patients (5.3%) in the SU-AVR group and in 1 patient (2.7%) in the TA-TAVI group (P = 1.0). Predischarge echocardiographic data showed that the incidence of paravalvular leak (at least mild) was greater in the TA-TAVI group (44.7% vs 15.8%, P = .001), but there were no differences in terms of mean transprosthetic gradient (10.3 ± 5 mm Hg vs 11 ± 3.7 mm Hg, P = .59). This preliminary experience showed that, in patients at high risk for conventional surgery, SU-AVR is as safe and effective as TA-TAVI and that it is associated with a lower rate of postprocedural paravalvular leak.

Transcatheter aortic valve implantation: 10-year anniversary. Part II: clinical implications

Transcatheter aortic valve implantation (TAVI) has been increasingly recognized as a curative treatment for severe aortic stenosis (AS). Despite important improvements in current device technology and implantation techniques, specific complications still remain and warrant consideration. Vascular complications and peri-procedural neurological events were the first concerns to emerge with this new technology. Recently, significant post procedural para-valvular leak has been shown to be more frequent after TAVI than after surgical aortic valve replacement (SAVR), and its potential association with worse long-term prognostic has raised concerns. In moving toward treatment of lower risk populations, structural integrity and long-term durability of heat valve prosthesis are becoming of central importance. Emerging technologies and newer generations of devices seem promising in dealing with these matters.

Incidence and Predictors of Early and Late Mortality After Transcatheter Aortic Valve Implantation in 663 Patients With Severe Aortic Stenosis

There is a lack of information on the incidence and predictors of early mortality at 30 days and late mortality between 30 days and 1 year after transcatheter aortic valve implantation (TAVI) with the self-expanding CoreValve Revalving prosthesis. A total of 663 consecutive patients (mean age 81.0 ± 7.3 years) underwent TAVI with the third generation 18-Fr CoreValve device in 14 centers. Procedural success and intraprocedural mortality were 98% and 0.9%, respectively. The cumulative incidences of mortality were 5.4% at 30 days, 12.2% at 6 months, and 15.0% at 1 year. The incidence density of mortality was 12.3 per 100 person-year of observation. Clinical and hemodynamic benefits observed acutely after TAVI were sustained at 1 year. Paravalvular leakages were trace to mild in the majority of cases. Conversion to open heart surgery (odds ratio [OR] 38.68), cardiac tamponade (OR 10.97), major access site complications (OR 8.47), left ventricular ejection fraction <40% (OR 3.51), prior balloon valvuloplasty (OR 2.87), and diabetes mellitus (OR 2.66) were independent predictors of mortality at 30 days, whereas prior stroke (hazard ratio [HR] 5.47), postprocedural paravalvular leak ≥ 2+ (HR 3.79), prior acute pulmonary edema (HR 2.70), and chronic kidney disease (HR 2.53) were independent predictors of mortality between 30 days and 1 year. Benefit of TAVI with the CoreValve Revalving System is maintained over time up to 1 year, with acceptable mortality rates at various time points. Although procedural complications are strongly associated with early mortality at 30 days, comorbidities and postprocedural paravalvular aortic regurgitation ≥ 2+ mainly impact late outcomes between 30 days and 1 year.

Transcatheter aortic valve implantation: role of multimodality cardiac imaging

Current evidence based on more than 8000 high-risk patients with severe aortic stenosis has demonstrated that transcatheter aortic valve implantation (TAVI) is a feasible alternative to surgical aortic valve replacement in selected patients. Despite current promising results on hemodynamic and clinical improvements, there are several unresolved safety issues, such as the frequency of vascular complications, postprocedural paravalvular leak, atrioventricular heart block and stroke. Multimodality cardiac imaging may help to minimize these complications and may play a central role before (optimizing patient selection, selection of appropriate prosthesis size and anticipating the procedural approach), during and after TAVI (evaluating the immediate and long-term procedural results). This article reviews the state-of-the-art TAVI procedures and the role that multimodality cardiac imaging plays before, during and after TAVI.