Pre Transcatheter Aortic Valve Implantation Research Articles

Shear-Sensing by C-Reactive Protein: Linking Aortic Stenosis and Inflammation.

CRP (C-reactive protein) is a prototypical acute phase reactant. Upon dissociation of the pentameric isoform (pCRP [pentameric CRP]) into its monomeric subunits (mCRP [monomeric CRP]), it exhibits prothrombotic and proinflammatory activity. Pathophysiological shear rates as observed in aortic valve stenosis (AS) can influence protein conformation and function as observed with vWF (von Willebrand factor). Given the proinflammatory function of dissociated CRP and the important role of inflammation in the pathogenesis of AS, we investigated whether shear stress can modify CRP conformation and induce inflammatory effects relevant to AS. To determine the effects of pathological shear rates on the function of human CRP, pCRP was subjected to pathophysiologically relevant shear rates and analyzed using biophysical and biochemical methods. To investigate the effect of shear on CRP conformation in vivo, we used a mouse model of arterial stenosis. Levels of mCRP and pCRP were measured in patients with severe AS pre- and post-transcatheter aortic valve implantation, and the presence of CRP was investigated on excised valves from patients undergoing aortic valve replacement surgery for severe AS. Microfluidic models of AS were then used to recapitulate the shear rates of patients with AS and to investigate this shear-dependent dissociation of pCRP and its inflammatory function. Exposed to high shear rates, pCRP dissociates into its proinflammatory monomers (mCRP) and aggregates into large particles. Our in vitro findings were further confirmed in a mouse carotid artery stenosis model, where the administration of human pCRP led to the deposition of mCRP poststenosis. Patients undergoing transcatheter aortic valve implantation demonstrated significantly higher mCRP bound to circulating microvesicles pre-transcatheter aortic valve implantation compared with post-transcatheter aortic valve implantation. Excised human stenotic aortic valves display mCRP deposition. pCRP dissociated in a microfluidic model of AS and induces endothelial cell activation as measured by increased ICAM-1 (intercellular adhesion molecule 1) and P-selectin expression. mCRP also induces platelet activation and TGF-β (transforming growth factor beta) expression on platelets. We identify a novel mechanism of shear-induced pCRP dissociation, which results in the activation of cells central to the development of AS. This novel mechanosensing mechanism of pCRP dissociation to mCRP is likely also relevant to other pathologies involving increased shear rates, such as in atherosclerotic and injured arteries.

Coronary artery assessment on pre transcatheter aortic valve implantation computed tomography may avoid the need for additional coronary angiography

PurposeThe purpose of this study was to evaluate the percentage of coronary angiography that can be securely avoided by the interpretation of coronary arteries on pre transcatheter aortic valve implantation CT (TAVI-CT), using CT images obtained with deep-learning reconstruction and motion correction algorithms. Material and methodAll consecutive patients who underwent TAVI-CT and coronary angiography, from December 2021 to July 2022 were screened for inclusion in the study. Patients who had previous coronary artery revascularization or who did not undergo TAVI were excluded. All TAVI-CT examinations were obtained using deep-learning reconstruction and motion correction algorithms. On TAVI-CT examinations, quality and stenosis of coronary artery were analyzed retrospectively. When insufficient image quality and/or when diagnosis or doubt of one significant coronary artery stenosis, patients were considered as having possible coronary artery stenosis. The results of coronary angiography were used as the standard of reference for significant CAS. ResultsA total of 206 patients (92 men; mean age, 80.6 years) were included; of these 27/206 (13%) had significant coronary artery stenosis on coronary angiography and were referred for potential revascularization. Sensitivity, specificity, negative predictive value, positive predictive value, and accuracy of TAVI-CT to identify patients requiring coronary artery revascularization was 100% (95% confidence interval [CI]: 87.2–100%), 100% (95% CI: 96.3–100%), 54% (95% CI: 46.6–61.6), 25% (95% CI: 17.0–34.0%) and 60% (95% CI: 53.1–66.9%) respectively. Intra- and inter observer variability was substantial agreement for quality and decision to recommend coronary angiography. Mean reading time was 2 ± 1.2 (standard deviation) min (range: 1–5 min). Overall, TAVI-CT could potentially rule out indication for revascularization for 97 patients (47%). ConclusionAnalysis of coronary artery on TAVI-CT using deep-learning reconstruction and motion correction algorithms can potentially safely avoid coronary angiography in 47% of patients.

P17 MITRAL ANNULUS CALCIFICATION IN TRANSCATHETER AORTIC VALVE IMPLANTS

Abstract Background Mitral annular calcium (MAC) is a common finding in patients undergoing transcatheter aortic valve implantation (TAVI). However, assessment of MAC in the pre–TAVI diagnostic pathway is not among the procedures routinely performed. Aim of the study In this retrospective study conducted in patients undergoing TAVI, we evaluated (1) the presence and extent of MAC using a multimodal imaging approach; (2) the clinical and structural factors associated with it; and (3) the possible prognostic role of MAC. Methods Between 2016 and 2022, 62 patients with severe aortic stenosis underwent TAVI at the Cardiovascular Department of A.O.U. Careggi (Florence, Italy). Baseline and post–TAVI clinical and echocardiographic data were collected at Santo Stefano Hospital (Prato, Italy). MAC assessment was performed by quantitative analysis on echocardiographic and computed tomography (CT) images, obtaining a MAC severity score. A clinical follow–up was conducted at 30–day intervals in all patients. Results MAC was detected in 48 patients (77%), a severe MAC in 16 patients (26%). CT analysis was more accurate in defining the presence and extent of MAC. Patients with MAC were more female, older in age, with greater cardiovascular risk profile and comorbidities; they presented more frequently mitral valvulopathy and arrhythmias. These differences were amplified by stratifying the population according to MAC severity score. Patients with severe MAC had a pattern of ventricular remodeling with predominantly concentric hypertrophy. Post–TAVI, patients with severe MAC had less hemodynamic benefit and a greater need for pacemaker implantation. A trend of increasing all–cause mortality as MAC score increased was noted. Conclusions Assessment of mitral annular calcium and its extension should become an integral part of the patient‘s pre–TAVI risk stratification process. A phenotypic pattern of concentric left ventricular hypertrophy, mainly associated with patients with severe MAC, identifies a category with lower post procedural recovery.

Evaluation of the second-generation whole-heart motion correction algorithm (SSF2) used to demonstrate the aortic annulus on cardiac CT

The main purpose of pre-transcatheter aortic valve implantation (TAVI) cardiac computed tomography (CT) for patients with severe aortic stenosis is aortic annulus measurements. However, motion artifacts present a technical challenge because they can reduce the measurement accuracy of the aortic annulus. Therefore, we applied the recently developed second-generation whole-heart motion correction algorithm (SnapShot Freeze 2.0, SSF2) to pre-TAVI cardiac CT and investigated its clinical utility by stratified analysis of the patient's heart rate during scanning. We found that SSF2 reconstruction significantly reduced aortic annulus motion artifacts and improved the image quality and measurement accuracy compared to standard reconstruction, especially in patients with high heart rate or a 40% R-R interval (systolic phase). SSF2 may contribute to improving the measurement accuracy of the aortic annulus.

Usefulness of Coronary Artery Calcium Score to Rule Out Obstructive Coronary Artery Disease Before Transcatheter Aortic Valve Implantation

Pretranscatheter aortic valve implantation (pre-TAVI) coronary evaluation using computed tomography coronary angiography (CTA) remains suboptimal. We aimed to evaluate whether coronary artery calcium score (CAC) may rule out obstructive coronary artery disease (CAD) pre-TAVI. TAVI candidates (n=230; mean age 80 ± 8 years), 49% men, underwent preprocedural CTA and invasive coronary angiography. Obstructive CAD was defined as luminal diameter stenosis of ≥50% of left main or 3 major vessels ≥70%. Vessels with coronary stents or bypass were excluded. CAC score was calculated using the Agatston method. Receiver operating characteristic was applied to establish the CAC threshold for obstructive CAD. Multivariable analysis with adjustment for clinical covariates was applied. Net reclassification for nonobstructive disease using CAC score was calculated among nondiagnostic CT scans. Median CAC score was 1,176 (interquartile range 613 to 1,967). Receiver operating characteristic analysis showed high negative predictive value (NPV) for obstructive CAD as follows: left main CAC score 252, NPV 99%; left anterior descending CAC score 250, NPV 97%; left circumflex CAC score 297, NPV 92%; and right coronary artery CAC score 250, NPV 91%. Multivariate analysis showed the highest tertile of CAC score (≥1,670) to be an independent predictor of obstructive CAD (odds ratio 10.7, 95% confidence interval 4.6 to 25, p <0.001). Among nondiagnostic CTA, net reclassification showed reclassification of 76%, 13%, 45%, and 34% of left main, left anterior descending, left circumflex, and right coronary artery for nonobstructive CAD, respectively. In conclusion, CAC score cutoffs can be used to predict nonobstructive CAD. Implementing CAC score on pre-TAVI imaging can reduce a significant proportion of invasive coronary angiography.

Temporal Trends in the Utilization and Outcomes of Balloon Aortic Valvuloplasty in the Pre-Transcatheter Aortic Valve Implantation (TAVI) and TAVI Eras

We used a nationwide cohort to (1) compare characteristics and outcomes of patients who underwent balloon aortic valvuloplasty (BAV) in pre-transcatheter aortic valve transplantation (TAVI) and TAVI eras, (2) examine trends in utilization and outcomes of BAV from 2005 to 2017, (3) assess the association of BAV procedural volume with hospital-based TAVI volume, and (4) understand trends and outcomes of BAV in TAVI and non-TAVI centers in the TAVI era. Pre-TAVI era included hospitalizations from 2005 to 2011, and TAVI era included hospitalizations from 2012 to 2017. In the TAVI era, hospitals were classified into quartiles based on the number of TAVI procedures performed. Trends in volume of BAV procedures from 2012 to 2017 were assessed in non-TAVI and TAVI centers (based on TAVI volume). Between 2005 and 2017, a total of 6,962 hospitalizations for BAV were identified. There were no significant differences in in-hospital mortality or stroke between pre-TAVI and TAVI eras (mortality: pre-TAVI, 8.5% vs TAVI era, 9.3%, p=0.354; stroke: pre-TAVI, 1.9% vs TAVI era, 1.3%, p=0.083). However, acute kidney injury was more prevalent in the TAVI era and blood transfusion in the pre-TAVI era. Importantly, patients who underwent BAV in the TAVI era were more likely to have a greater number of co-morbidities and to undergo nonelective procedures. From 2005 to 2017, there was 10-fold increase in utilization of BAV. In the TAVI era, the maximum increase in number of BAV procedures was seen in hospitals with highest TAVI volume. In conclusion, although BAV procedural volume increased approximately 10-fold between 2005 and 2017, with concomitant expansion of TAVI, rates of mortality and stroke have remained stable. Despite this, the rate of BAV utilization continues to increase, thereby indicating a significant opportunity to improve outcomes in this patient population.

C38 RIGHT VENTRICULAR FREE WALL LONGITUDINAL STRAIN (RVFWSL) A NEW OUTCOME PREDICTOR IN PATIENTS CANDIDATE FOR TAVI

Abstract Background Right ventricular (RV) systolic dysfunction is considered an outcome predictor in various cardiovascular diseases. RV dysfunction, assessed by RV free wall longitudinal strain (RVFWSL) in patients candidate for trans–catheter aortic valve implantation (TAVI), has not been extensively explored as an outcome predictor. Purpose Evaluate the prognostic value of pre intervention RVFWSL in patients undergoing TAVI. Methods: retrospective analysis of 100 patients who underwent transfemoral TAVI in our hospital from 2015 to 2019, with at least a pre and post–TAVI echocardiography. Clinical and echocardiographic data before and after TAVI and follow–up data were collected. We considered the value of [23.3]% the cut–off of normality for RVFWSL. The primary end–point was a composite of death from any cause and hospitalization for heart failure. Results The median age of the patients was 81 years (79–83) with a functional status NYHA II–III (81%) before the intervention. EF was preserved in most of the patients (median 56%, 55–58), while Right ventricle dysfunction assessed with RVFWLS was reduced in half of the patients at baseline. At a median follow–up of 1023 days (630–1387), the univariate analysis demonstrated a predictive value for a reduced RVFWSL ( &amp;lt; [23.3]%, P = 0.015) and EF &amp;lt; 50% (P = 0.014) before TAVI. Cox regression analysis found that pre–TAVI reduced RVFWSL (HR 2.875, I.C. 95% 1.113–7.425; P = 0.03) and EF &amp;lt; 50% (HR 2.511, I.C. 95% 1.07–5.892; P = 0.03) were independently associated with composite end–point of the study. Moreover, a reduced EF associated with RVFWSL &amp;lt; [23.3]% showed an incremental value in predicting the outcome (P = 0.021). Conclusions Among patients with severe aortic stenosis undergoing TAVI, a reduced pre–implant RVFWSL is able to predict long–term outcome.

Relationship between septo-valvular angle and risk of pacemaker implantation after transcatheter aortic valve implantation: a preliminary study.

Pre-transcatheter aortic valve implantation (TAVI) computed tomography (CT) has proven to be crucial in identifying pre- and post-procedural predicting factors predisposing the onset of major arrhythmias that require permanent pacemaker (PPM) implantation caused by the compressive effects of the prostheses on the conduction system at the membranous septum (MS) and the muscular crest of the interventricular septum.Our analysis aims to verify if the pre-TAVI assessment of the angle between the MS and the aortic annulus (SVA) might be a predictive factor for the onset of arrhythmias that requires PPM. Two cardiovascular specialist radiologists retrospectively and double-blind evaluated a randomized list of preprocedural CT of 57 patients who underwent TAVI with a self-expandable valve from April 2019 to February 2020. Two anatomical features were measured by readers: width of the SVA and MS length (MSL). A PPM was implanted in 18 patients (31%) after the procedure. There was no significant difference in the anatomical measurements performed between the two observers, regarding both anatomical measurements (intraclass correlation coefficient was 0.944 for the SVA and 0.774 for the MSL]. Receiver-operating characteristic curves (ROC) performed for both measurements have documented: for the SVA sensitivity 94% and Negative predictive value (NPV) 96% (area under the curve: 0.77; 95% confidence interval 0.66-0.90). The MSL ROC was not significant. The mean SVA value stratified for patients who did not undergo PPM implantation and patients who did resulted as significant (P < 0.005). Measurement of the SVA performed in preprocedural CT scans has proven to be related to the onset of major arrhythmias after TAVI requiring permanent pacemaker implantation with high sensitivity (94%) and NPV (96%).

Performance of quantitative flow ratio in patients with aortic stenosis undergoing transcatheter aortic valve implantation.

This study aims to evaluate the diagnostic performance of quantitative flow ratio (QFR) pre transcatheter aortic valve implantation (TAVI) in patients with aortic valve stenosis (AS) and coronary artery disease (CAD). Post-TAVI fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) was used as reference. CAD is prevalent in patients with AS, but the hemodynamics of AS confounds evaluation using pressure wire-based assessments. QFR might be less sensitive to the presence of AS thereby allowing for CAD evaluation before aortic valve replacement. Further, QFR does not require the use of pressure wire and therefore has the potential for reducing costs and complications related to insertion of a coronary pressure wire. The diagnostic performance of QFR in coronary angiograms from 28 patients undergoing TAVI was evaluated. In all patients, both FFR and iFR were measured pre- and immediately post-TAVI while QFR was measured pre-TAVI. Using post-TAVI FFR and iFR as reference the diagnostic accuracy of pre-TAVI QFR were 83% (95%CI; 68-97) and 52% (95%CI; 30-74) p=.008, respectively. Pre-TAVI QFR showed a good diagnostic performance using post-TAVI FFR as reference. QFR could become a wire-free, safe, and quick way of evaluating CAD in patients with severe AS undergoing TAVI.

Prognostic impact of suspected cardiac amyloidosis in aortic stenosis patients referred for transcatheter aortic valve implantation

Abstract Background The prevalence of cardiac amyloidosis (CA) and aortic stenosis (AS) both increase with age. Transcatheter aortic valve implantation (TAVI) expands the number of patients (P) eligible for treatment of AS, emphasizing the need to understand the prevalence of CA in AS and its prognostic associations. Echocardiography with speckle tracking has emerged as a useful method to enhance the clinical suspicion and to provide prognostic information. Purpose To estimate the prevalence of CA in P with severe AS referred for TAVI and to evaluate the impact of concomitant CA in prognosis. Methods 94 consecutive AS P who underwent TAVI with maximum left ventricular wall thickness (LVWT)&amp;gt;12 mm were retrospectively identified. Clinical data, pre TAVI echocardiographic parameters and follow up (FU) data regarding all-cause mortality and MACE (including all-cause mortality, admission for heart failure, pacemaker implantation and stroke) were analysed. We registered apical sparing pattern in bull's eye plots (ASPB), calculated relative apical longitudinal strain formula (RALS) [average apical LS/(average basal LS + mid-LS)] and ejection fraction/global longitudinal strain (EF/GLS) ratio. Results Mean age was 82.2±5.8 years (Y), with 43 men (45.7%). 27.7% were in NYHA functional class II, 64.9% in functional class III and 7.4% in functional class IV. Median EF was 57±15% and 26.6% presented EF&amp;lt;50%. Suspected CA evaluated by ASPB was found in 39 P (41.5%) and RALS &amp;gt;1 was identified in 22 P (23.4%). An EF/GLS ratio &amp;gt;4.1 was obtained in 53 P (56.4%). Over a median follow-up of 13.4±25.8 months, 28 deaths (29.8%) and 31 MACEs (33.0%) occurred. The presence of ASPB was associated with increased all-cause mortality (33.3% vs. 5.6%, p=0.002) and MACE (48.7% vs 22.2%, p=0.01). RALS&amp;gt;1 correlated also with all-cause mortality (31.8% vs. 12.5%, p=0.04) and with new bundle branch block and indication for pacemaker implantation (46.2% vs 37.0%, p=0.05). P with GLS&amp;gt;−14.8% and ASPB had significantly worse prognosis regarding all-cause mortality (p=0.003) and MACE (p=0.007). Kaplan–Meier survival analysis showed that survival was significantly worse for P with ASPB (log-rank 0.002). With multivariate Cox regression analysis, ASPB was independently associated with all-cause mortality (HR=4.49, p=0.039). Conclusions Suspected CA appears prevalent among patients with AS and associates with all-cause mortality. The importance of screening for CA in older AS patients and optimal treatment strategies in those with CA warrant further investigation, especially in the era of transcatheter aortic valve implantation. Funding Acknowledgement Type of funding source: None

Short term clinical outcomes and analysis of risk factors for pacemaker implantation: a single center experience of self-expandable TAVI valves

ObjectivesTranscatheter aortic valve implantation is a recognized treatment for patients with severe aortic stenosis at all risk groups. However, permanent pacemaker rates remain high for self expandable transcatheter valves and permanent pacemaker implantation has been associated with increased morbidity. In this analysis we aim to evaluate short term clinical outcomes post self expandable transcatheter aortic valve implantation and determine risk factors for permanent pacemaker implantation.Methods88 patients with severe aortic stenosis with transcatheter aortic valve implantation performed between the year 2016–2018 were retrospectively analyzed. Outcomes of interest included 1- year all cause mortality, 30-day major adverse cardiovascular events, permanent pacemaker and paravalvular leak rates. Survival analysis was performed with Kaplan Meier analysis and risk factors for survival and permanent pacemaker rates were identified with log rank test and regression analysis.ResultsThe mean age of the cohort was 80.3 +/− 6.9 years. The mean STS score was 9.25. The 30 day all-cause mortality was 5.7% and 1-year all cause mortality was 16.7%. 80 patients had transfemoral transcatheter aortic valve implantation, and a majority of the patients (85.2%) were implanted with Corevalve Evolut R device. The device success rate was 88.6%. Multivariate analysis identified concomitant severe coronary artery disease (OR = 18.2 +/− 0.9; P = 0.002), pre transcatheter aortic valve implantation atrial fibrillation (OR = 8.6 +/− 0.91; P = 0.02) and post procedural disabling stroke (OR = 32.6 +/− 1.35; P = 0.01) as risk factors for 1-year mortality. The 30-day pacemaker rate was 17.6%. The presence of right bundle branch block (OR 11.1 +/− 0.86; P = 0.005), non-coronary cusp implantation depth (OR = 1.34 +/− 0.15; P = 0.05) and a non coronary cusp implantation depth / membranous septal length ratio of more than 50% were associated with post procedural pacemaker implantation (OR = 29.9 +/− 1.72; P = 0.05). Among the 15 patients with post procedural pacemaker implantation, 40% were found to be non-pacemaker dependent at 1 year.ConclusionShort term outcomes of transcatheter aortic valve implantation in severe aortic stenosis patients are promising. Pacemaker rates remain high. More studies are needed to evaluate the factors that influence pacemaker rates and dependence to further improve transcatheter aortic valve implantation outcomes.

1226 Prognostic impact of concomitant cardiac amyloidosis in aortic stenosis patients referred for transcatheter aortic valve implantation

Abstract Background The prevalence of cardiac amyloidosis (CA) and aortic stenosis (AS) both increase with age. Transcatheter aortic valve implantation (TAVI) expands the number of patients (P) eligible for treatment of AS, emphasizing the need to understand the prevalence of CA in AS and its prognostic associations. Echocardiography with speckle tracking has emerged as a useful method to enhance the clinical suspicion and to provide prognostic information. Purpose To estimate the prevalence of CA in P with severe AS referred for TAVI and to evaluate the impact of concomitant CA in prognosis. Methods 94 consecutive AS P who underwent TAVI with maximum left ventricular wall thickness (LVWT)&amp;gt;12 mm were retrospectively identified. Clinical data, pre TAVI echocardiographic parameters and follow up (FU) data regarding all-cause mortality and MACE (including all-cause mortality, admission for heart failure, pacemaker implantation and stroke) were analysed. We registered apical sparing pattern in bull’s eye plots (ASPB), calculated relative apical longitudinal strain formula (RALS) [average apical LS/(average basal LS + mid-LS)] and ejection fraction/global longitudinal strain (EF/GLS) ratio. Results Mean age was 82.2 ± 5.8 years (Y), with 43 men (45.7%). 27.7% were in NYHA functional class II, 64.9% in functional class III and 7.4% in functional class IV. Median EF was 57 ± 15% and 26.6% presented EF &amp;lt; 50%. Suspected CA evaluated by ASPB was found in 39 P (41.5%) and RALS &amp;gt; 1 was identified in 22 P (23.4%). An EF/GLS ratio &amp;gt; 4.1 was obtained in 53 P (56.4%). Over a median follow-up of 13.4 ± 25.8 months, 28 deaths (29.8%) and 31 MACEs (33.0%) occurred. The presence of ASPB was associated with increased all-cause mortality (33.3% vs. 5.6%, p = 0.002), new bundle branch block and indication for pacemaker implantation (46.2% vs 37.0%, p = 0.05) and MACE (48.7% vs 22.2%, p = 0.01). All-cause mortality was also higher in P with RALS (31.8% vs. 12.5%, p = 0.04). P with GLS&amp;gt;-14.8% and ASPB had significantly worse prognosis regarding all-cause mortality (p = 0.003) and MACE (p = 0.007). Kaplan–Meier survival analysis showed that survival was significantly worse for P with ASPB (log-rank 0.002). With multivariate Cox regression analysis, ASPB was independently associated with all-cause mortality (HR = 4.49, p = 0.039). Conclusions Suspected CA appears prevalent among patients with AS and associates with all-cause mortality. The importance of screening for CA in older AS patients and optimal treatment strategies in those with CA warrant further investigation, especially in the era of transcatheter aortic valve implantation. Abstract 1226 Figure. Kaplan–Meier curves and ASPB

LV systolic dysfunction stands to gain the most post transcatheter aortic valve implantation (TAVI).

We aimed to evaluate the extent of left ventricular (LV) recovery post transcatheter aortic valve implantation (TAVI) and its clinical predictors. This was a retrospective study on patients treated with TAVI from August 2008 to September 2017. Patients were sub-classified according to their baseline LV function as normal, mildly impaired, moderately impaired or severely impaired. Echo pre TAVI and early post TAVI were compared to assess LV function change. Predictors of LV function change were sought from univariate and multivariate ordinal logistic regression analyses. There were 662 patients included in this study. Nearly half of them, 323 patients (49%), had abnormal LV systolic dysfunction of various degrees. Of these, 193 (60%) showed LV function improvement post TAVI. Based on their pre-TAVI LV function, 55% of the mild LV dysfunction cohort, 62% of the moderate LV dysfunction cohort and 74% of the severe LV dysfunction cohort had LV function improvement post TAVI. Multivariate logistic regression analysis revealed baseline LV dysfunction as the only significant predictor of LV function improvement post TAVI. The majority of patients with baseline LV dysfunction had LV improvement post TAVI, more so those patients with severe LV dysfunction.

From the Circulation Family of Journals.

From the Circulation Family of Journals.

Pre-transcatheter aortic valve implantation assessment in patients with renal failure

Pre-transcatheter aortic valve implantation assessment in patients with renal failure

Incidental abnormal CT scan findings during transcatheter aortic valve implantation assessment: incidence and implications

ObjectivesThe aim of this retrospective series is to describe the prevalence and clinical significance of the incidental findings found during pre–transcatheter aortic valve implantation (TAVI) work-up and to ascertain the...

Do Opportunistic Radiological Markers of Frailty on Pre–Transcatheter Aortic Valve Implantation Computed Tomography Predict Outcomes?

Do Opportunistic Radiological Markers of Frailty on Pre–Transcatheter Aortic Valve Implantation Computed Tomography Predict Outcomes?

11. Transcathether implantation without preballoon dilation – How can echocardiography help

Abstract Type Clinical Research. Presentation Type Oral Presentation. Introduction Transcatheter aortic valve implantation (TAVI) is performed usually with preballoon dilation (PBD) which has its pros and cons. The aim of this study was to show the role of transesophageal echocardiographic (TEE) in selection of patients for TAVI without PBD and compare the results with those underwent PBD. Methodology 62 consecutive patients with severe symptomatic aortic stenosis underwent TEE evaluation before TAVI. 2D and 3D TEE imaging was used to assess aortic valve for suitability for direct valve implantation without PBD. Using echocardiographic criteria including sinotubular junction diameter, intersinus diameter, valve area, calcification, and degree of AR, echocardiographer agreed with the interventionist to consider patients either for TAVI with PBD or without PBD. We have 2 groups, group A underwent TAVI without PBD (n = 23) and group B underwent TAVI with PBD (n = 39). Results 62 patients (median age, 80.2 ± 11.7 years) with severe AS were evaluated. The mean aortic valve area was 0.74 ± 0.17 cm2. In group A, Edward valves were implanted in 21.7% (n = 5) and Core valves in 78.3% (n = 18). In group B, Edward valves were implanted in 46.2% (n = 18) and Core valves in 53.8% (n = 21). Post implantation balloon dilation to decrease or eliminate paravalvular leak was done in 21.7% (n = 5) in group A, vs 20.5% (n = 8) in group B, P = 0.9. In group A, residual paravalvular leak was seen in 13% vs 28.2% in group B, P = 0.2. Procedure-related mortality was not signii¬_cantly differ in both groups 4.3% (n = 1) vs 5.1% (n = 2), P = 0.89 and also longterm mortality at 29 ± 5 months, 17.4% (n = 4) vs 23.1% (n = 9) P = 0.59. Conclusion Pre TAVI TEE assessment of aortic valve can give a great help in selection of patients for TAVI without BPD which is feasible and safe. In our patients there was no difference in paravalvular leak or mortality in both groups.

Validation of 3D-reconstructed computed tomography images using OsiriX® software for pre-transcatheter aortic valve implantation aortic annulus sizing.

We report validation of OsiriX® -an image processing freeware-to measure multi-slice computed tomography-derived annulus diameters for preprocedural transcatheter aortic valve implantation planning. A total of 137 patients (82 ± 6.5 years, 42.3% male, logistic EuroSCORE 24.1 ± 14.2%) with severe aortic stenosis at high surgical risk underwent transcatheter aortic valve implantation assessment: transoesophageal echocardiography, angiography and multi-slice computed tomography. Retrospectively, 3D multi-slice computed tomography reconstructions were generated using OsiriX and the reliability evaluated regarding inter- and intraobserver variability, intermodality correlation and estimation of the clinical impact on transcatheter aortic valve implantation sizing. Reliability of the novel OsiriX software was high with an interobserver mean difference of 0.6 ± 1.4 mm and intraclass correlation of absolute agreement of 0.84 (95% confidence interval 0.74-0.90). The intermodality accuracy between OsiriX measurements and conventional 2D computed tomography reconstructions, transoesophageal echocardiography and angiography revealed significantly larger sizing with OsiriX, with a mean difference to 2D computed tomography of 0.4 ± 2.2 mm, which would have changed valve sizing in 38% of patients. In 28%, a larger size would have been chosen, and this correlated highly with the occurrence of postoperative severe aortic regurgitation (P < 0.001). While OsiriX measurements are an accurate and reproducible assessment of the aortic annulus, there are distinct and clinically relevant differences in aortic annulus dimensions between OsiriX measurements and previously standard imaging modalities. Sizing with OsiriX resulted in a larger perimeter compared with conventional 2D imaging. Careful assessment of valve size will take into account multiple imaging modalities.

A New Technique of Defining a Crossing Angle in Bicuspid Aortic Valve Stenosis

Introduction: Crossing bicuspid aortic valve (BAV) stenosis is challenging given the very eccentric opening of the valve. We describe a novel algorithm to define the plane of this eccentric orifice and our initial experience in aiding crossing the valve with a catheter and J-wire. Methods: Between 1st July 2015 and 28th Feb 2017, all BAV stenosis cases requiring transcatheter aortic valve implantation (TAVI) at St Andrew's War Memorial Hospital had a novel algorithm applied to their CT TAVI data with the aid of OsiriX MD medical software to determine a crossing angle pre TAVI. The plane of the virtual ring was determined by annular segmentation on multiplanar reformats and then points of interests (POI) placed along the circumference of the virtual ring. Immediately superior to this plane, POI were allocated along the commissural line. A three dimensional maximum intensity projection was then reconstructed to define the exact angle where the POI along the commissural line formed one point and the POI along the virtual ring plane formed a straight line. This angle showed both cusps in profile with the opening of the valves in the middle. Crossing times in this angle were then recorded at the time of TAVI. Results: 4 patients were included. A steep RAO Caudal view was always best for crossing. Using a catheter and straight wire, all valves were crossed in < 60 seconds. Conclusions: This unique technique for crossing BAV stenosis with the aid of CT reconstruction is feasible and may decrease xray and procedural time.