STS Score Research Articles

Temporal Trends in Patient Characteristics and Clinical Outcomes of TAVR: Over a Decade of Practice.

Background/Objective: Transcatheter aortic valve replacement (TAVR) is indicated for severe aortic stenosis patients with a prohibitive surgical risk. However, its use has been expanding in recent years to include intermediate- and low-risk patients. Thus, registry data describing changes in patient characteristics and outcomes are needed. The aim of this study was to analyse the temporal changes in patient profiles and clinical outcomes of all-comer TAVR. Methods: Baseline characteristics and VARC-3 outcomes of 1632 consecutive patients undergoing TAVR between 2008 and 2021 were analysed. Results: The annual rate of TAVR increased from 30 procedures in 2008-2009 to 398 in 2020-2021. Over the follow-up period, patient age decreased from 85 ± 4 to 80 ± 6.8 (p < 0.001) and the STS score decreased from 5.9% to 2.8% (p < 0.001). Procedural characteristics significantly changed, representing a shift into a minimally invasive approach: adoption of local anaesthesia (none to 48%, p < 0.001) and preference of transfemoral access (74% in 2011-2012 vs. 94.5% in 2020-2021, p < 0.001). The rates of almost all procedural complications decreased, including major vascular and bleeding complications, acute kidney injury (AKI) and in-hospital heart failure. There was a striking decline in rates of complete atrioventricular block (CAVB) and the need for a permanent pacemaker (PPM). PPM rates, however, remain high (17.8%). Thirty-day and one-year mortality significantly declined to 1.8% and 8.3%, respectively. Multivariable analysis shows that AKI, bleeding and stroke are strong predictors of one-year mortality (p < 0.001). Conclusions: The TAVR procedure has changed dramatically during the last 14 years in terms of patient characteristics, procedural aspects and device maturity. These shifts have led to improved procedural safety, contributing to improved short- and long-term patient outcomes.

Combined Computed Coronary Tomography Angiography and Transcatheter Aortic Valve Implantation (TAVI) Planning Computed Tomography Reliably Detects Relevant Coronary Artery Disease Pre-TAVI.

Background: Before surgical or transcatheter aortic valve implantation (TAVI), coronary status evaluation is required. The role of combined computed coronary tomography angiography (cCTA) and TAVI planning CT in this context is not yet well elucidated. This study assessed whether relevant proximal coronary disease requiring coronary revascularization can be safely detected by combined cCTA and TAVI planning CT, including CT-derived fractional flow reserve (FFR) calculation in patients with severe aortic stenosis. Methods: This study analyzed patients with successful cCTA combined with TAVI planning CT using a 128-slice dual-source scanner. The detection via cCTA of relevant left main stem stenosis (>50%) or proximal coronary artery stenosis (>70%) was compared to invasive coronary angiography (ICA). Results: This study comprised 101 consecutive TAVI patients with a median age of 83 [77-86] years, a median STS score of 3.7 [2.4-6.1] and 54% of whom had known coronary artery disease. Of 15 patients with relevant coronary stenoses, 14 (93.3%) were detected with cCTA, while false positive results were found in 25 patients. Only in patients with previous percutaneous coronary stent implantation (PCI) were false positive rates (11/29) increased. In the subgroup without previous PCI, an improved classification performance of 87.5%, being mainly due to 11.1% false positive classifications, led to a negative predictive value of 98.5%. Conclusions: Combined cCTA and CT-FFR with TAVI planning CT via state-of-the-art scanners and protocols as a one-stop shop can replace routine ICA in patients prior to TAVI due to its safe detection of relevant coronary artery stenosis, although diagnostic performance of cCTA is only reduced in patients with coronary stents.

The impact of the Naples Prognostic Score on the short- and long-term prognosis of patients undergoing transcatheter aortic valve implantation.

Preoperative systemic inflammation and nutritional status have been shown to affect prognosis in patients undergoing transcatheter aortic valve implantation (TAVI). In this study, we investigated the effect of the Naples Prognostic Score (NPS), which consists of four different parameters including these two components on short- and long-term prognosis in patients undergoing TAVI. In 343 patients (mean age 78.1 ± 8.4 years, 51.3% female) who underwent TAVI, the NPS score was calculated from the blood tests obtained before the procedure and the study population was divided into three according to the NPS value: those with 0 and 1 were divided into Group-1, those with 2 into Group-2, and those with 3 and 4 into Group-3. The relationship between NPS group and in-hospital adverse events and long-term survival was evaluated. Systolic pulmonary artery pressure, STS score, presence of chronic lung disease and being in NPS Group-3 [adjusted odds ratio (adjOR): 3.93, 95% confidence interval (CI) (1.02-15.17), P = 0.047] were found to be independent predictors of in-hospital mortality. According to the multivariate Cox-regression model, both Group-2 NPS [adjusted hazard ratio (adjHR): 4.81, 95% CI (1.09-21.14), P = 0.037] and Group-3 NPS [adjHR: 10.1, 95% CI (2.31-43.36), P = 0.002] was an independent predictor of 2-year all-cause mortality after TAVI. There was no significant difference in perioperative adverse events between the groups except for postprocedural acute kidney injury. According to receiver-operating characteristic analysis, the optimal predictive value of NPS for in-hospital and long-term mortality was 2.5. In patients who will be candidates for TAVI, NPS is a simple and effective tool for determining both short- and long-term prognosis.

A RARE COMPLICATION OF MITRAL TEER PROCEDURE: CLIP LATE DETACHMENT AND EMBOLIZATION

Abstract Intraprocedural and late complications of MitraClip implantation have already been described. This report highlights the importance of conventional surgical options in the event of percutaneous treatment failure. An 85–year–old woman with a history of chronic anemia, and thalassemia Minor was referred to our clinic for severe mitral regurgitation (MR) due to a P2 flail with significant calcification of the posterior mitral annulus. During the Heart Team discussion, age and comorbidities led to consider the patient eligible for TEER with the MitraClip system (EuroSCORE II 9,34%; STS score 7,47%). TEER procedure was uneventful: one XTW was deployed at the level of the flail (A2–P2), a second XTW was then placed more lateral to treat a separate residual jet, and one NTW was finally placed between them. MR reduction was considered acceptable (moderate MR, mean grad 6 mmHg). After two months, symptoms worsened, and TTE showed severe MR (no device detachment) with increased sPAP and associated moderate TR. A couple of weeks later, the patient was hospitalized. Chest X–ray revealed clip embolization confirmed by coronary angiography that showed an XTW Clip embolized to the Right coronary sinus with partial occlusion of the ostium. Percutaneous clip retrieval is described in the literature, but the embolized device position and the presence of recurrent severe MR led us to prefer an urgent surgical intervention. Under CPB, the embolized XTW was easily retrieved through a small aortotomy; the intervention was completed by mitral valve replacement and tricuspid valve repair. The postoperative course was uneventful. Predischarge TTE showed normal mitral bioprosthesis function, mild AR, mild TR, and preserved LV function. DISCUSSION Clip embolization is a rare but potentially critical complication of TEER and can happen periprocedurally or on early follow–up. Single leaflet detachment is more common, but complete detachment and embolization can occur. Therapeutic options are represented by surgical or transcatheter approaches according to embolization sites and patient comorbidities. In our case, the risk of potential coronary obstruction or thrombosis and the concomitant need for MR treatment have led us to consider surgery as the first option. CONCLUSION TEER can be graved by acute or late complications. The best approach has to be tailored to each patient, and surgery can be an effective and safe option even for initially discarded high–risk patients.

CCT‘S CRYSTAL BALL: PREDICTING CARDIOVASCULAR RISK IN AORTIC VALVE STENOSIS PATIENTS UNDERGOING VALVE REPLACEMENT

Abstract Background and Aims Currently, computed tomography cardiac imaging (CTCI) plays a fundamental role in the pre–procedural planning of degenerative–calcific aortic valve stenosis(AS) correction. However, its prognostic role in assessing mortality and major adverse cardiovascular events (MACE) has not been extensively explored. CTCI allows for the evaluation of coronary artery calcification(CAC), mitral annular calcifications (MAC), aortic valve calcifications (CVA), and thoracic aorta calcifications (CAT). The aim of our study was to assess whether the presence and extent of CAC, MAC, CVA, and CAT could influence non–cardiovascular mortality (NCM), cardiovascular mortality (CM), and MACE in patients undergoing valve replacement(VR). Materials and Methods We collected retrospectivelly clinical and instrumental data and reviewed CTCI using a semi–quantitative approach. CACs were classified according to the visual 2022 Coronary Artery Disease–Reporting and Data System. MACs were defined following the Guerrero et al. study, CVAs according to the Win Registry and CATs were assessed in the ascending aorta, aortic arch, and descending aorta according to the Vos classification. Results 244 patients(59% male, mean age 80.1±6.6 years), with 91% undergoing transfemoral VR, were enrolled(2016–2018). CM was significantly higher in patients with hypertension,cerebro/peripheral vascular disease, stage IV–V renal insufficiency and history of atrial fibrillation (p=0.012,p&amp;lt;0.001,p=0.005, p=0.034 and p=0.024, respectively). CM was also more pronounced in patients with STS SCORE≥6.7±5.2 and EuroSCOREII≥ 5.5±5.8(p=0.016 and p=0.037). Extensive CAC(p=0.019), a MAC score&amp;gt;7(p=0.051), moderate and severe AVC (p=0.029 and p=0.053) and TAC&amp;gt;270° in aortic arch(p=0.019) were linked to CM. In multivariate analysis, a high MAC score and the presence of moderate AVC persisted as risk factors for CM. The presence of a MAC score &amp;gt;7(p=0.006) and the extension of descending TAC &amp;gt;1.5 mm (p=0.034) were associated with an increased risk of NCM.The presence of extensive TAC (≥270°) measured in the aortic arch and descending aorta were associated with MACE (p=0.034 and p=0.0504 respectively). Conclusions CTCI emerges as a crucial tool for evaluating prognostic risk in patients undergoing VR for AS. This type of evaluation can assist clinicians in pre–procedural planning and patient management, allowing for better identification of high–risk patients and optimization of therapeutic strategies

Percutaneous balloon mitral valvuloplasty with shockwave lithotripsy for the treatment of calcific mitral valve stenosis.

Calcific mitral stenosis (calcific MS) presents a challenge for surgical treatment and is a contraindication for most contemporary transcatheter mitral valve replacement devices (TMVR), rendering patients with very limited therapeutic options. This study aims to assess the clinical and hemodynamic follow-up after mitral valve lithotripsy (MVL). All consecutive patients who underwent MVL to treat symptomatic calcific MS at St Michael's Hospital, Toronto, Canada, were included. Patients were deemed unsuitable for mitral surgery or TMVR after heart team assessment. Patients with rheumatic MS or ≥moderate mitral regurgitation (MR) were excluded. The primary endpoint was a reduction in the invasive mitral gradient by ≥50% without significant (≥moderate) MR. Fifteen patients underwent MVL between 2021 and 2023 with a mean age of 74 ± 9 years; 53% were female, with a mean STS score of 10% ± 0.1%. Following MVL, there was a reduction in the invasively measured mean trans-mitral gradient compared to baseline (14 mmHg vs. 6 mmHg; p < 0.05). The primary endpoint was achieved in 8 patients (53%) with no major procedural complications. At follow-up (median 90 days, IQR 58-115 days), 14 (93%) patients reported improved symptoms from New York Heart Association (NYHA) Class III-IV to NYHA Class I-II (p < 0.01) with stable echo-derived mean gradient (7.7 mmHg ± 2 mmHg vs. 8.4 mmHg ± 2.9 mmHg (p = 0.7). In selected patients with symptomatic inoperable calcific MS, MVL was safe and associated with significant short-term clinical and hemodynamic improvement. MVL may represent a new compassionate therapy for this challenging cohort. Further studies are needed to determine the long-term outcomes and help define the role of IVL technology in treating calcific valvular conditions.

Abstract 2113: Transcatheter Aortic Valve Replacement (TAVR) Complication: Intraoperative Mitral Regurgitation.

Introduction: Transcatheter aortic valve replacement (TAVR) is the preferred treatment for aortic stenosis (AS) in patients with high surgical risk. This case report delves into a rare, significant intra-procedural mitral regurgitation (MR) of TAVR. Case Presentation: A 94-year-old female with severe AS and a STS score of 3.9% underwent TAVR. A recent 2D ECHO revealed severe AS. CT angiogram pre-TAVR exhibited scattered coronary artery calcifications, severe aortic valve calcification, and calcified atherosclerotic plaque. During the procedure, a 26mm CoreValve was deployed appropriately, with no perivalvular leak observed on angiography and transesophageal echocardiography (TEE). However, post-deployment, the patient experienced a sudden drop in blood pressure, and intra-procedural TEE revealed severe MR, not detected in previous studies. Treatment included pressors, non-invasive positive pressure ventilation, and diuretics, resulting in a favorable response. Subsequent TTE on the 4th day showed improvement in MR. A one-year follow-up TTE revealed only trace MR, confirming the normal functioning of the prosthetic valve. Discussion: Acute mitral regurgitation is an uncommon TAVR complication with potential morbidity and mortality. Various studies propose multiple mechanisms, and in this case, we attribute it to intraoperative global hypoperfusion causing transient MR. Hypoperfusion of the papillary muscle disrupted leaflet coaptation, leading to MR, as supported by its resolution with improved blood pressure. Studies have reported different mechanisms for acute MR, including papillary muscle rupture, leaflet perforation, guidewire impingement, and global hypoperfusion, with some indicating a higher incidence in CoreValve compared to other valve types. Conclusion: Given the rarity of acute MR during TAVR and the unclear pathophysiology, there are no established society guidelines for its management. With TAVR becoming routine, further clinical trials are crucial for optimizing treatment, including head-to-head comparisons of valves and procedural techniques, and developing comprehensive management strategies based on the specific mechanisms of this acute complication.

A Modified Tip-to-Base LAMPOON to Prevent Left Ventricular Outflow Tract Obstruction in Valve-in-Ring or Valve-in-Valve Transcatheter Mitral Valve Replacement.

The Laceration of the Anterior Mitral leaflet to Prevent Outflow ObtructioN (LAMPOON) procedure may be performed from the leaflet tip to base to prevent left ventricular outflow tract obstruction (LVOTO) in patients with high-risk anatomy undergoing valve-in-valve (VIV) or valve-in-(complete)-ring (VIR) transcatheter mitral valve replacement (TMVR). Thirteen consecutive patients (6 females, average age 67.7 years) with a mean left ventricular ejection fraction of 60%, a median STS score of 3.2%, and degenerative surgical mitral bioprosthesis or ring were treated with a combined, single-stage procedure of preventive LAMPOON and trans-septal TMVR with SAPIEN 3 valves (Edwards Lifesciences, Irvine, CA). Under real-time 3-dimensional transesophageal echocardiography (RT 3D-TEE) guidance, we included the rendezvous technique in the LAMPOON procedure, and all 13 patients were successfully treated by tip-to-base LAMPOON and TMVR. The use of a modified LAMPOON procedure, aided by a rendezvous technique and guided by RT 3D-TEE imaging, offers precise guidance for positioning and aligning the guidewire. This approach not only reduces the need for fluoroscopy and shortens procedure times, but also significantly increases the likelihood of a successful outcome. Importantly, none of the patients in our study experienced unintentional aortic or aortic valve injuries, nor did they develop significant LVOTO following TMVR. In 11 of the 13 (85%) patients, we used a transcatheter SENTINELTM cerebral protection device (Boston Scientific, Marlborough, MA) for stroke prevention and capture of debris ≥ 2 mm were detected in 8/11 (73%) of the cases. Utilizing intra-operative RT 3D-TEE in conjunction with the rendezvous technique can make the tip-to-base LAMPOON procedure even safer and more effective for patients undergoing VIV or VIR TMVR. Our study also suggests that cerebral protection is indicated in patients undergoing TMVR.

Cut-down Access to Avoid Vascular Complications During Transcatheter Aortic Valve Implantation

Objective: Vascular Complications (VCs) are independent predictors of mortality after Transcatheter Aortic Valve Implantation with Transfemoral Access (TF-TAVI) and remain an unsolved problem regardless of the Percutaneous (PC) or Surgical Cut-down (SC) access for patients with severe Aortic Valve Stenosis (AVS). The debate about the short- and long-term results, safety, risks of procedural complications and the complementary roles of SC and PC approaches is still open. We aim to show VCs in our series of patients submitted to TF-TAVI using a surgical-cutdown. Methodsː Retrospective analysis of consecutive patients with symptomatic severe AVS receiving TF-TAVI. The accesses were studied by computed tomography and Echo Color Doppler. The STS score was &lt;4 in 172 (66.4%), 4-8 in 72 (27.8%) and &gt;8 in 15 (5.8%) patients. The outcomes were the incidence of VCs. SC procedures were applied by Edwards SAPIENTM 3 (Edwards Lifesciences, Irvine, CA, USA) BE device. Resultsː We enrolled 259 patients, 244 (94.2%) underwent TF-TAVI with the SC approach. The mean patients’ age was 82 ± 2 (range: 58-99). Female patients were 160/259 (62%) and male 99/259 (38%). The mean fluoroscopic time was 22 minutes. The 30-day mortality rate was 0.77% (two deaths). Intraoperative VCs were 6 (2.3%) and 1 (0.4%) at 1-year follow-up. The ICU stay was one day, the median post-operative hospitalization was two days. Conclusionː This study contributes to the debate about the advantages of the SC approach compared to PC according to the patients’ profile with AVS and proposes multicenter prospective trials, especially for a future TAVI use in young and low-risk patients.

Transcarotid versus transfemoral transcatheter aortic valve replacement: A systematic review and meta-analysis

BackgroundIn the 2021 Transcatheter Valve Therapy (TVT) registry, 8.9 % of patients underwent TAVR via access sites other than the femoral artery. Transthoracic approaches may be contraindicated in some patients and may be associated with poorer outcomes. Therefore other alternative access routes are increasingly being performed. We conducted a systematic review of the literature on transcarotid transcatheter aortic valve replacement (TC-TAVR) and meta-analysis comparing outcomes of TC-TAVR and other access routes. MethodsWe comprehensively searched for controlled randomized and non-randomized studies from 4 online databases. We presented data using risk ratios (95 % confidence intervals) and measured heterogeneity using Higgins' I2. ResultsSixteen observational studies on transcarotid TAVR were included in the analysis; 4 studies compared TC-TAVR vs TF-TAVR. The mean age and STS score for patients undergoing TC-TAVR were 80 years and 7.6 respectively. For TF-TAVR patients, mean age and STS score were 81.2 years and 6.5 respectively. There was no difference between patients undergoing TC-TAVR and TF-TAVR in the following 30-day outcomes: MACE [8.4 % vs 6.7 %; OR 1.32 (95 % CI 0.71–2.46 p = 0.38) I2 = 0 %], mortality [5.6 % vs 4.0 %; OR 0.42 (95 % CI 0.60–3.37, P = 0.42) I2 = 0 %] and stroke [0.7 % vs 2.3 %; OR 0.49 (95 % CI 0.09–2.56, P = 0.40) I2 = 0 %]. There was no difference in 30-day major vascular complications [0.7 % vs 3 %; OR 0.55 (95 % CI 0.06–5.29, P = 0.61) I2 = 39 %], major bleeding [0.7 % vs 3.8 %; OR 0.39 (95 % CI 0.09–1.67, P = 0.21) I2 = 0 %], and moderate or severe aortic valve regurgitation [8.6 % vs 9.9 %; OR 0.89 (95 % CI 0.48–1.65, P = 0.72) I2 = 0 %]. ConclusionThere are no significant differences in mortality, stroke MACE and major or life-threatening bleeding or vascular complications when TC-TAVR is compared to TF-TAVR approaches.

Baseline NT-proBNP predicts acute kidney injury following transcatheter aortic valve implantation

Background/purposeAcute kidney injury (AKI) after transcatheter aortic valve implantation (TAVI) increases morbidity and mortality. Our study aimed to investigate the role of baseline N-terminal pro B-type natriuretic peptide (NT-proBNP) as a predictor of AKI following TAVI. MethodsAll consecutive TAVI patients were included in the analysis, except patients with dialysis and those with a GFR < 15 ml/min/1.73 m2 at baseline. Rates of AKI after TAVI were assessed according to the updated valve academic research consortium definitions using AKIN classification in three stages. NT-proBNP was measured at baseline. One-year mortality rates were assessed. ResultsWe included 1973 patients treated with TAVI between January 2006 and December 2016. Median [IQR] age was 81.0 [77.0;84.0] years, the STS score was 6.2 [3.9;9.0], and the logEuroScore was 14.5 [9.0;23.0]. 30-day and one-year mortality was 5.1 % and 16.1 % for all patients, respectively. Multivariate analysis revealed that patients with NT-proBNP levels higher than two times above the upper level of normal (ULN) had an increased risk for AKI after TAVI compared to patients with NT-proBNP levels < 2× ULN (OR 1.40 [1.03–1.91]). ConclusionsRoutine assessment of baseline NT-proBNP levels might be an additional tool to identify patients at increased risk for AKI after TAVI.

Balloon Aortic Valvuloplasty with or without Percutaneous Coronary Intervention in the Transcatheter Aortic Valve Replacement Era

Introduction: The role of balloon aortic valvuloplasty (BAV) in the era of transcatheter aortic valve replacement remains a topic of debate. We sought to study the safety and feasibility of combined BAV and percutaneous coronary intervention (BAV-PCI). Methods: Between November 2009 and July 2020, all patients undergoing BAV were identified and divided into three groups: combined BAV-PCI (group A), BAV with significant unrevascularised CAD (group B), and BAV without significant CAD (group C). Procedural outcomes and 30-day and one-year mortality were compared. Results: A total of 264 patients were studied (n = 84, 93, and 87 patients in groups A, B, and C, respectively). The STS score was 10.2 ± 8, 13.3 ± 19, and 8.1 ± 7, p = 0.026, in groups A, B, and C, respectively. VARC-3 adjudicated complications were similar among groups (11%, 13%, and 5%, respectively, p = 0.168, respectively). Thirty-day and one-year mortality were 9.8% (n = 26) and 32% (n = 86) of the entire cohort. The differences among groups did not reach statistical significance. Using univariate Cox regression analysis, group B patients were at higher risk of dying compared to group A patients (HR 1.58, 95% CI: 1.11–2.25, p = 0.010). With multivariate Cox regression analysis, the predictors of mortality were STS score, cardiogenic shock, mode of presentation, and lack of subsequent definitive valve intervention. Conclusion: In high-risk patients with aortic valve stenosis, combined BAV-PCI is safe and feasible with comparable outcomes to BAV with and without significant CAD.

Third-Generation Transcatheter Aortic Heart Valve with Reverse Parachute Sealing Cuff in Patients with Aortic Valve Disease

The Navitor (Abbott Inc, IL, USA) transcatheter heart valve is a novel third-generation self-expanding bioprosthesis with specific features to mitigate paravalvular regurgitation (PVR). Owing to its novelty, there is a paucity of data on its application in clinical practice. Consecutive cohort analysis of the use of the Navitor system in an as-treated clinical setting at a quaternary heart hospital. Sixty consecutive non-clinical trial patients treated with Navitor were identified. All patients underwent a successful procedure. The mean age was 79.3 years (±SD 7.82), 56.67% (n=34) were female, and the mean STS score was 4.87 (±SD 5.70). At 30 days post-procedure, all patients were alive with no readmissions for heart failure. One patient had a major vascular complication (1.7%). Four patients (7.14% of patients without a pre-existing pacemaker) received a new permanent pacemaker. Two patients (3.4%) had a non-disabling stroke. PVR at 30 days was trivial or none in 75% of patients, and no patient had worse than mild PVR. The Navitor system in this as-treated cohort was associated with favourable clinical, haemodynamic, and safety outcomes.

Prognostic impact of main pulmonary artery to ascending aorta diameter ratio in patients with severe aortic stenosis underwent transcatheter aortic valve implantation.

Pulmonary hypertension (PH) and right ventricular dysfunctionare poor prognostic predictors in patients underwent transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS). The prognostic impact of the main pulmonary artery/ascending aorta diameter ratio (MPA/AOr), measured simply by computed-tomographic angiography (CTA), was investigated in this patient group. A total of 374 retrospectively evaluated patients (mean age 78.1 ± 8.4 years, 192 [51.3%]females)who underwent TAVI for severe AS were included. MPA/AOr was measured on preprocedural CTA in all patients and the effect of this measurement on the presence of PH, in-hospital and 2-year-overall long-term mortality was investigated. The presence of PH was defined as a systolic pulmonary artery pressure (sPAP) >42 mmHg measured by echocardiography. According to multivariate-logistic-regression analysis, MPA/AOr(adjusted [Adj] odds ratio [OR]: 1.188, confidence interval [CI] 95% [1.002-1.410], p = 0.048), tricuspid annular plane systolic excursion (TAPSE)(adj OR:0.736, CI 95% [0.663-0.816], p < 0.001)and left atrial diameter (adj OR:1.051, CI 95% [1.007-1.098], p = 0.024)were identified as independent predictors of PH. In addition, a statistically significant correlation was found between MPA/AOr and TAPSE (r: -0.283, p < 0.001). Furthermore, MPA/AOr was found to be an independent predictor of both in-hospital (adj OR:1.434, CI 95% [1.093-1.881], p = 0.009)and 2-year long-term (adj OR:1.518, CI 95% [1.243-1.853], p < 0.001)mortality in multivariate analysis including TAPSE, STS score and sPAP. In the 2-year Kaplan-Meier survival probability analysis, an MPA/AOr >0.86 was found to have ahazard ratioof 3.697 (95% CI: 2.341-5.840), with a log-rank p < 0.001. MPA/AOr, which can be measured simply by CTA, may be useful as an indicator of the presence of PH and poor prognosis in patients planned for TAVI for severe AS.

Valve Surgery After the Age Of 70: Evaluation Risk Factors for Hospital Mortality

Objective: Valve surgery after the age of 70 is increasingly common in Algeria. The aim of this study was to identify risk factors for in-hospital mortality in this population. Methods: 56 patients with a mean age of 72 years (70-81) underwent valve surgery between 2016 and December 2019. 32 patients (57.4%) had aortic valve replacement, 17 patients (29.7%) had mitral surgery and 07 patients (12.9%) had aorto-mitral surgery. 04 procedures (8%) were urgent. The Euroscore was used to predict operative risk. The mean additive Euroscore was 9.05 and the mean logistic Euroscore was 14.2%. Results: Operative mortality was 3.8%. Preoperative risk factors were: NYHA III class, repeat operations, critical status according to the Euroscore,STS score , PAH, mitral surgery and tricuspid surgery. Post-operative complications were: low flow (12%), supra-ventricular arrhythmia (32.7%), renal dysfunction (14.6%), pulmonary (11%), intestinal (3.5%), infection (4%) and surgical re-exploration (6.5%). Post-operative risk factors for mortality were low flow, renal dysfunction, gastrointestinal complications and surgical re-exploration. Conclusion: Valve surgery after the age of 70 is a low-risk procedure. Our data are correlated with the Euroscore.

Tumour necrosis factor-alpha serum level is an independent predictor of medium-term all-cause mortality after transcatheter aortic valve replacement

Background Transcatheter aortic valve implantation (TAVI) is a suitable treatment for patients with severe aortic stenosis and severely increased operative risk. There is need for a better preoperative risk assessment for TAVI candidates. Aim To determine whether Tumour necrosis factor-alfa (TNFα) is an independent predictor of survival 500 days after TAVI. Methods Sixty patients undergoing TAVI were enrolled in the study. TNFα was determined. The CT measured low-density muscle fraction (LDM%) of the psoas muscle was determined. Operative risk assessment by Logistic EuroSCORE, EuroSCORE II, and STS score was performed. Frailty scores (FRAIL scale and Barthel index) were determined. Results Mean age was 81.01 ± 7.54 years. Twenty-six (43.3%) of the patients were males. In the univariable analyses, FRAIL scale and Barthel index were no predictors of survival after TAVI. In the multivariable analysis, including EuroSCORE II, LDM% and TNFα serum concentration, TNFα serum level was an independent predictor of survival 500 days after TAVI (HR: 3.167; 95%: 1.279–7.842; p = 0.013). The multivariable analysis, including TNFα as a categorical variable, showed that compared to patients in the conjugated first and second TNFα serum level tertile, patients in the third tertile had a hazard ratio (HR) of 10.606 (95%CI: 1.203 − 93.467) (p = 0.033). Conclusion TNFα is an incremental independent predictor of long-term survival after TAVI.

Single-Center Experience with the Balloon-Expandable Myval Transcatheter Aortic Valve System in Patients with Bicuspid Anatomy: Procedural and 30-Day Follow-Up.

Aims: To report our single-center data regarding the initial 52 consecutive patients with a bicuspid aortic valve who underwent a Transcatheter Aortic Valve Implantation (TAVI) procedure using the new balloon-expandable MYVAL system. The focus is on reporting procedural details and outcomes over the 30-day postoperative period. Methods: From December 2019 to July 2023, 52 consecutive patients underwent a TAVI procedure with bicuspid anatomy. All patients had moderate to-high surgical risk or were unsuitable for surgical aortic valve replacement based on the Heart Team's decision. Outcomes were analyzed according to the VARC-2 criteria. The results of bicuspid patients were compared to patients with tricuspid anatomy in the overall study group, and further analysis involved a comparison between 52 pairs after propensity score matching. The device performance was evaluated using transthoracic echocardiography. Data collection was allowed by the Local Ethical Committee. Results: The mean age was 71 ± 7.1 years, and 65.4% were male. The mean Euroscore II and STS score were 3.3 ± 3.2 and 5.2 ± 3.3, respectively. Baseline characteristics and echocardiographic parameters were well balanced even in the unmatched comparison. Procedures were significantly longer in the bicuspid group and resulted in a significantly higher ARI index. All relevant anatomic dimensions based on the CT scans were significantly higher in bicuspid anatomy, including a higher implantation angulation, a higher rate of horizontal aorta and a higher proportion of patients with aortopathy. In the unmatched bicuspid vs. tricuspid comparison, postprocedural outcomes were as follows: in-hospital mortality 0% vs. 1.4% (p = 0.394), device success 100% vs. 99.1% (p = 0.487), TIA 1.9% vs. 0% (p = 0.041), stroke 1.9% vs. 0.9% (p = 0.537), major vascular complication 3.8% vs. 2.3% (p = 0.530), permanent pacemaker implantation 34% vs. 30.4% (p = 0.429), and cardiac tamponade 0% vs. 0.5% (p = 0.624). In the propensity-matched bicuspid vs. tricuspid comparison, postprocedural outcomes were as follows: in-hospital mortality 0% vs. 0%, device success 100% vs. 100%, TIA 1.9% vs. 0% (p = 0.315), stroke 1.9% vs. 0.9% (p = 0.315), major vascular complication 3.8% vs. 0% (p = 0.475), permanent pacemaker implantation 34% vs. 24% (p = 0.274), and cardiac tamponade 0% vs. 0%. There was no annular rupture nor need for second valve or severe aortic regurgitation in both the unmatched and matched comparison. The peak and mean aortic gradients did not differ at discharge and at 30-day follow-up between the two groups regardless of whether the comparison was unmatched or matched. There were no paravalvular leakages (moderate or above) in the bicuspid patients. Intermediate and extra sizes of the Myval THV system used a significantly higher proportion in bicuspid anatomy with a significantly higher oversize percentage in tricuspid anatomy. Conclusions: The TAVI procedure using the Myval THV system in patients with significant aortic stenosis and bicuspid aortic valve anatomy is safe and effective. Hemodynamic parameters do not differ between tricuspid and bicuspid patients. However, the permanent pacemaker implantation rate is higher than expected; its relevance on long-term survival is controversial.

MICRA AV implantation after transcatheter aortic valve replacement

BackgroundTranscatheter aortic valve replacement (TAVR) has evolved as a breakthrough therapy for patients with severe aortic valve stenosis. While TAVR has revolutionized the management of aortic valve disease, the procedure may be associated with the development of conduction disturbances requiring permanent pacemaker implantation. Traditionally, conventional transvenous pacemakers have been used to address these complications. However, the introduction of leadless pacemaker technology, such as the MICRA Transcatheter Pacing System (TPS), offers a novel alternative. Materials and methodsThis was a retrospective single-center study where all patients who underwent TAVR at our center and subsequently required permanent pacemaker implantation within 30 days were reviewed. We included only the patients who underwent leadless pacemaker placement. We then conducted a retrospective chart review to identify patient and procedural characteristics, procedural details, and relevant clinical outcomes. ResultsA total of 9 patients were identified. All of the patients underwent MICRA AV placement within 30 days post-TAVR by an interventional cardiologist. The average age of the cohort was 79.6 years with an average STS score of 3.7 %. The majority of the patients received balloon-expandable valves (78 %). There were no procedural complications in any of the patients. At an average follow-up of 353 days, capture thresholds and lead impedance remained stable with an average RV pacing of 13 %. ConclusionThis small, retrospective cohort demonstrates that the use of MICRA AV leadless pacemakers is feasible after TAVR and is associated with low periprocedural complications. Leadless pacemakers provide stable pacing thresholds and AV synchrony.

Patient selection criteria for transcatheter implantation of aortic valve

The aim – to conduct a literature review, analyze and, based on our own results, present an algorithm for choosing the tactics of surgical treatment of patients with severe aortic stenosis.Materials and methods. In this prospective study, the medical records of adult patients (from 18 years of age) who underwent surgical or transcatheter aortic valve replacement at the Heart Institute of the Ministry of Health of Ukraine, between 2018 and 2023 were analyzed.Results. The algorithm for the selection of surgical treatment of patients included in the study was built based on a thorough analysis of the anamnesis, clinical, laboratory and instrumental examination data. An important stage in choosing the optimal surgical tactics is the assessment of the development of intraoperative and postoperative complications according to the EuroSCORE and STS SCORE scales, which are most widely used in cardiac surgery practice and allow predicting the complicated course of the early postoperative period in patients with acquired valvular heart defects. Although there is an increasing trend towards TAVI in younger, lower-risk patients, the more frequent possibility of residual paravalvular insufficiency and the need for permanent pacemaker implantation should be considered. As the experience of interventional cardiologists increases and new valve designs and delivery systems are developed, better clinical outcomes and lower complication rates can be expected, which will contribute to the expansion of indications for TAVI.Conclusions. Today, TAVI remains the only way to correct aortic valve defects for inoperable patients with severe symptomatic aortic stenosis. Based on the results of several randomized controlled trials, TAVI is associated with a much lower rate of postoperative complications and a faster recovery, and should be the method of choice in all high surgical risk patients and a competitive alternative to aortic valve replacement in intermediate risk patients.

Risk-Predictive Models for Adverse Events in Cardiac Surgery: A Review

Risk prediction models are an important part of assessing operative mortality and postoperative complication rates in current cardiac surgery practice. Furthermore, they guide clinical decision-making and perioperative patient management. In recent years, a variety of clinical prediction models have been developed in China and other countries to assess the risk of mortality and complications after cardiac surgery. Currently, the most widely used and mature models are the new version of the European Cardiac Surgery Evaluation System (EuroSCORE II), the American Society of Thoracic Surgeons Cardiac Surgery Risk Model (STS score), and the Chinese Coronary Artery Bypass Graft Surgery Risk Evaluation System (SinoSCORE). This article reviews the application of these three risk prediction models, to identify the optimal model for guiding clinical practice.