Successful Transcatheter Aortic Valve Implantation Research Articles

Successful transcatheter aortic valve implantation (TAVI) with SNARE technique

Successful transcatheter aortic valve implantation (TAVI) with SNARE technique

Computational study of the balloon dilation steps on transcatheter aortic valve replacement.

Balloon dilation is a commonly used assistant method in transcatheter aortic valve replacement (TAVR) and plays an important role during valve implantation procedure. The balloon dilation steps need to be fully considered in TAVR numerical simulations. This study aims to establish a TAVR simulation procedure with two different balloon dilation steps to analyze the impact of balloon dilation on the results of TAVR implantation. Two cases of aortic stenosis were constructed based on medical images. An implantation simulation procedure with self-expandable valve was established, and multiple models including different simulation steps such as balloon pre-dilation and balloon post-dilation were constructed to compare the different effects on vascular stress, stent morphology and paravalvular leakage. Results show that balloon pre-dilation of TAVR makes less impact on post-operative outcomes, while post-dilation can effectively improve the implantation morphology of the stent, which is beneficial to the function and durability of the valve. It can effectively improve the adhesion of the stent and reduce the paravalvular leakage volume more than 30% after implantation. However, balloon post-dilation may also lead to about 20% or more increased stress on the aorta and increase the risk of damage. The balloon dilation makes an important impact on the TAVR outcomes. Balloon dilation needs to be fully considered during pre-operative analysis to obtain a better clinical result.

OP147 Measuring Health Technology Assessment Impact On The Introduction Of Transcatheter Aortic Valve Replacement In A Private Healthcare System

IntroductionAortic stenosis is an insidious disease that has a high mortality rate when it becomes symptomatic. Surgical valve replacement is the treatment of choice and has predictable risks. Transcatheter aortic valve replacement (TAVR) is a less invasive alternative to surgery, which is indicated for high-risk patients.Complications after TAVR include paravalvular leak, cerebrovascular events, and the need for pacemaker implantation. A health technology assessment report carried out by the Health Technology Assessment Unimed-BH group in 2018, two years before it became part of the National Supplementary Health Agency, recommended the introduction of TAVR with the following criteria: indications provided by a group of specialists; forwarding of a report with detailed clinical data; results of imaging exams; and follow-up results for up to one year after the procedure. After the introduction of TAVR with the agreed criteria, it was possible to access TAVR results from the private healthcare system of Unimed-BH.MethodsAdministrative data were collected from the Unimed-BH database. All patients who received a TAVR implant from 2013 to 2017 were included by virtue of a court injunction, and after 2018 by operator concession and within agreed criteria.ResultsFrom July 2013 to June 2019, 83 patients underwent TAVR implantation by Unimed BH. The median age of patients was 83.4 years (interquartile range 66.5 to 97.9), most of whom were women (56%). There was a predominance of patients in New York Heart Association classification III (50%) and IV (29%). There were 36 patients who underwent TAVR before 2018 and 47 patients within the agreed criteria. In the period prior to the agreed criteria, 28 percent needed a pacemaker, compared with 23 percent after 2018. During the follow-up period, 39 patients died: 18 (50%) before 2018 and 11 (23%) after 2018.ConclusionsThe agreement made with the providers, which included the obligation of having a team of specialists responsible for the indication and access to clinical data through the report, improved patient outcomes. This may be due to having a better indication for the procedure or to the greater experience of the professionals involved in its delivery.

Prognostic role of extracardiac incidentalomas detected with computed tomography in patients with severe aortic stenosis candidates for transcatheter aortic valve replacement

Abstract Background Aortic stenosis is one of the most common valvular heart diseases worldwide, especially among older individuals. According to the latest guidelines for the management of valvular heart disease, in patient with high surgical risk and aged 75 years and older, transcatheter aortic valve replacement (TAVR) is the first therapeutic option to be considered (1). Every patient undergoing TAVR should perform a computed tomography (CT) scan before percutaneous procedure. An incidentaloma is defined as an unexpected finding on a CT scan performed for another clinical reason. Purpose The purpose of this study is to determine the prognostic role of incidentalomas found on CT scan performed pre-TAVR procedure in elderly patients with severe aortic stenosis. Methods We performed a monocentric retrospective observational study of 284 patients with severe aortic stenosis evaluated for TAVR from January 2016 to December 2022. All data were collected retrospectively and processed anonymously. Patients' clinical data (past medical history, cardiovascular risk factors, comorbidities, echocardiogram and coronary artery angiography findings) were collected, and all CT scans were reviewed for the presence of incidentalomas. An incidentaloma was considered clinically relevant only if further investigations were required following its diagnosis. Statistical analyses were performed using Mann-Whitney test, uni- and multivariate Cox regression models. Only variables with p<0,05 on univariate analysis were included in multivariate models. The primary endpoint of the study was delay in TAVR implantation. The secondary endpoint was death. Results We analyzed 284 patients’ data with a median age of 87 (83-90) years. The median follow-up was 713 (464-1130) days in which 165 (58%) patients underwent TAVR and 83 (29%) deceased. Among the patients, 43 incidentalomas were diagnosed (Table 1). About primary endpoint, within patients who underwent TAVR, median delay to the procedure was 217 (160-284) days and there was not statically difference in delay between patients with or without incidentalomas (Mann-Whitney test p=0,08) (Figure 1). Furthermore, about the secondary endpoint, incidentalomas were not associated with death on univariate analysis (p=0,38) (Figure 2). Atrial fibrillation, chronic kidney disease (CKD), dilatation of left ventricle, left ventricular ejection fraction (LVEF) and TAVR were statistically significant among patients survived or not. LVEF was not associated with outcome (p=0,06) on univariate Cox regression analysis. In multivariate model (Table 2) TAVR reduced risk of death, instead CKD and dilated left ventricle increased risk. Conclusion Between patients with severe aortic stenosis candidates for TAVR presence of clinically relevant incidentalomas on CT scan was not associated with significant delay in procedure or death. Further studies are needed to prospectively confirm these results on a larger cohort of patients.Table 1 and Table 2Figure 1 and Figure 2

Abstract 11994: Lithotripsy-Assisted Transcatheter Aortic Valve Implantation: An Emerging Approach to Vascular Access Issues in Severe Peripheral Arterial Disease

Introduction: Advances in minimally invasive valvular interventions like transcatheter aortic valve implantation (TAVI) allow for treatment of an increasingly older population. Severe calcific iliofemoral peripheral arterial disease (PAD) can preclude large sheath introduction necessary in TAVI. Conventional peripheral angioplasty has limited efficacy in these situations given its high-pressure dilation, which increases the risk of vascular complications. Intravascular shockwave lithotripsy (IVL) for PAD is an emerging and safe alternative for vascular access. Case Description: A 90-year-old man with severe symptomatic aortic stenosis (AS), coronary artery disease (CAD) status-post CABG and extensive PAD was referred for TAVI following balloon aortic valvuloplasty. Transthoracic echocardiogram showed severe, low-flow, low-gradient AS despite recent balloon aortic valvuloplasty. Abdominal imaging showed severe atherosclerosis and calcification of the bilateral common and external iliac arteries. Prior to TAVI, peripheral angiogram was performed, followed by IVL for a total of nine runs, each for fifteen seconds with a 7x60mm balloon to the right iliac and femoral arteries. Then, the right femoral groin sheath was upsized from six to eighteen French, followed by deployment of a 29mm Medtronic Evolute Pro+ self-expanding bioprosthetic aortic valve. Following successful TAVI, the patient was discharged home on aspirin and clopidogrel. Conclusion: IVL utilizes pulsatile mechanical shockwaves to modify plaque burden without altering arterial elasticity or structural integrity, which greatly reduces the risk for vascular complications in severely calcified arteries. The DISRUPT-PAD-III trial showed IVL was superior to percutaneous transluminal angioplasty with fewer complications in patients with calcified PAD. Therefore, IVL can be a safe alternative approach for PAD limiting vascular access in percutaneous valvular interventions.

Transcatheter Aortic Valve Therapy for Bicuspid Aortic Valve Stenosis.

Transcatheter aortic valve implantation (TAVI) has become first-line treatment for older adults with severe aortic stenosis (AS), however, patients with bicuspid aortic valve (BAV) have been traditionally excluded from randomised trials and guidelines. As familiarity and proficiency of TAVI operators have improved, case-series and observational data have demonstrated the feasibility of successful TAVI in bicuspid aortic valve aortic stenosis (BAV-AS), however, patients with BAV-AS have several distinct characteristics that influence the likelihood of TAVI success. This review aims to summarise the pathophysiology and classification of BAV, published safety data, anatomical challenges and procedural considerations essential for pre-procedural planning, patient selection and procedural success of TAVI in BAV.

Predictors of All-Cause Mortality After Successful Transcatheter Aortic Valve Implantation in Patients With Atrial Fibrillation

Prevalent and incident atrial fibrillation are common in patients who undergo transcatheter aortic valve implantation and are associated with impaired postprocedural outcomes, including mortality. We determined predictors of long-term mortality in patients with atrial fibrillation after successful transcatheter aortic valve implantation. The EdoxabaN Versus standard of care and theIr effectS on clinical outcomes in pAtients havinG undergonE Transcatheter Aortic Valve Implantation-Atrial Fibrillation (ENVISAGE-TAVI AF) trial (NCT02943785) was a multicenter, prospective, randomized controlled trial in patients with prevalent or incident atrial fibrillation after successful transcatheter aortic valve implantation who received edoxaban or vitamin K antagonists. A Cox proportional hazard model was performed to identify predictors of all-cause mortality using a stepwise approach for multiple regression analysis. In addition, we assessed the performance of different risk scores and prediction models using ENVISAGE-TAVI AF data. Of 1,426 patients in ENVISAGE-TAVI AF, 178 (12.5%) died during the follow-up period (median 548days). Our stepwise approach identified greater risk of mortality with older age, impaired renal function, nonparoxysmal atrial fibrillation, excessive alcohol use, New York Heart Association heart failure class III/IV, peripheral artery disease, and history of major bleeding or predisposition to bleeding. The present model (concordance statistic [c-statistic] 0.67) was a better discriminator than were other frequently used risk scores, such as the Society of Thoracic Surgeons score (c-statistic 0.56); Congestive heart failure, Hypertension, Age ≥75, Diabetes, Stroke, Vascular disease, Age 65 to 74years, and Sex category (CHA2DS2-VASc) score (c-statistic 0.54); or Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly, and Drugs/alcohol concomitantly (HAS-BLED) score (c-statistic 0.58). In ENVISAGE-TAVI AF, several modifiable and nonmodifiable clinical characteristics were significantly associated with greater long-term all-cause mortality. Improved risk stratification to estimate the probability of mortality after successful transcatheter aortic valve implantation in patients with atrial fibrillation may improve long-term patient prognosis.

Comparison of steady-state and transient flow measurements for the characterization of paravalvular leakage of transcatheter-aortic valve prostheses

Abstract Severe aortic valve stenosis has been successfully treated with minimally invasive transcatheter aortic valve replacement (TAVR) for more than 20 years. The therapy is applied to an increasing cohort of patients. Nevertheless, paravalvular leakage (PVL) remains one of the main complications after TAVR implantation reducing safety and efficacy of the implant. To improve TAVR performance, virtual patient cohorts can be used to generate a significant amount of data with biologically varying conditions comparable to clinically realworld data. For this purpose, in silico models need to be established which are used to evaluate the possible occurrence of PVL. When establishing in silico models, the question between simplification to reduce computational effort and still valid information from the model must always be clarified. Thus, we investigated the comparability between steadystate and transient PVL measurements as an input parameter for simulations in virtual cohorts. A clinically established TAVR was implanted into different annulus models and tested in a steady-state back-flow test bench and in a pulse duplicator system. As a result, leakage rates were compared and assumptions for the in silico models were derived. Although the trend of PVL is comparable in steady-state and transient conditions, absolute values differ making it difficult to extract generalized assumptions. Especially when PVL increased, e.g. in a larger implantation diameter or in an imperfect annulus, the variation also increased up to 50% of the measured value.

An investigator-sponsored pragmatic randomized controlled trial of AntiCoagulation vs AcetylSalicylic Acid after Transcatheter Aortic Valve Implantation: Rationale and design of ACASA-TAVI

The optimal antithrombotic therapy after transcatheter aortic valve implantation (TAVI) is unknown. Bioprosthetic valve dysfunction (BVD) is associated with adverse outcomes and may be prevented by anticoagulation therapy. A dedicated randomized trial comparing monotherapy NOAC to single antiplatelet therapy has not been performed previously. We hypothesize that therapy with any anti-factor Xa NOAC will reduce BVD compared to antiplatelet therapy, without compromising safety. ACASA-TAVI is a multicenter, prospective, randomized, open-label, blinded endpoint, all-comers trial comparing a monotherapy anti-factor Xa NOAC strategy (intervention arm) with a single antiplatelet therapy strategy (control arm) after successful TAVI. Three-hundred and sixty patients without indication for oral anticoagulation will be randomized in a 1:1 ratio to either apixaban 5 mg twice per day, edoxaban 60 mg daily, or rivaroxaban 20 mg daily for 12 months followed by acetylsalicylic acid 75 mg daily indefinitely, or to acetylsalicylic acid 75 mg daily indefinitely. The 2 co-primary outcomes are (1) incidence of Hypo-Attenuated Leaflet Thickening (HALT) on 4-dimensional cardiac CT at 12 months, and (2) a Safety Composite of VARC-3 bleeding events, thromboembolic events (myocardial infarction and stroke), and death from any cause, at 12 months. The first 100 patients had a mean age of 74 ± 3.6 years, 33% were female, the average body-mass index was 27.9 ± 4.4 kg/m2, and 15% were smokers. A balloon-expanded valve was used in 82% and a self-expandable valve in 18%. The trial is planned, initiated, funded, and conducted without industry involvement. ClinicalTrials.gov Identifier NCT05035277.

Improving access to transcatheter aortic valve implantation across Europe by restructuring cardiovascular services: An expert council consensus statement.

Transcatheter aortic valve implantation (TAVI) is recommended for a growing range of patients with severe aortic stenosis in the European Society of Cardiology and European Association for Cardio-Thoracic Surgery (ESC/EACTS) 2021 Guidelines update. However, guideline implementation programs are needed to ensure the application of clinical recommendations which will favorably influence disease outcomes. An Expert Council was convened to identify whether cardiology services across Europe are set up to address the growing needs of patients with severe aortic stenosis for increased access to TAVI by identifying the key challenges faced in growing TAVI programs and mapping associated solutions. Wide variation exists across Europe in terms of TAVI availability and capacity to deliver the increased demand for TAVI in different countries. The recommendations of this Expert Council focus on the short-to-medium-term aspects where the most immediate, actionable impact can be achieved. The focus on improving procedural efficiency and optimizing the patient pathway via clinical practice and patient management demonstrates how to mitigate the current major issues of shortfall in catheterization laboratory, workforce, and bed capacity. Procedural efficiencies may be achieved through steps including streamlined patient assessment, the benchmarking of standards for minimalist procedures, standardized approaches around patient monitoring and conduction issues, and the implementation of nurse specialists and dedicated TAVI coordinators to manage organization, logistics, and early mobilization. Increased collaboration with wider stakeholders within institutions will support successful TAVI uptake and improve patient and economic outcomes. Further, increased education, collaboration, and partnership between cardiology centers will facilitate sharing of expertise and best clinical practice.

Evolution of non-invasive myocardial work parameters after transcatheter aortic valve implantation in patients with severe aortic stenosis

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Guidelines recommend replacement in patients with severe aortic stenosis (AS) who present with symptoms or left ventricular ejection fraction (LVEF) < 50%, both conditions representing a late stage of the disease. While global longitudinal strain (GLS) is load dependant but interesting for assessing prognosis, myocardial work has emerged. We aim to evaluate acute changes in myocardial work occurring in patients undergoing transcatheter aortic valve implantation (TAVI). Methods Patients who underwent TAVI were evaluated before and after by echocardiography. Complete echocardiographies were considered. Myocardial work indices (global work index (GWI), Global constructive work (GCW), Global work efficiency (GWE), Global wasted work (GWW)) were calculated integrating mean transaortic pressure-gradient and brachial-cuff systolic pressure. Results 125 patients underwent successful TAVI with significant decrease of the transaortic mean gradient (52.5 ± 16.1 to 12.2 ± 5.0, P<.0001). There was no significant change in LVEF post-TAVI. Myocardial work data post-TAVR showed a significant reduction of GWI (1389 ± 537 vs. 2014 ± 714, P<.0001), GCW (1693 ± 543 vs. 2379 ± 761, P<.0001) and GWE (85,0 ± 7,06 vs. 87,1 ± 5,98, P=0,0034). Decrease of GWI and GCW after TAVI was homogeneous among different sub-groups based on their GLS, LVEF of NYHA status before TAVI. We observed a significant association between GWI and GCW before TAVI and a GLS degradation after TAVI. Conclusion Myocardial work parameters show promising potential in best understanding the LV-myocardial consequences of AS and its correction. By their ability to discriminate NYHA status and GLS evolution, we can hypothesize on their clinical value.

P98 A CASE OF “RECURRENT” AORTIC VALVE STENOSIS

Abstract Clinical Case A 80–year–old man underwent coronary angiography in 2006 because of stable angina. There was chronic total occlusion of middle left anterior descending artery requiring percutaneous intervention. In 2009 he underwent coronary angiography for recurrent angina: a severe stent restenosis was treated with stenting in stent (DES in BMS). The patient was subsequently asymptomatic till 2018 when he complained of exertional dyspnea and angina. Stent patency and severe aortic valve stenosis (AVA 0.85 cm2) were documented. The patient underwent successful transcatheter aortic valve implantation and discharged with dual antiplatelet therapy (DAPT) (Asa 100 mg and Clopidogrel 75 mg). Clinical and echocardiographic follow–up was unremarkable (mean prosthetic gradient 17 mmHg, DVI=0.45). In July 2021 during a cardiological check the patient complained of bruising: ASA was discontinued. In February 2022 the patient suffered from an exertional angina. A dipyridamole stress–echocardiography failed to demonstrate inducible ischemia, although the patient experienced angina at the peak load step. Transthoracic echocardiogram (TTE) revealed high mean trans–prosthetic aortic gradient (52 mmHg, DVI=0.18). A trans–esophageal echocardiogram (TEE) showed reduced mobility of the thickened left coronary and non–coronary aortic prosthetic leaflets. In the hypothesis of prosthetic valve thrombosis, warfarin (INR range 2–3) was started after stopping clopidogrel. After three months a TTE showed normalized mean trans–prosthetic gradients (17 mmHg, DVI=0.5). When a 6 month–period of anticoagulant therapy was accomplished, warfarin was stopped and DAPT administered again. In September 2022 the patient complained of worsening dyspnea and chest pain on exertion. At TTE mean trans–prosthetic gradients (46 mmHg) was increased. A new TEE showed thickening of non–coronary and right coronary leaflets, suggestive of recurrent valve thrombosis. After stopping DAPT, warfarin was started again with good result (mean prosthetic gradient 12 mmHg, DVI=0.5). Conclusion Thrombosis of aortic valve prothesis is an infrequent event usually occurring in early post–implantation period. In our case it occurred four years after implantation following DAPT interruption. The likely initial prosthetic valve degeneration together with a simplification of DAPT may have had a causative role. Since the proved efficacy of warfarin and the limited experience of DOAC in this field, the patient was given warfarin sine die.

PO-05-049 OPTIMAL TIMING OF PERMANENT PACEMAKER IMPLANTATION FOLLOWING TRANSCATHETER AORTIC VALVE REPLACEMENT

Atrioventricular nodal block (AVB) is a common complication following transcatheter aortic valve replacement (TAVR). The timing of permanent pacemaker (PPM) implantation with respect to conduction disease and recovery is not well established. The purpose of this study is to determine the optimal timing of PPM implantation for AVB following TAVR. Patients were retrospectively reviewed for AB and pacemaker (PPM) implantation by ECG and progress note data in the electronic medical record following TAVR implantation, and PPM interrogation data was reviewed for long-term pacing requirements. Pacemaker dependence was defined as absence of underlying rhythm at < 40 bpm. Definite/probable pacing need was defined as 2nd degree AVB, complete heart block (CHB), or atrial fibrillation with bradycardia and pacing burden > 40%. A total of 458 consecutive patients who underwent TAVR were retrospectively identified. Of these, 99 had a previously implanted PPM and were excluded, leaving 359 total patients. CHB or 2nd degree AVB was noted in 73 patients (20%). On day 0 post-TAVR, 67 patients had CHB (92%) and 6 patients had 2nd degree AVB (8%), and of these, 21 patients (28%) had subsequent recovery of conduction with no clear long-term pacing need. At day 1 post-TAVR, 10 patients (14%) demonstrated recovery of AV conduction and did not require PPM; 48 patients (66%) had persistent CHB; and 15 patients (20%) had intermittent CHB or 2nd degree AVB, for a total of 63 patients who underwent PPM placement. PPM interrogation was performed 7-30 days following implantation. Of the 48 patients with persistent CHB at post-TAVR day 1, 42 had follow-up after >7d. Of these, 36 (86%) remained pacemaker-dependent, and 6 (14%) had no clear pacing need. Of the 14 patients with intermittent CHB or 2nd degree AVB at day 1 who had later follow-up, 9 (64%) had no clear pacing need, and only 5 (36%) had definite/probable pacing need (Fig 1). A significant number of patients with CHB after TAVR will demonstrate conduction recovery, and PPM implantation on the same day may not be justified. Of those with no conduction recovery after 1 day, relatively few patients had subsequent conduction recovery, and PPM implantation could be considered then. However, patients with intermittent CHB or 2nd degree AVB one day after TAVR had a high rate of subsequent return of conduction, and longer observation may be appropriate before proceeding with PPM implantation.

Left Axillary Access for Transcatheter Aortic Valve Implantation in a Patient With Two Dependent Internal Mammary Artery Grafts and a Permanent Left-Sided Implanted Pacemaker

Transfemoral access has been established as the gold standard approach for the majority of patients undergoing transcatheter aortic valve implantation (TAVI). However, in cases with anatomical difficulties or severely diffused peripheral arterial disease, alternative vascular access may be considered such as the transaxillary approach. We present the case of a 92-year-old gentleman with exertional dyspnea due to severe symptomatic aortic stenosis and a history of peripheral femoro-femoral bypass surgery, coronary arterial bypass surgery and a permanent dual-chamber left-side implanted pacemaker. Due to the high surgical risk and the severe anatomical difficulties, the method of TAVI using the left axillary approach was opted. A 14-F vascular sheath was inserted with surgical cutdown and with fluoroscopic guidance while small injections of contrast confirmed the non-occlusive position and the patency of the left internal mammary artery (LIMA) graft. A stiff guidewire was used to cross the heavily calcified aortic valve and subsequently was placed into the left ventricle. Balloon aortic valvuloplasty was performed followed by a successful TAVI with no significant aortic regurgitation or paravalvular leak. The patient recuperated uneventfully and was discharged after 72 h. Axillary access for TAVI is a feasible option for high-risk patients with extended peripheral arteriopathy. To our knowledge this is the first case report describing the implantation of a newer type of intra-annular self-expanding valve platform in a nonagenarian patient with severe comorbidities and such a remarkable history of multiple previous interventions in the selected access site. Meticulous upfront strategy planning and efficient collaboration between specialties is of outmost importance in hybrid procedures for favorable clinical outcomes, especially in cases with challenging anatomies.

Interatrial blocks in patients with tavi and their associations with clinic parameters

Aims: The present study attempted to evaluate the prevalence of basal interatrial blocks (IABs), their associations with clinical parameters, and the interatrial conduction in the follow-up after a successful transcatheter aortic valve implantation (TAVI) procedure among patients with severe aortic stenosis. Methods: We retrospectively evaluated the findings of 90 patients undergoing TAVI in our center. Overall, we considered the presence and grades of IABs and P-wave durations in electrocardiograms (ECG), preoperative echocardiography (ECHO) findings (maximum and mean gradients and left atrium (LA) diameter), valve size and type, and changes in these parameters at sixth month. Results: Forty-six patients were included in the study which are suitable for the pre-determined inclusion criteria. We found the mean age of the patients to be 74.78 ± 8.66 years. In preoperatively-evaluated ECGs, while we detected partial IABs in 37% of the patients, there were advanced IABs in 6.5%, but 56.5% yielded no interatrial conduction disorder. On the other hand, in postoperatively-evaluated ECGs, while we observed partial IABs in 30.4% of the patients, there were advanced IABs among 21.7% (p = 0.017). Nevertheless, we could not conclude any IABs among 47.8% of the patients. Besides, 54.3% of the patients received a self-expandable valve, and a balloon-expandable valve was inserted in 45.7%. In this regard, we detected partial (7 patients) and advanced (2 patients) IABs in the preoperatively-evaluated ECGs of the patients receiving a self-expandable valve. In the postoperative ECGs of these patients, while the partial IAB remained the same in 4 patients (57.1%), it progressed to an advanced IAB in 3 (42.9%). In addition, while the advanced IAB regressed to a partial IAB in one patient, it remained the same for the other patient. In this group, the mean P-wave durations were found to be 118.4±22.67 before the TAVI and 119.6±21.69 after the TAVI (p = 0.113). In the preoperative ECGs of 21 patients with a balloon-expandable valve, we detected partial IABs in 10 patients and an advanced IAB in one patient. While a partial IAB developed in five patients (p = 0.022), five patients with a partial IAB developed an advanced IAB following the procedure (p = 0.022). In this group, we noticed a significant difference between preoperative (127.62±19.4) and postoperative (138.71+ 32.03) P-wave durations (p = 0.038). Conclusion: In a nutshell, we concluded no significant change in interatrial conduction time of the patients with TAVI compared to the baseline in their sixth-month ECGs. When considered by valve type, we concluded that the development and progression of IABs were significant among those with a balloon-expandable valve. The higher postoperative mean gradient among those with a balloon-expandable valve compared to those with a self-expandable valve may be associated with significantly longer P-wave duration among those with a balloon-expandable valve.

Left bundle branch area pacing: How to prevent a coronary venous fistula.

Left bundle branch area pacing: How to prevent a coronary venous fistula.

Impact of Intraprocedural Pressure Changes on Hemodynamic Outcome During Self-Expanding TAVR.

During the transcatheter aortic valve replacement (TAVR) procedure, hemodynamic measurements can be used to evaluate transcatheter heart valve (THV) performance. We hypothesized that the occurrence of a significant decrease in invasive aortic pressure immediately after annular contact by a self-expanding THV indicates effective annular sealing. This phenomenon could thus be used as a marker for the occurrence of paravalvular leak (PVL). Thirty-eight patients undergoing TAVR procedure with a self-expandable Evolut R or Evolut Pro (Medtronic) valve prosthesis were included in the study. Drop in aortic pressure during valve expansion was defined as a decrease in systolic pressure of 30mmHg immediately after annular contact. The primary endpoint was the occurrence of more than mild PVL immediately after valve implantation. A pressure drop was seen in 60.5% (23/38) of patients. More than mild PVL requiring balloon post-dilatation (BPD) was significantly more frequent in patients who did not have a systolic pressure decrease > 30 mmHg during valve implantation (46.7% [7/15] vs. 13.0% [3/23], respectively; p = 0.03). Patients without a systolic pressure decrease > 30 mmHg also had a lower mean cover index on computed tomography analysis (16.2% vs. 13.3%; p = 0.016). The 30-day outcomes were similar between the two groups, and echocardiography at 30days demonstrated more than none/trace PVL in 21.1% (8/38) of patients, with no difference between the two groups. A decrease in aortic pressure after annular contact is associated with an increased probability of good hemodynamic outcome after self-expanding TAVR implantation. In addition to other methods, this parameter could be used as an additional marker for optimal valve positioning and hemodynamic outcome during the implantation procedure.

Evolution of non-invasive myocardial work variables after transcatheter aortic valve implantation in patients with severe aortic stenosis

IntroductionGuidelines recommend aortic valve replacement in patients with severe aortic stenosis who present with symptoms or left ventricular ejection fraction<50%, both conditions representing a late stage of the disease. Whereas global longitudinal strain is load dependent, but interesting for assessing prognosis, myocardial work has emerged. AimTo evaluate acute changes in myocardial work occurring in patients undergoing transcatheter aortic valve implantation (TAVI). MethodsPatients who underwent TAVI were evaluated before and after by echocardiography. Complete echocardiographies were considered. Myocardial work indices (global work index, global constructive work, global work efficiency, global wasted work) were calculated integrating mean transaortic pressure gradient and brachial cuff systolic pressure. ResultsOne hundred and twenty-five patients underwent successful TAVI, with a significant decrease in mean transaortic gradient (from 52.5±16.1 to 12.2±5.0; P<0.0001). There was no significant change in left ventricular ejection fraction after TAVI. Myocardial work data after TAVI showed a significant reduction in global work index (1389±537 vs. 2014±714; P<0.0001), global constructive work (1693±543 vs. 2379±761; P<0.0001) and global work efficiency (85.0±7.06 vs. 87.1±5.98; P=0.0034). The decrease in global work index and global constructive work after TAVI was homogeneous among different subgroups, based on global longitudinal strain, left ventricular ejection fraction and New York Heart Association status before TAVI. We observed a significant association between global work index and global constructive work before TAVI, and global longitudinal strain degradation after TAVI. ConclusionsMyocardial work variables show promising potential in best understanding the left ventricular myocardial consequences of aortic stenosis and its correction. Given their ability to discriminate between New York Heart Association status and global longitudinal strain evolution, we can hypothesize about their clinical value.

Analysis of thrombosis risk of commissural misaligned transcatheter aortic valve prostheses using particle image velocimetry

Abstract Due to excellent clinical results, transcatheter aortic valve replacement (TAVR) has evolved to a treatment option for patients with low surgical risk, resulting in an increasing demand for durable heart valve prostheses. Durability of TAVR could be limited by leaflet thrombosis. Thrombus formation in the aortic root is mainly affected by the hemodynamic situation, which is dependent on the positioning of the implant. We investigated the flow field in the aortic root after TAVR implantation by means of particle image velocimetry. To quantify the influence of the implant-position with respect to an alignment or misalignment of the leaflet commissures on the thrombogenic potential, we used a transport equation for residence time (RT) to consider washout behavior. Furthermore, we introduced a shear effect criterion (SIE) to address platelet activation as a measure for a potential thrombus formation. Misaligned implantation of a TAVR resulted in a reversed direction of rotation of the occurring recirculation area. This led to fluid flow with comparable areas of increased relative blood RT (RTaligned: 97.6%, RTmisaligned: 88.0%) and a smaller area of low shear load for the misaligned TAVR (SIEaligned: 57.7%, SIEmisaligned: 3.70%) into the sinus region, indicating a higher potential for thrombus formation.

Dedicated Next Day Discharge Post Minimalist TAVI: The Tasmanian Experience.

To assess the safety, feasibility and independent predictors of next day discharge (NDD) in patients undergoing minimalist transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS) in a real-world Australian population. This single centre study reviewed 135 consecutive patients who underwent minimalist transfemoral TAVI from June 2020 to February 2022. Baseline demographics, procedural characteristic and outcomes were obtained. All patients were assessed by the local protocol for NDD. Patients were then divided into two groups: those who achieved next day discharge (NDD) and those requiring >1 overnight hospital stay. Univariate, bivariate and stepwise multivariate logistic regression modelling was used to identify the predictors of successful next day discharge. The mean age of the cohort was 82.9±5.7 years with 62.3% patients male, the average STS score was 4.1±2.4. All 135 patients underwent a successful transfemoral TAVI procedure, with 131 (97%) receiving a balloon-expandable valve. Ninety-seven (97) (71.9%) patients achieved NDD. Thirty (30)-day outcomes were excellent with a 30-day mortality of 0.7%, transient ischaemic attack/cardiovascular accident (TIA/CVA) 1.5%, major vascular complication 1.5% and 11.4% need for permanent pacemaker (PPM). In patients not achieving NDD, the average length of stay (LOS) was 3.0 days. Baseline characteristics demonstrated pre-existing first degree atrioventricular (AV) block and right bundle branch block (RBBB) as statistically significant negative predictors of NDD on univariate analysis. Next day discharge was achievable in only 50% of patients who suffered any minor or major procedural complication (15/30). Stepwise multivariate logistic regression modelling demonstrated female gender (OR 3.094, 95% CI 1.141-8.391, p=0.026), smaller aortic valve area (AVA) (OR 48.265, 95% CI 2.269-102.6, p=0.013), the presence of diabetes mellitus (OR 0.594, 95% CI 0.356-0.991, p=0.046) and a longer procedure time (OR 0.960, 95% CI 0.935-0.986, p=0.002) as statistically significant negative predictors of NDD. In addition, there was no difference in 30-day readmission rates between the NDD and non-NDD cohort (7.2% vs 10.5%, p=0.386). Next day discharge is safe and feasible in almost three quarters of patients undergoing minimalist TAVI for severe AS in a predominantly balloon expandable valve cohort, with a very low rate of 30-day readmission. NDD provides advantages for hospital efficiency and improved cost-effectiveness. Female gender, smaller AVA, the presence of diabetes mellitus and a longer procedure time were independent negative predictors of successful NDD.