Symptomatic Aortic Valve Stenosis Research Articles

Obesity paradox in 12,381 patients undergoing transfemoral transcatheter aortic valve implantation: from the CENTER-collaboration

Abstract Background Transcatheter aortic valve implantation (TAVI) is a well-established treatment for symptomatic aortic valve stenosis. The majority of patients treated are overweight or obese. Obesity has traditionally been linked to reduced survival and worse cardiovascular outcomes. However, an “obesity paradox” has been described in some diseases, with improved survival of obese patients after invasive and surgical procedures. Methods The CENTER-collaboration included data from 10 registries or clinical trials of patients undergoing transfemoral TAVI from 2007 to 2018. Patients were divided in four groups according to body mass index (BMI): underweight: BMI <18.5 kg/m2, normal weight: BMI 18.5 to 24.9 kg/m2, overweight: BMI 25 to 29.9 kg/m2, and obese: BMI ≥30 kg/m2. The primary endpoints of this analysis were differences in 30-day all-cause mortality and stroke after TAVI. Results Of the 12,381 patients analysed, 2% (n=205) were underweight, 29% (n=3552) had normal weight, 44% (n=5460) were overweight and 25% (n=3140) obese. Older patients had lower BMI (median of 84 years for underweight and 81 years for obese patients, p<0.001). Cardiovascular risk factors such as hypertension, diabetes mellitus and dyslipidaemia increased progressively with increase of BMI category. As to clinical outcomes, there were no differences for stroke rates across BMI groups. In-hospital mortality was highest in patients who were underweight, namely 8.4%, compared to normal weight, overweight and obese patients (6.2%, 4.3% and 4.6% respectively, p<0.001) as was 30-day mortality (9.8% compared to 6.9%, 5.3% and 5.2% respectively, p=0.001). On the other hand, extremely obese patients (BMI ≥40.0 kg/m2) also had worse prognosis, with a 30-day mortality of 7.6%. Conclusions In this global analysis of more than 12 000 patients undergoing transfemoral TAVI, overweight and obese patients had better in-hospital and 30-day survival than normal weight patients, confirming the obesity paradox. There was an inverted J-shaped relationship of body mass index with prognosis, with higher mortality rates for underweight and extremely obese patients. Mortality and stroke per BMI category Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): The Dutch Heart Foundation; Netherlands Organisation for Health Research and Development

Contemporary management of severe symptomatic bicuspid aortic valve stenosis: the BiTri Registry.

A greater number of patients with bicuspid aortic valves (BAV) may be identified and treated as indications for transcatheter aortic valve implantation (TAVI) are expected to expand to younger patients. We evaluated the contemporary frequency and management of symptomatic patients with stenotic BAV in a multicenter European registry. Between November 2017 and February 2018, all consecutive patients admitted for symptomatic aortic stenosis across six high-volume European hospitals were prospectively enrolled in the BiTri registry. Of the 832 patients, 17% (n = 138) had a BAV. The most frequent BAV phenotypes were type 1 (left--right coronary cusps fusion 64%) and type 1 (right-noncoronary cusps fusion 17%). Type 0 and type 2 accounted for 12 and 2%, respectively. When compared with tricuspid patients (n = 694), BAV patients were younger, with lower surgical risk. The transthoracic echocardiography (TTE) identified BAV in 64% of patients. Multisliced computed tomography (MSCT) additionally completed the diagnosis in 20% of patients. Surgical inspection finally identified the remaining undiagnosed 16% of BAV. A combination of TTE and MSCT was the most common diagnosis method for BAV. Surgical aortic valve replacement (SAVR) was the predominant therapeutic option for BAV (70%) whilst TAVI was performed in 26%. BAV is frequently observed in symptomatic patients with aortic stenosis. These patients are younger, have a lower risk profile and are predominantly treated with SAVR as compared with tricuspid patients. However, TAVI is performed in almost one-third of BAV patients in contemporary European practice. TTE combined with MSCT identified 84% of BAV.

One-stage off pump combined transapical aortic valve replacement and ascending aorta endografting.

An 84-year-old patient was referred for severe symptomatic aortic valve stenosis and focal chronic dissection of the ascending aorta. After multidisciplinary discussion, the patient was scheduled for combined transapical transcatheter aortic valve replacement and ascending aorta stent-grafting. The procedure was performed with a balloon aortic valvuloplasty followed by a custom-made stent graft implantation into the ascending aorta and then by balloon-expandable transapical transcatheter aortic valve replacement. The patient had an uneventful hospital stay. In conclusion, in selected high-risk patients, transapical combined ascending aorta stent-grafting and transcatheter aortic valve replacement are feasible and safe.

Predictors of ventricular pacing burden after permanent pacemaker implantation following transcatheter aortic valve replacement.

BackgroundIn the era of an expanding use of transcatheter aortic valve replacement (TAVR), conduction disturbances and the requirement for permanent pacemaker (PPM) implantation remains a clinical concern.HypothesisUsing a single‐center experience, we sought to identify predictors of ventricular pacing burden after TAVR in patients who required PPM implantation.MethodsWe conducted a retrospective study of 359 consecutive patients with symptomatic severe aortic valve stenosis who underwent TAVR at our institution between September 2013 and July 2019. Thirty patients (8.4%) required a PPM within 30 days after TAVR. Pre and post‐TAVR electrocardiograms, pre‐TAVR echocardiograms and computed tomography (CT), TAVR procedural details and post‐TAVR device interrogation records at 1, 3, and 6 months were reviewed.ResultsMean percentage of ventricular pacing (VP%) at 1, 3, and 6 months was 58%, 59%, and 56% respectively. Using univariate logistic regression analysis, patients who had low VP% < 5% at 6 months were more likely to have a prosthesis/echocardiography‐derived left ventricular outflow tract (LVOT) diameter ratio < 1.3 (OR 7.00, P‐value .048), prosthesis/CT‐derived aortic annulus diameter ratio < 1.02 (OR 7.11, P‐value .047), post‐TAVR new‐onset LBBB (OR 16.80, P‐value .019), time to PPM implantation greater than 2 days post‐TAVR (OR 9.38, P‐value .026) and pre‐TAVR use of a beta blocker (OR 9.40, P‐value .026).ConclusionsIn patients who required a PPM implantation post‐TAVR, a lower TAVR prosthesis/LVOT or aortic annulus diameter ratio, post‐TAVR new‐onset LBBB and later time of PPM implantation showed a trend toward predicting a low VP% at 6 months.

Regional anesthesia combined with virtual reality hypnosis for extended orthopedic surgery: two case reports

Background : Virtual reality hypnosis is a combination of visual immersion in a virtual reality environment and clinical hypnosis. It can be used in addition to conventional techniques, for sedation and pain management during wound care. Patients undergoing painful and long-lasting procedures under regional anesthesia could also benefit, from this technique alleviating the need for sedative-hypnotic medication. Case presentation : Two patients with relative contra- indications for general anesthesia underwent lengthy orthopedic surgery of the upper limbs under regional anesthesia with additional virtual reality hypnosis. Written informed consent was obtained from both patients before surgery. A 69-year-old man, with a previous medical history of severe symptomatic aortic valve stenosis (ѳ 0.69cm2, max/mean gradient of 91/58mmHg) sustained a proximal humerus fracture-dislocation and was scheduled to undergo shoulder hemi-arthroplasty. Anesthesia was provided with ultrasound-guided continuous interscalene block at the C5-C6 level (11mL levobupivacaine 0.5%) combined with a single-shot superficial cervical plexus block (6mL levobupivacaine 0.5%). The second case was a 56-year-old man suffering from rheumatoid arthritis with severe restrictive lung function due to interstitial lung disease and bilateral bronchiectasis. He received a unilateral elbow prosthesis. Continuous infra-clavicular brachial plexus block, per- formed under ultrasound guidance was provided (20 mL mepivacaine 1.5%). Both patients required prolonged immobilization on the operating table. We used virtual reality hypnosis to induce sedation and improve comfort without using medication. This was provided by headphones and head-mounted goggles, showing computer generated images of underwater scenes (Aqua module, Oncomfort ™). Both surgeries were uneventful during which time cardiorespiratory stability was maintained. Patients were comfortable during and satisfied after surgery. No sedative drugs were given before nor during the procedures. Conclusion : Non-pharmacological sedation can be achieved with virtual reality hypnosis. When com- bined with regional anesthesia, this technique provides satisfactory sedation when pharmacological methods may be hazardous.

Racial Differences in the Use of Aortic Valve Replacement for Treatment of Symptomatic Severe Aortic Valve Stenosis in the Transcatheter Aortic Valve Replacement Era.

BackgroundAortic valve replacement (AVR) is a life‐saving treatment for patients with symptomatic severe aortic valve stenosis. We sought to determine whether transcatheter AVR has resulted in a more equitable treatment rate by race in the United States.Methods and ResultsA total of 32 853 patients with symptomatic severe aortic valve stenosis were retrospectively identified via Optum’s deidentified electronic health records database (2007–2017). AVR rates in non‐Hispanic Black and White patients were assessed in the year after diagnosis. Multivariate Fine‐Gray hazards models were used to evaluate the likelihood of AVR by race, with adjustment for patient factors and the managing cardiologist. Time‐trend and 1‐year symptomatic severe aortic valve stenosis survival analyses were also performed. From 2011 to 2016, the rate of AVR increased from 20.1% to 37.1%. Overall, Black individuals were less likely than Whites to receive AVR (22.9% versus 31.0%; unadjusted hazard ratio [HR], 0.70; 95% CI, 0.62–0.79; fully adjusted HR, 0.76; 95% CI, 0.67–0.85). Yet, during 2015 to 2016, AVR racial differences were attenuated (29.5% versus 35.2%; adjusted HR, 0.86; 95% CI, 0.74–1.02) because of greater uptake of transcatheter AVR in Blacks than Whites (53.4% of AVRs versus 47.3%; P=0.128). Untreated patients had significantly higher 1‐year mortality than those treated (adjusted HR, 0.57; 95% CI, 0.53–0.61), which was consistent by race (interaction P value=0.52).ConclusionsAlthough transcatheter AVR has increased the use of AVR in the United States, treatment rates remain low. Black patients with symptomatic severe aortic valve stenosis were less likely than White patients to receive AVR, yet these differences have recently narrowed.

Choice of transcatheter heart valve: should we select the device according to each patient's characteristics or should it be "one valve fits all"?

Since its introduction at the beginning of the century, transcatheter aortic valve replacement (TAVR) has implicated a paradigm shift in the treatment of patients with symptomatic aortic valve stenosis. The past years have brought about major improvements of procedural outcomes owing to advances in imaging and patient selection, global experience, and device technology. Whereas in the early stages of TAVR, only two different devices with limited sizes and access options were used, currently a variety of different transcatheter heart valves (THVs) are available. This has expanded the spectrum of patients that can be treated with TAVR and has allowed for sophisticated device selection tailored to the patients’ individual anatomy and comorbidities. The big question is whether such a customized device selection is really necessary—or is there one valve type that fits all patients? With this question in mind, the authors provide an overview of contemporary THVs, including technical specifications and clinical data, that help us to understand the potential value of a differential use of THVs.

Valve Thrombosis Or Hypo-attenuating Leaflet Thickening After Tavr And Savr: Is There A Need For Different Therapeutic Strategies?

Introduction: Transcatheter aortic valve repair (TAVR) and conventional cardiac surgery with valve replacement using sutureless bioprostheses are possible options to treat severe symptomatic aortic valve stenosis. No definite guidelines exist regarding the postinterventional anticoagulation therapy especially in patients with atrial fibrillation.

The effect of multiple-inflation balloon aortic valvuloplasty.

Recent improvements of balloon aortic valvuloplasty (BAV) devices and procedures have provided improved outcomes, but it is not clear whether the multiple-inflation BAV technique is effective in patients with symptomatic severe aortic valve stenosis (AS). We conducted an analysis of the impact of multiple-inflation BAV (at least 6 times inflation) on the mean aortic valve area (AVA) and mean aortic valve pressure gradient (AV-PG) in patients with symptomatic severe aortic stenosis as compared with conventional BAV (from single to three times inflation). We identified two studies of multiple-inflation BAV with antegrade approach using Inoue-balloon catheter (425 patients) and four studies of conventional BAV (170 patients) with retrograde approach. Using a random intercept model, we found that multiple-inflation BAV significantly increased mean AVA (mean difference (MD) [95% indicates confidence interval (CI)] = 0.25 [0.16-0.34], P < 0.001) and significantly decreased mean AV-PG (MD [95% CI] = - 20.2 [- 27.8, - 12.70], P < 0.001) as compared with the conventional BAV. Furthermore, despite an extremely high Society of Thoracic Surgeons (STS) score (9.2-14.5), the all-cause mortality rate at one year of multiple-inflation BAV was 16-17%. The results of our analyses indicate that the multiple-inflation BAV technique seem to be effective for patients with symptomatic severe AS as compared with conventional BAV.

Lipid levels linked to symptomatic aortic valve stenosis: evidence from Mendelian randomization?

Abstract

Preprocedural valvuloarterial impedance as a predictor of left ventricular ejection fraction improvement after transcatheter aortic valve replacement in patients with reduced left ventricular ejection fraction.

Predictors of left ventricular ejection fraction (LVEF) improvement after transcatheter aortic valve replacement (TAVR) in patients with a preoperative reduced LVEF are limited. This study aimed to investigate the relationship between preprocedural valuvuloarterial impedance (ZVa), which represents the global LV afterload, and LVEF improvement after TAVR. This was a single-center, retrospective study, which included patients with symptomatic aortic valve stenosis (AS) with a reduced baseline LVEF (< 50%) underwent TAVR. Based on the difference in the LVEF before and 1month after the procedure, they were divided into two groups: improved group (≥ 10% improvement) and non-improved group (< 10% improvement or worsening). Preprocedural ZVa and clinical outcomes were then compared. ZVa was calculated using preprocedural transthoracic echocardiography data. Among 473 cases of TAVR performed from May 2012 to July 2017 at Queen's Medical Center (Honolulu, HI, USA), 99 patients (improved group, n = 42; mean age 82.0 ± 8.6years vs. non-improved group, n = 57, mean age 81.4 ± 9.5years) were included. The improved group had a higher baseline ZVa {4.83 (4.15-6.89)mmHg/ml/m2 vs. 4.04 (3.56-4.63)mmHg/ml/m2, respectively, p = 0.0009} and prevalence of ZVa > 5mmHg/ml/m2 (45.2% vs. 17.5%, respectively, p = 0.0028). Multivariable analysis of predictors of LVEF improvement ≥ 10% at 1month identified ZVa > 5mmHg/ml/m2 [odds ratio (OR): 3.31, 95% confidence interval (CI): 1.05-11.8] as a predictor. The improved group had a lower readmission rate due to heart failure than the non-improved group (log-rank test, p = 0.043). In conclusion, Zva is a simple, noninvasive marker that shows promise as a predictor of LVEF improvement after TAVR in reduced LVEF patients.

Right ventricular assessment in patients undergoing transcatheter or surgical aortic valve replacement

Transcatheter aortic valve replacement (TAVR) is an alternative treatment option to surgical aortic valve replacement (SAVR) in selected high-risk patients. In this study, we aimed to evaluate the prognostic value of right ventricular (RV) functional imaging to predict clinical response to TAVR and SAVR. One hundred and ten patients with symptomatic severe aortic valve stenosis (AVS) undergoing successful TAVR and 32 controls undergoing SAVR were prospectively enrolled. Six months follow up (FU) included two-dimensional (2D) transthoracic echocardiography (TTE) with RV deformation imaging. Baseline TTE showed no significant differences between groups (TAVR and SAVR) in conventional left ventricular (LV) and RV functional parameters (LV ejection fraction [LV-EF]: p = .21; tricuspidal annular plane systolic excursion [TAPSE]: 1.8 ± 0.5 cm, 1.9 ± 0.4 cm, p = .21), and RV strain (right ventricular-global longitudinal strain [RV-GLS] -11.6 ± 5.2%, -11.5 ± 6.5%, p = .70). At FU LV function was unchanged in both groups (p > .05); RV function was significantly improved after TAVR (RV-GLS: -11.6 ± 5.2%, -13.4 ± 6.1%, p = .005; TAPSE: 1.8 ± 0.5 cm, 1.9 ± 0.3 cm, p = .05), and worsened after SAVR (RV-GLS: -11.5 ± 6.5%, -8.9 ± 5.2%, p = .04; TAPSE: 1.9 ± 0.4 cm, 1.5 ± 0.3 cm, p < .001). Functional New York Heart Association (NYHA) class remained unchanged in patients after SAVR (p = .21), and improved after TAVR (p < .001). Baseline RV function was linked with clinical response to TAVR (TAPSE, p < .0001; RV-GLS, p = .04), and the development of RV-GLS was associated with functional worsening after SAVR (p = .05). Baseline RV function and changes of right heart mechanics are closely associated with functional improvements after AVR. SAVR, but not TAVR, seems to have detrimental effects on RV-function.

Aortic Valve Stenosis: From Basic Mechanisms to Novel Therapeutic Targets.

Aortic valve stenosis is the most prevalent heart valve disease worldwide. Although interventional treatment options have rapidly improved in recent years, symptomatic aortic valve stenosis is still associated with high morbidity and mortality. Calcific aortic valve stenosis is characterized by a progressive fibro-calcific remodeling and thickening of the aortic valve cusps, which subsequently leads to valve obstruction. The underlying pathophysiology is complex and involves endothelial dysfunction, immune cell infiltration, myofibroblastic and osteoblastic differentiation, and, subsequently, calcification. To date, no pharmacotherapy has been established to prevent aortic valve calcification. However, novel promising therapeutic targets have been recently identified. This review summarizes the current knowledge of pathomechanisms involved in aortic valve calcification and points out novel treatment strategies.

Recursive multiresolution convolutional neural networks for 3D aortic valve annulus planimetry.

Transcatheter aortic valve replacement (TAVR) is the standard of care in a large population of patients with severe symptomatic aortic valve stenosis. The sizing of TAVR devices is done from ECG-gated CT angiographic image volumes. The most crucial step of the analysis is the determination of the aortic valve annular plane. In this paper, we present a fully tridimensional recursive multiresolution convolutional neural network (CNN) to infer the location and orientation of the aortic valve annular plane. We manually labeled 1007 ECG-gated CT volumes from 94 patients with severe degenerative aortic valve stenosis. The algorithm was implemented and trained using the TensorFlow framework (Google LLC, USA). We performed K-fold cross-validation with K = 9 groups such that CT volumes from a given patient are assigned to only one group. We achieved an average out-of-plane localization error of (0.7 ± 0.6) mm for the training dataset and of (0.9 ± 0.8) mm for the evaluation dataset, which is on par with other published methods and clinically insignificant. The angular orientation error was (3.9 ± 2.3)° for the training dataset and (6.4 ± 4.0)° for the evaluation dataset. For the evaluation dataset, 84.6% of evaluation image volumes had a better than 10° angular error, which is similar to expert-level accuracy. When measured in the inferred annular plane, the relative measurement error was (4.73±5.32)% for the annular area and (2.46±2.94)% for the annular perimeter. The proposed algorithm is the first application of CNN to aortic valve planimetry and achieves an accuracy on par with proposed automated methods for localization and approaches an expert-level accuracy for orientation. The method relies on no heuristic specific to the aortic valve and may be generalizable to other anatomical features.

Geriatric assessment in the prediction of delirium and long-term survival after transcatheter aortic valve implantation

ObjectivesTranscatheter aortic valve implantation (TAVI) has emerged as the preferred management strategy for elderly patients with severe symptomatic aortic valve stenosis. These patients are often at high risk of postoperative delirium (POD), which is associated with morbidity and mortality. Since POD may be prevented in a considerable part of these patients, identification of patients at risk is essential. The aim of current study was to identify geriatric assessment tools associated with delirium after TAVI, and long-term mortality. MethodsConsecutive patients were preoperatively assessed by a geriatrician between 2012 and 2017. Geriatric assessment tools consisted of cognitive, functional, mobility, and nutritional tests. POD was prospectively assessed during hospitalization after TAVI. Mortality tracking was performed by consulting municipal registries. ResultsA total of 511 patients were included. Median age was 80 [76-84] years, 44.8% (n = 229) were male, and 14.1% (n = 72) had a history of POD. Delirium was observed in 66 (12.9%) patients. Impaired mobility was the strongest geriatric assessment tool associated with POD (adjusted odds ratio, 2.1 [1.1-4.2], P = .028) and 2-year mortality (adjusted hazard ratio, 2.5 [1.4-4.5], P = .003). Two-year survival was reduced with more than 10% in patients with impaired mobility before TAVI (79.4% vs 91.4%, P = .013). ConclusionsThis study shows that impaired mobility is currently the best single predictor for POD and 2-year mortality in high-risk patients undergoing TAVI. Prospective multicenter studies are needed to optimize and to further explore the facilitation of routine use of POD predictors in TAVI pathways of care, and subsequent preventive interventions.

Assessment of Left Ventricular Function after Transcatheter Aortic Valve Implantation in Sever Aortic Stenosis: A Speckle Tracking Imaging Study

Background: Long standing aortic stenosis leads to elevated left ventricular (LV) pressure and as a result LV hypertrophy and myocardial fibrosis shall increase. The left ventricular ejection fraction (EF) usually remains adequately-preserved until advanced and late stages of aortic stenosis. But the preserved muscle of the LV is only limited to a portion of the entire myocardium. Speckle tracking echocardiography has proved its superiority to the standard two-dimensional echocardiography method in the detection of Left Ventricular (LV) function. Global Longitudinal strain (GLS) is considered as the most robust myocardial strain component. Objective: The aim of the study is to assess the early course of left ventricular reverse remodelling after Transcutaneous Aortic Valve Implantation (TAVI) in patients with symptomatic severe aortic valve stenosis. Methods: 50 patients with severe symptomatic valvular aortic stenosis undergoing TAVI as decided by the heart team after comprehensive discussion. Standard transthoracic echocardiography including Doppler analysis was performed. 2D speckle-tracking strain assessment of Global radial, circumferential and longitudinal strain at parasternal mid-ventricular short-axis view (at the level of papillary muscle) and from the apical long-axis, two-chamber and four-chamber views with a frame rate between 40 and 80 frames per second. Tracing of endocardial borders was done. Patients with significant coronary artery disease were fully revascularized by percutaneous coronary intervention prior to the study and the procedure. Results: 23 (46%) patients were males, while 27 (54%) were females. The patients’ stratification according to comorbidities/associated risk factors revealed that 54% of the patients had DM, 86% were hypertensive, 38% had chronic kidney disease (CKD), and 32% had a previous percutaneous coronary intervention (PCI). The mean age for our study participants ranged from 60 to 92 years (Mean ± SD = 76.60 ± 5.96). Left ventricular diastolic diameter (LVDd) was 44.24 ± 2.8 mm before TAVI that became 45.5 ± 2.6 mm after TAVI, and ejection fraction (EF) increased from 52.82 ± 6.3 before TAVI to 56.70 ± 5.4 after TAVI, both with highly significant difference (P P value less than 0.001. Global circumferential strain (GCS) also improved significantly from -20.14 ± 1.8 before TAVI to -21.72 ± 1.7 after TAVI with a P value less than 0.001. Global radial strain (GRS) also increased significantly from 37.38 ± 8 before TAVI to 41.68 ± 6.3 after TAVI with a P value less than 0.001. Conclusion: TAVI is effective in improving left ventricular function presented not only by ejection fraction (EF%), but also in global longitudinal strain (GLS), global circumferential strain (GCS), and global radial strain (GRS).

New Insight in the Assessment of Left Ventricular Function in Paradoxical Low Flow Aortic Stenosis Patients with Normal Left Ventricular Ejection Fraction: A Mini-Review

Paradoxical valvular aortic stenosis (VAS) is a challenging area of clinical cardiology for the practitioners. It involves a small aortic valve area, low flow rate and mean pressure gradient although there is normal left ventricular ejection fraction. The aim of this study was to assess left ventricular (LV) dysfunction in a symptomatic severe aortic valve stenosis which is of crucial importance in identifying patients at risk of heart failure, postoperative complications and increased mortality. There are new insights which are involved in assessment of LV myocardial function including global longitudinal strain (GLS) by two-dimensional speckle tracking echocardiography (2D STE), myocardial performance index (MPI) and maximum rate of LV pressure rise (+dP/dt) during isovolumetric contraction time of the LV. This information can provide both diagnostic and prognostic information in addition to standard echocardiographic and clinical parameters. However, a profound understanding of the complex interaction between loading conditions, chamber geometry and contractility is necessary for the correct interpretation of myocardial deformation in order to draw appropriate conclusions in patients with aortic valve disease. This mini review is related to new and novel insights into the assessment of left ventricular function (LVF) in paradoxical low flow aortic stenosis patients with normal left ventricular ejection fraction (LVEF).

Transfemoral transcatheter aortic valve replacement in the presence of a mitral prosthesis.

In the current case series, we present our experience with the self-expanding CoreValve or Evolut R (Medtronic Inc.) in patients with severe symptomatic aortic valve stenosis and concomitant mitral valve prosthesis. Twelve patients with previous mitral valve prosthesis underwent transcatheter aortic valve replacement for severe symptomatic aortic valve stenosis and/or aortic valve regurgitation. All patients underwent evaluation with an echocardiogram, computed tomography and coronary angiogram. After the index intervention and before discharge all patients underwent transthoracic echocardiography. All outcomes were defined according to the Valve Academic Research Consortium-2 criteria. Eleven patients underwent transcatheter aortic valve replacement for severe symptomatic aortic valve stenosis and one patient for severe aortic valve regurgitation. There was immediate improvement of patients' hemodynamic status; no cases of procedural death, stroke, myocardial infarction, or urgent cardiac surgery occurred. There was no 30-day mortality and all patients improved, with 91.6% in functional New York Heart Association class I-II. The current study demonstrates that in patients with severe aortic valve stenosis or regurgitation and mitral valve prosthesis, the implantation of a self-expanding aortic valve via the transfemoral route is safe and feasible, with maintained long-term results.

Permanent Pacemaker Implantation After Trans-Catheter Aortic Valve Implantation And Surgical Aortic Valve Replacement In Zagazig University Hospitals And National Heart Institute

Background: Permanent pacemaker implantation (PPI) and heart conduction disturbances are the most common complications of TAVR. Several predictors of PPI after TAVR have been consistently identified.Objective: This study was aimed to estimate occurrence and detect predictors of permanent pacemaker implantation after trans-catheter aortic valve implantation versus surgical aortic valve replacement.Methods: Prospective cohort study from November 2014 to April 2017 in National Heart Institute and Zagazig University Hospitals in elderly severe symptomatic aortic valve stenosis patients who were candidates for aortic valve replacement.Results: The incidence of AV conduction disorders was significant high in TAVI group compared to SAVR group 50% vs. 20% (p value =0.03) derived mainly by significant increased incidence of LBBB and complete heart block. Permanent pacemaker implantation was done post procedure to three cases in TAVI group and to one case in surgical aortic valve replacement group. After one-month pacemaker implantation was done to another one patient in the TAVI group. Conclusion: Transcatheter aortic valve implantation is significantly followed by incidence of atrio-ventricular conduction disorders mainly the third-degree atrio-ventricular block demanding for permanent pacemaker implantation and left bundle branch block in comparison to surgical aortic valve replacement.

Management of aortic valve replacement according to the gradient across symptomatic aortic valve stenosis and its prognostic impact.

Treatment strategy for low-gradient (LG) aortic stenosis (AS) remains an unresolved issue. The presence of a low aortic gradient and preserved left ventricular ejection fraction (LVEF) might lead toward the underestimation of aortic stenosis severity and a more conservative management. We sought (a) to describe the nature and timing of intervention according to flow/gradient subgroups in patibents with LG-AS, (2) to determine the factors associated with the decision to intervene, and (c) to describe prognosis. One hundred and ten patients prospectively included in this study underwent a standardized clinical and imaging evaluation at inclusion and at 1-year follow-up. According to aortic flow, gradient and LVEF, patients were divided into 4 groups: LG-normal flow [n=27], LG-low flow-low LVEF [n=27], LG-low flow-normal LVEF [n=16], and high gradient (HG) [n=40]). 73% of patients underwent AVR 86±59days after the initial assessment. The HG subgroup had significantly higher intervention rates (P<.001). In multivariable analysis, four parameters were associated with the AVR: aortic gradient (HR 1.52 [1.10-2.11], P=.012), LVEF (HR 0.58 [0.40-0.85], P=.006), atrial fibrillation (HR 0.43 [0.021-0.87], P=.019), and NT-proBNP (HR 0.92[0.86-0.98), P=.008]. Patients operated earlier had better outcomes than those having a delayed AVR (P=.042). LG-AS patients had worse outcomes than HG-AS patients (P<.001). Compared to HG-AS, LG-AS is less likely to benefit from an AVR and had a significantly worse outcome. Further interventional studies are needed to investigate the timing of AVR in these patients.