TAVI Procedure Research Articles

Chronic systemic glucocorticoid therapy is associated with increased risk of major vascular complications and cardiac tamponade after transcatheter aortic valve implantation: a systematic review and meta-analysis.

TAVI-related complications, such as conduction disturbances, vascular complications or death may be related to increased inflammatory response. The aim of this study was to elucidate the efficacy and safety of the systemic glucocorticoid therapy regarding the adverse events after TAVI deployment. We conducted a systemic search of PubMed, a reference list of relevant articles, and Medline. The main efficacy outcomes of interest were all-cause death, cardiac and non-cardiac death, permanent pacemaker implantation (PPM), new left bundle branch block (LBBB), stroke, and myocardial infarction (MI). Safety endpoints were major vascular complications, major bleeding events, and cardiac tamponade. A total of 7 studies including data from 3439 patients with a median follow-up was 30 days. Systemic glucocorticoid compared to the control group were associated with an increased risk of non-cardiac death (Relative Risk [RR] 5.90 95%CI [2.95; 11.80], P<0.001) major vascular complications (RR 1.78, 95%CI [1.22 - 2.61], P=0.003) and cardiac tamponade (RR 3.42, 95%CI [1.69 - 6.92], P<0.001). However, there were no differences in all-cause death, cardiac death, new LBBB, stroke, MI, or major bleeding events (all P values >0.05). Glucocorticoid therapy before the TAVI procedure was associated with an increase in non-cardiac death, major vascular events and cardiac tamponade. There were no differences in the risk of all-cause death, cardiac death, PPM or LBBB, stroke, or MI.

Comparing Planned Surgical versus Percutaneous Access Vascular Outcomes and Complications in Patients Undergoing Transcatheter Aortic Valve Implantation

Abstract Background Increased expertise and technical advancements lead to a significant reduction of major access site-related vascular complications that occur, nowadays Post and intra-procedural in &amp;lt; 10% of cases. Due to its wide diffusion and feasibility, the trans-femoral access is the preferred route in the majority of the clinical trials and is recommended as first choice by all guidelines and consensus documents, as vascular complications are a non-comparable factor to traditional SAVR so it is a new side effect that has emerged with TAVI that is in need to be minimized. Aim The aim of this work is to compare surgical versus percutaneous access peripheral vascular outcomes in TAVI procedure during hospital stay. Patients and Methods This was a Comparative cross-sectional study that was conducted at Ain Shams university hospitals &amp; Helwan university hospital this study included 68 retrospective and prospective patients that were scheduled for TAVI 29 with percutaneous access followed by device closure (Proglide) and 37 surgical cut-down patients followed by surgical closure. Result A total of 68 patients were enrolled, 34 patients were females (50 %) and 34 patients were males (50 %). Their age ranged from 65-97 years with mean age (75.12) years. Patients in this study are classified into 2 groups: Group I: included patients who did the procedure with percutaneous vascular approach followed by device closure. Group II: included patients included patients who did the procedure with surgical cutdown vascular approach. Conclusion There is no significant difference in vascular complications between the 2 approaches indicating that whenever closure devices (Proglide) are available it can be used safely on patients undergoing TAVI, a more dedicated closure device to larger puncture sites such as MANTA should be properly studied as a promising step. Recommendation Larger studies with increased sample size are recommended for proper evaluation of intra and post procedural predictors of vascular complications. Further studies on the new MANTA device as it is a dedicated device to larger puncture sites. Long-term follow up.

Mortality after radial-only balloon aortic valvuloplasty: a long-term follow-up and a bridge-to-TAVI analysis

Abstract Background The benefits of distal radial balloon aortic valvuloplasty were recently reported: same efficacy as the classical femoral approach, with no vascular complications. The long-term outcomes for these patients remain unknown. Methods We retrospectively analyzed the long-term mortality and the impact of TAVI in a cohort of 30 patients who underwent distal radial (DR) BAV. Results The mean age was 78.3 ± 7.14 years and the median follow-up was 22.8 months. The indication for BAV was stable aortic stenosis in 70% of patients, while 23% of patients had concomitant acute heart failure symptoms and 6.6% of patients were in cardiogenic shock. A total of 16 patients (53.3%) received TAVI during follow-up after their BAV procedure while the remainder only received BAV. All-cause mortality was 20%, with only 1 death (6.3%) in the “BAV + TAVI” group compared to 5 deaths (35.7%) in the “BAV only” group (p = 0.089). All of the TAVI procedures were performed within 7 months after BAV. Cumulative incidence of TAVI was 40.0% at 5 months and 50.0% at 10 months. Cumulative incidence of death was 6.7% at 5 months, 13.3% at 10 months, 16.7% at 15 months, and 20.0% at 25 months. The probability of being alive without TAVI decreased from 53.3% at 5 months to 30.0% at 25 months. Conclusion In the present study, we could show that half of the patients undergoing BAV eventually need TAVI, most of them within 5 months after BAV, and that BAV remains associated with high mortality after the procedure, with 35% of those undergoing isolated BAV dying during short-term follow-up.

Impact of transcatheter aortic valve implantation on circulating von Willebrand factor in patients with severe aortic stenosis.

Severe aortic stenosis (AS) can lead to degradation of high molecular weight (HMW) von Willebrand factor (VWF) which can result in haemostatic abnormalities. While studies have explored changes in VWF profiles before and after surgical aortic valve replacement (SAVR), the longer-term changes in VWF profiles pre- and post-transcatheter aortic valve implantation (TAVI) are less understood. Our primary objective was to identify differences in VWF multimer profiles and VWF function pre-TAVI and 1-month post-TAVI. Our secondary objective was to correlate VWF markers with measures of AS severity. Adult patients with severe AS referred for TAVI at our institution were prospectively enrolled in this cohort study. Blood samples were collected for plasma analysis at three time points for all patients: 1day pre-TAVI, 3days post-TAVI, and 1-month post-TAVI. VWF antigen, activity, propeptide, collagen binding, multimers, and factor VIII coagulant activity were determined at each time point. Correlations between VWF parameters and severity of AS were assessed. Twenty participants (15 males, five females) with severe AS were recruited for the study. There was a significant increase in HMW VWF between pre-procedure and 1-month post-TAVI (p<.05). There was a transient increase in VWF antigen levels and activity at 3-days post TAVI that decreased to pre-TAVI levels at 1-month. There were no statistically significant correlations between VWF markers and AS severity. This is the first study to elucidate longer-term (>1week) improvements in HMW VWF after a TAVI procedure in severe AS patients.

Standardising TAVI procedures: a step towards improved patient care.

Standardising TAVI procedures: a step towards improved patient care.

P114 NO CONTRAST APPROACH FOR TRANSCATHETER AORTIC VALVE IMPLANTATION IN PATIENTS WITH SEVERE RENAL DISFUNCTION

Abstract Introduction Transcatheter aortic valve implantation (TAVI) is nowadays the preferred procedure for patients with symptomatic aortic stenosis (AS) older than 75 years or not suitable for surgery. On the other hand, acute kidney injury (AKI) is one of the strongest predictors of mortality after TAVI The purpose of our study has been to evaluate the impact of a no–contrast approach for TAVI in patients with severe renal disfunction. Methods 41 consecutive patients were enrolled from April 2021 to June 2022 in our Center. Mean age was 83 ± 5 yo, 43% were women. Mean glomerular filtration rate 29 ± 4.2 ml/min; The Society of Thoracic Surgeons mortality score (STS Score) was 16.1 ± 4.5. All procedures were performed without use of contrast dye. All patients underwent angio computed tomography (CT) and Coronary angiography with a minimal use of contrast dye at least two months before the procedure. Echo scan was perfomed to evaluate the femoral and carotid arteries anatomy Outcomes and events were evaluated according to the Valvular Academic Research Consortium 2 criteria (VARC–2). Baseline and postopertative creatinine were collected for each patient and glomerular filtration rate was calculated using CKD–EPI (Chronic Kidney Disease Epidemiology Collaboration) equation. Acute kidney injury was defined using KDIGO definitions as an increase in serum creatinine (Scr) by ≥ 0.3 mg/dl (26.5 mol/l) within 48 hours; or increase in SCr to ≥ 1.5 times base–line or urine volume &amp;lt; 0.5 ml/kg/h for 6 hours. TAVI procedure was performed under general anesthesia. Intraprocedural transesophageal echocardiogram was used for annulus valve sizing and to monitor proper positioning of self–expanding bioprosthesis. Results No patients died during hospital stay. A permanent pacemaker before discharge was required in 2 cases. No patients developed acute kidney injury at 48 h or at discharge. At 3 and 6 months of follow up, two patients died, one for cerebral event and one for sudden death; mean glomerular filtration rate and creatinine values were similar to pre–discharge values. Conclusions Our data show that a zero–contrast TAVI approach in patients with advanced chronic kidney disease is feasible and should always be considered for these subset of patients

P300 AORN A. CARDARELLI NAPOLI/ FEDERICO II UNIVERSITY INTERHOSPITAL PROTOCOL: TAVI IN A COMPLEX SCENARIO

Abstract Rational: In order to provide the best treatment for patients affected by severe aortic stenosis at intermediate–high surgical risk, since more than 3 years an interhospital protocol beetween the Cardiology, UTIC and Cath–lab department of AORN A. Cardarelli of Naples, a center without cardiac surgery, and the cath–lab of the department of Cardiovascular Emergencies, Clinical Medicine and Ageing Medicine of AOU Federico II, is active. The agreement provides the carrying out of a TAVI procedures for patients hospitalized at the A. Cardarelli, by transfering them with a resuscitation ambulance to the Federico II cath–lab, and subsequent return to the department of origin after the execution of the interventional procedure. Case report: 85 year old lady with hypertension, moderate–severe chronic respiratory failure and atrial fibrillation treated with NOAC, is admitted in the emergency room for acute pulmonary edema and contextual diagnosis of severe aortic stenosis is made. After clinical stabilization, the TAVI program is started: both an angio–CT scan and a coronary angiography are carried out, with the detection of a critical calcified stenosis involving left main branch and proximal LAD and a chronic occlusion of Cx branch. Multidisciplinary evaluation and collegial evaluation with the colleagues from the Federico II University are carried out, and indication is given to TAVI with contextual PTCA of LM and LAD critical stenosis. A joint procedure of PTCA with 2 DES and TAVI with Evolute R 29 valve is then carried out in a single session at the Federico II University of Naples and after post–procedural observation, the patient is transferred back to the UTIC of A. Cardarelli for hospitalization. During the hospital stay, no procedural complications are reported and the patient is discharged 4 days after in good clinical conditions; a triple therapy with NOAC and DAPT is started, continuing it for 1 month with subsequent suspension of ASA and carrying on therapy with NOAC + Clopidogrel. At 1 and 6 months clinical follow–up, the patient is stable and well compensated, without significant clinical complications and with NYHA class 2. Conclusions The results of these years–experience, highlight the feasibility and safety of this strategy, making it possible to plan and carry out TAVI procedures even in centers that do not have onsite cardiac surgery, considering the growing indications for TAVI and the subsequent increase of patients who need this procedure

C49 NO CONTRAST TAVI

Abstract Background Chronic renal failure is a common comorbidity in patients undergoing TAVI. Large amounts of contrast media are generally needed to safely perform TAVI with potential deleterious effects on renal function and long term life quality. Objectives Every step of the procedure can be safely replaced by no contrast techniques: ultrasound guided vascular puncture and final check, alignement of 3 guides in Valsalva sinuses to check coplanarity or cusp overlap, coupling of hemodynamics and transthoracic echocardiography to check the results and need of postdilatation, measure of gradient across the arterial puncture to rule out iatrogenic stenosis. Matherials and Methods 3 patients with severe renal failure (GFR &amp;lt; 30 ml/min/ 1.73 m2) and 1 patient with moderate renal failure and previous double renal transplantation underwent TAVI with protocol without contrast in our center in the last year. All cases were performed with local anesthesia and conscious sedation. 3 cases were performed with balloon expandable bioprosthesis and 1 with self expandable bioprosthesis. Results We were able to perform TAVI procedure without contrast in all 4 patients in which the technique was attempted without complications. Hemodynamics was excellent in all cases with no residual gradient or significant leaks. No vascular complication occured. Procedural time was generally 20% longer than average procedure but X rays dose exposure was reduced because less cine acquisitions were needed. Conclusions TAVI with no use of contrast media is feasible and safe by extensive use of vascular ultrasound, hemodynamics, transthoracic echocardiography and multiple guides to depict coronary sinuses and assure correct prothesis implantation.

Radiation Doses in Cardiovascular Computed Tomography.

We discussed the contemporary views on the effects of ionising radiation on living organisms and the process of estimating radiation doses in CT examinations and the definitions of the CTDI, CTDIvol, DLP, SSDE, ED. We reviewed the reports from large analyses on the radiation doses in CT examinations of the coronary arteries prior to TAVI procedures, including the CRESCENT, PROTECTION, German Cardiac CT Registry studies. These studies were carried out over the last 10 years and can help confront the daily practice of performing cardiovascular CT examinations in most centres. The reference dose levels for these examinations were also collected. The methods to optimise the radiation dose included tube voltage reduction, ECG-monitored tube current modulation, iterative and deep learning reconstruction techniques, a reduction in the scan range, prospective study protocols, automatic exposure control, heart rate control, rational use of the calcium score, multi-slices and dual-source and wide-field tomography. We also present the studies that indicated the need to raise the organ conversion factor for cardiovascular studies from the 0.014-0.017 mSv/mGy*cm used for chest studies to date to a value of 0.0264-0.03 mSv/mGy*cm.

Using artificial intelligence for device identification and characterization in angiographic sequences of TAVI procedures as radiomic biomarkers for prosthesis deterioration

Abstract Introduction Transcatheter Aortic Valve Implantation (TAVI) has been established as the preferential option for patients suffering from symptomatic severe aortic stenosis with high surgical risk. Due to the implantation of prosthesis on younger patients, the durability of TAVI devices becomes a crucial issue, especially beyond 5 years of follow-up [1]. Therefore, an application of growing interest is the assessment of the prosthesis deterioration, which is directly related to the measurement of the stent tip deflection [2]. In order to extract this parameter from angiographic sequences, a prior requirement relies on the automatic detection of the prosthesis in the image, pointing directly to the use of Artificial Intelligence. Purpose Automatically segment TAVI prostheses in angiographic sequences using Deep Learning [3]. The aim is allowing the extraction of information from these images, as the measurement of the stent tip deflection for evaluating the prosthesis deterioration, to improve the clinical practice. Methods A U-Net, which is a Deep Learning architecture designed for the analysis of biomedical imaging, has been trained for the segmentation of TAVI prostheses in angiographies [3]. The self-built dataset includes 50 sequences captured during TAVI from a population of 15 patients, obtaining 2827 frames (examples provided in Fig. 1). This dataset is randomly split into training and test sets using an 80/20 ratio. The U-Net is trained using the training set and its annotations (manually generated), optimised during 50 epochs using Adam optimiser, and binary cross-entropy as the cost function. Once the model has been trained, it is used for the segmentation of the images in the test set. Results The segmentation results have been evaluated in separate subsets of frames extracted from the test set, regarding the stage of the procedure they correspond. Such subsets are aortic root previous to the device delivery (Fig. 1A), prosthesis deployment (Fig. 1B), prosthesis fully-expanded (Fig. 1C), and contrast agent injection (Fig. 1D). Fig. 2 provides examples of the results obtained for the images in Fig. 1, showing the original frames and the segmentation result overlaid. The results have been evaluated in terms of different classification metrics, obtaining the mean values in the following ranges for the four groups: accuracy 0.99–1.00, recall 0.70–0.97, and area under the receiver operating characteristic curve (AUROC) 0.85–0.98. Conclusion U-Net has been successfully applied to angiographic imaging captured during TAVI procedure for segmenting the prosthesis, with AUROC values between 0.85 and 0.98. The prosthesis identification and characterization allow the extraction of imaging biomarkers of great interest that can be used for the evaluation of the prosthesis deterioration. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Axencia Galega de Innovaciόn (GAIN) (Code Numbers IN845D-2020/29 and IN607B-2021/18)

Trends in Coronary and Structural Heart Interventions in Switzerland over the Last 16 Years and Impact of COVID-19: Insights from the National Swiss PCI Survey.

Considering the global burden of cardiovascular disease, we analysed trends in interventional coronary and structural procedures over the past 16 years (2005-2021), using continuous data from the Swiss national registry. Based on a standardised questionnaire, data on coronary and structural interventions in Switzerland were assessed by the Working Group Interventional Cardiology of the Swiss Society of Cardiology (SSC). Here, we analysed the trend of annually performed interventions from 2005 to 2021 in Switzerland and the impact of the COVID-19 pandemic. We observed a constant increase in the total number of cases (including coronary angiographies (CA) and percutaneous coronary interventions (PCI)) from 36,436 cases in 2005 to 56,555 cases in 2021 (+55%). With 18 cases in 2007, TAVI procedures have increased to 2004 cases in 2021. During the early phase of the COVID-19 pandemic in 2020, a slight decrease in CAs and PCIs of 9.15% was observed. In contrast, we did not observe an impact of the COVID-19 pandemic on the number of no TAVI procedures. Most importantly, all cause in-hospital mortality for coronary interventions before and during the peak of the COVID-19 pandemic was comparable (1.4% vs. 1.3%). Over a 16-year period, we observed an upward trend in diagnostic and therapeutic procedures for coronary as well as structural heart disease, with only a small short-term impact of the COVID-19 pandemic on interventions and a similar procedure-related in-hospital-mortality in Switzerland.

574 DOUBLE VASCULAR COMPLICATION IN THE SITE OF PUNCTURE AFTER TAVI: A CASE REPORT

Abstract Hemorrhages represent one of the most frequent complications during TAVI. Their rapid recognition and a prompt treatment are necessary to avoid hemorrhagic shock, which can lead the patient to death in a short time. We report the case of a 79-year-old woman affected by severe and symptomatic aortic stenosis, who underwent TAVI in our Cath-lab. Through a right femoral echo-guided arterial access, implantation of a 26 mm self-expandable aortic bio-prosthesis and hemostasis in the site of puncture with 18F Manta vascular closure device were performed. At the end of the procedure, through radial artery, a femoral angiography was performed, showing an important leak of contrast medium upper the site of puncture, without any change in arterial pressure or heart rate. After echo-guided cannulation of left femoral artery with 8F sheath, implantation of endoprosthesis in the site of hemorrhage and hemostasis of left femoral artery with 8F AngioSeal VIP vascular closure device were performed. In cardiac intensive care unit (CICU) low dosage of vasoactive agents and blood were administered, guaranteeing a good arterial pressure. Computed tomography (CT) was performed after two days and confirmed the presence of a retroperitoneal hematoma, without active bleeding. After six days, the patient left CICU and was admitted to the cardiological ward, starting a gradual mobilization. However, after 48 hours she reported abdominal pain and became rapidly hypotensive, tachycardic and asthenic, requiring readmission in CICU. Serum exams showed low hemoglobin concentration, an abdominal CT was perfomed, showing an active bleeding from left femoral artery and a homolateral retroperitoneal hematoma. The patient was rapidly lead in the cath lab. Angiography confirmed the hemorrage and an endoprosthesis was successfully implanted in the left femoral artery. Blood and vasoactive agents were administered with a progressive improvement in hemodynamic and clinical conditions of the patients. Post-operative course was complicated by fever and empiric antiobiotic therapy was administered until blood culture revealed no bacterial growth. A third CT showed the stability of the hematomas and the absence of active bleeding, allowing hospital discharge of the patient. Vascular complications are frequent and sneaky during TAVI procedures. A prompt treatment is of paramount importance to prevent hemorrhagic shock. TAVI operators should have experience in the field of peripheral intervention for the management of vascular complications.

460 BIOPROSTHESIS HEMODYNAMICS AND CORONARY FLOW AFTER TAVI IN TAVI

Abstract Background TAVI-in-TAVI is a complex intervention, potentially associated with feared complications such as coronary artery obstruction or Sinus of Valsalva (SOV)sequestration. Coronary obstruction risk is high when the degenerated bioprosthesis has supra-annular leaflets, the sinus of Valsalva is effaced, and/or sino-tubular Junction (STJ) is narrow. Clinical Case A 91 years old man, underwent TAVI with Acurate NEO M in 2016 with good results: post procedural mean gradient was 8mmHg and PVL was mild. He was admitted in our Institute after six years from index procedure for an episode of acute heart failure with echocardiogram findings of prolapse of one of the prosthetic leaflet causing severe aortic regurgitation without signs of active endocarditis. He was a potential candidate for transfemoral TAVI in TAVI and he had an intermediate risk score. The most important phase of this procedure was a careful planning through the preprocedural CTA. The potential maximal neoskirt of the Acurate M is 30mm. In this case, on one hand, we had wide SOV of 33mm of diameter and wide STJ of 30mm of diameter, on the other hand we had a left main ostia height of 15.5mm, a right coronary artery ostia height of 14mm and a STJ height of 25mm from the basal plane of the transcatheter heart valve (THV), hence we excluded THV with higher frame as Evolut or Acurate to prevent the formation of a long-covered stent of at least 23-24mm and 29-30mm respectively. In the trasversal annular plane obtained by multiplanar CT reconstruction we implanted a “virtual” valve at the geometric center simplified as a cylinder with a diameter of 23 mm to measure the valve to coronary (VTC) and valve to sino-tubular junction (VTSTJ) distance obtaining safe values of 5mm and 8mm respectively, both above the high risk threshold of 4mm for VTC and 2,5-3,5mm for VTSTJ. We chose a SAPIEN ULTRA 23mm for its short frame with a potential maximal neoskirt of 18mm and for its open cell strut to facilitate coronaries reaccess at the cost of a higher degree of first THV leaflets overhang. We decided to perform a low implant with more percentage of overhang THV but a low risk of coronaries flow impairment. Results Excellent result with correct positioning, coronaries patency and absence of leak. The selective cannulation of both coronaries was performed easily and successfully. The patient was discharged the next day with stable haemoglobin and a mean gradient of 8mmHg with no intraprosthetic aortic regurgitation. Conclusion In case of leaflets degeneration with preserved mobility, the low implantation a short frame THV could preserve the formation of the neoskirt above the top of its frame and determining an overhang of first THV leaflets without precluding acute and short-term hemodynamics Discussion In consideration of the expansion of TAVI indication even in younger patients we will encounter an increase of TAVI in TAVI procedures, therefore it is essential to familiarize with CTA reconstructions to assess the risk of direct or indirect coronary occlusion and to do the best THV choice according to the cause of the dysfunction and the anatomical features.

869 SUCCESSFUL TREATMENT OF COMBINED ANNULAR RUPTURE DURING TRANSCATHETER AORTIC VALVE IMPLANTATION: A CASE REPORT

Abstract Transcatheter aortic valve implantation (TAVI) has revolutionized the treatment of patients with severe, symptomatic aortic stenosis. Despite being less invasive than conventional open-chest surgery, TAVI remains associated with rare but serious complications such as vascular injury, stroke, coronary obstruction, cardiac perforation and annular rupture. We report a case of a combined annular rupture successful treated by emergent surgery. Case presentation: A low-risk (EuroSCORE:1.14%) 73-year-old male presenting with high-gradient, normal-flow severe aortic stenosis (AS) was referred to our centre. He had preserved left ventricular ejection fraction and heavily calcified aortic valve. The Heart Team recommended isolated surgical aortic valve replacement, but the patient refused this option. We decided to perform transfemoral-TAVI with a 26 mm Edwards valve which was deployed after predilatation with a 23 mm balloon. Immediately after valve deployment, the angiography revealed contrast leakage at the level of the Valsalva sinuses. The patient developed hypotension due to cardiac tamponade which was immediately managed with pericardial drainage. A bailout cardiac surgery was required to remove the TAVI prosthesis and the native aortic leaflets. A left ventricular outflow tract (LVOT) rupture was observed in addition to supra- annular and intra-annular injury. Repair of the left ventricle with a pericardial patch and implantation of a surgical bioprosthesis (Dafodil Meril 21 mm) were performed. No complications occurred post-operatively Annular rupture occurs in about 1% of all TAVI procedures and may involve the region of the aortic root and LVOT. According to the anatomical location of the injury, it can be classified into 4 types: intra-annular, sub-annular, supra-annular, and combined rupture. Annular rupture has been mainly observed after the use of balloon-expandable valves and only exceptionally after TAVI with self- expandable prosthesis. Nevertheless, the following anatomic characteristics are associated with an increased incidence of this catastrophic event: small aortic valve annulus (&amp;lt;20 mm), a narrow aortic root, heavy calcifications of aortic valve leaflets, annulus, LVOT and sinuses of Valsalva, bicuspid valve, short distance from a coronary artery to the annulus and LV hypertrophy. The voluminous amount of calcification located in the landing zone in addition to the force applied during the balloon expansion may be the main mechanism of this catastrophic complication. Clinical presentation is dramatic and emergent surgery can be the sole solution. Alternative bailout treatments, such as placing a second transcatheter valve to close the rupture have been occasionally reported. A precise preprocedural analysis of the device landing zone is mandatory. This includes determination of the size, morphology of all anatomical structures and a careful identification of possible factors for annular rupture. Moreover, in these cases, the availability of cardiac surgery onsite is pivotal to save patient's life. As more and younger patient will undergo TAVI in next years, our report highlightsthe need to optimize preprocedural planning and prosthesis selection. Improvements in devices, procedural techniques, and imaging tools may simplify TAVI and reduce possible complications.

Myocardial Perfusion and Coronary Physiology Assessment of Microvascular Dysfunction in Patients Undergoing Transcatheter Aortic Valve Implantation-Rationale and Design.

The prevalence of coronary artery disease (CAD) in patients with severe aortic stenosis (AS) is 30-68%. Nevertheless, there is still not enough evidence to use invasive assessment of lesion severity, because the hemodynamic milieu of AS may impact the fractional flow reserve (FFR) and non-hyperemic indices. Therefore, the aim of the study is two-fold. First, to measure acute and long-term changes of FFR, index of microvascular resistance (IMR), and coronary flow reserve (CFR) in patients undergoing TAVI procedure. Second, to compare the diagnostic accuracy of intracoronary indices with myocardial perfusion measured by cadmium-zinc-telluride single-photon emission tomography (CZT-SPECT) and find cut-off values defining significant stenosis. We plan to enroll 40 patients eligible for TAVI with intermediate stenosis (30-70%) in the left anterior descending (LAD) coronary artery. In each patient FFR, CFR, and IMR will be measured in addition to myocardial blood flow calculated by CZT-SPECT before and either immediately after TAVI (acute cohort) or in 6 months (late cohort) after the procedure. FFR, CFR, and IMR will be matched with the results of myocardial perfusion measured by CZT-SPECT in the area of LAD. As a result, cut-off values of FFR, CFR, and IMR defining the decreased blood flow will be found.

Subsequent cardiac surgery after transcatheter aortic valve implantation: Indications and outcomes.

Aim of this study was to report on indications and clinical outcomes of patients who underwent subsequent open-cardiac surgery after transcatheter aortic valve implantation TAVI. Between 01/2011 and 12/2020 our centre performed 4043 TAVI procedures. Twenty-seven patients (including patients in whom TAVI was performed in other centres) underwent subsequent open-heart surgery via cardiopulmonary bypass. Demographic, intraprocedural data, indications for, and outcomes after surgery were evaluated. Indications for cardiac surgery (aged 79 [IQR 76-84]; 59.3% male) were endocarditis (n = 11; 40.7%), annular rupture, severe paravalvular leak and severe stenosis in three (11.1%) patients, respectively as well as in one patient each (3.7%) severe tricuspid valve regurgitation, valve thrombosis, valve malposition, valve migration, ostial right coronary artery obstruction, left ventricular rupture and type A aortic dissection. The interval between the index TAVI procedure to open surgery was 3 months (IQR 0-26 months). Eight patients underwent emergent surgical conversions. Immediate procedural and procedural mortality was 25.9% and 40.7%, respectively and all-cause mortality was 51.9% (11/12 died for cardiovascular reasons). No disabling stroke was observed postoperatively. New permanent pacemaker implantation was required in threepatients (11.1%). Subsequent open-cardiac surgery after TAVI is rare, but may urgently become necessary due to TAVI related complications or progressing other cardiac pathologies. Despite a substantial early attrition rate clinical outcome is acceptable and a relevant number of these high-risk patients can be discharged even after emergency conversions. The option of subsequent surgical conversion remains.

Use of extended realities in interventional cardiology: mixed reality for TAVI procedure

Use of extended realities in interventional cardiology: mixed reality for TAVI procedure

Abstract 13977: The Impact of Left Atrial Functional Changes on Clinical Outcomes Following Transcatheter Aortic Valve Replacement

Background: In patients with aortic stenosis (AS) and preserved left ventricular (LV) function, pre-intervention left atrial (LA) enlargement is common and predicts adverse events. Changes in LA function are appropriate markers of LV response to AS but have not been well explored in patients undergoing TAVI. The objectives of the current study were to evaluate changes in LA function following TAVI and their impact upon clinical outcomes. Methods: A total of 313 consecutive patients undergoing TAVI were included. There were 160 (51%) paired echocardiographic datasets with a median time of 1 (range 0-57) days pre-TAVI and a median time of 120 (1.2-810) days post-TAVI. All studies were evaluated for LA maximum volume index (LAVI max ), LA minimum volume index (LAVI min ), total emptying volume (LAEV), total emptying fraction (LAEF) and expansion index (LAEI). The pre-defined endpoints were cardiac-related hospitalization and all-cause death. Results: During a mean follow-up of 18 (±9.7) months, there were 58 deaths (18.5%) and 35 (11.2%) hospitalizations for heart failure, whereas 9 (2.9%) patients continued to report symptoms (NYHA 3). The prevalence of atrial fibrillation was 16.3% and coronary artery disease 52.7%. In a multivariate cox regression analysis, lower body surface area (HR 3.79; 95% CI 1.07-13.33, p=0.038), higher serum creatinine (HR 1.004; 95% CI 1.002-1.006, p&lt;0.001) and LV ejection fraction (EF) &lt;50% (HR 1.94; 95% CI 1.08-3.48, p=0.027) were predictors of all-cause mortality, independent of age, aortic valve area, the presence of coronary artery disease and time from index echocardiography to TAVI procedure. All LA function parameters demonstrated an improvement following TAVI (Fig. 1). In univariate cox regression analyses, baseline LA functional parameters were not associated with all-cause mortality alone or a composite of all-cause mortality and cardiac related hospitalization. Conclusions: In patients undergoing TAVI, lower body surface area, higher serum creatinine and LVEF &lt;50% were independent predictors of all-cause mortality. TAVI led to successful reverse LA functional and structural remodeling and LV functional recovery. However, pre-TAVI LA functional and structural parameters were not predictors of survival.

Similar clinical outcomes with transcatheter aortic valve implantation and surgical aortic valve replacement in octogenarians with aortic stenosis.

Transcatheter aortic valve implantation (TAVI) is the preferred treatment option for severe aortic stenosis in the elderly and in patients with comorbidities. We sought to compare outcomes after TAVI and surgical aortic valve replacement (SAVR) in octogenarians. In this retrospective cohort study conducted at our tertiary center, clinical data were gathered before and after TAVI and SAVR procedures performed from January 2013 to May 2019; follow-up completed in March 2021. The primary outcome was 1-year mortality. Patients were stratified according to Society of Thoracic Surgeons (STS) score and procedure type. Propensity score-based matching was also performed. Of 542 patients who matched the inclusion criteria, 273 underwent TAVI and 269 SAVR. TAVI patients were older (85.8 ± 3.0 vs. 82.2 ± 2.2 years; P < 0.001) and had a higher mean STS score (5.0 ± 4.0 vs. 2.8 ± 1.3; P < 0.001) and EuroSCORE II (5.3 ± 4.1 vs. 2.8 ± 6.0; P < 0.001). Rates of postoperative permanent pacemaker insertion (15.0% vs. 9.3%; P = 0.040) and paravalvular leak (9.9% vs. 0.8%; P < 0.001) were higher and acute kidney injury lower (8.8% vs. 32.7%; P < 0.001) after TAVI, with no difference between treatment groups for major bleeding (11.0% vs. 6.7%; P = 0.130) or 30-day mortality (5.5% vs. 3.7%; P = 0.315). A statistically significant difference was found between TAVI and SAVR in low- and intermediate-risk groups when it came to occurrence of paravalvular leak, acute kidney injury, and new onset AF (all P < 0.001). This analysis of an octogenarian "real-life" population undergoing TAVI or SAVR (with a biological valve) showed similar outcomes regarding clinical endpoints in low- and medium-risk (STS score) groups.

Evaluation of non-breath-hold, ultra-fast, low-dose high-pitch (flash) CT scan as a practical alternative to standard spiral scan for pre-TAVI patients: a real-world single-center experience

Abstract Introduction and aim Aortic annulus dimensions change during the cardiac cycle. A retrospective ECG-gated (Spiral) scan is the default technique for pre TAVR evaluation since it includes systolic phases considered optimal for aortic annulus assessment. Ultra-fast, Low-Dose High-Pitch (FLASH) offers faster, potentially low radiation and low contrast dose scans. However, it lacks the ability to time data acquisition to the systole. Therefore, measurements derived from FLASH scan are considered suboptimal for reporting. The effect of this potential annular measurement difference on procedural success and safety was not evaluated. Therefore, we aimed to assess the feasibility and safety of FLASH vs. Spiral scan before TAVI. Methods We conducted a retrospective, single-center study. 409 patients underwent CT-TAVI scan with either FLASH or SPIRAL acquisition. Baseline characteristics, CT study, procedural and f/u data were acquired from the EMR. Outcomes defined by Valve Academic Research Consortium3 (VARC-2) endpoint definitions included in-hospital mortality, bleeding, vascular complications, acute kidney injury (AKI), conduction disorders, mechanical complications, and prosthetic aortic valve regurgitation. Composite endpoints such as device success were also examined. Results Of the 409 patients, 55.7% underwent FLASH scans. The median age was 80 years, and males accounted for 55%. The FLASH-protocol patients had higher rate of chronic kidney disease, their CT-measured aortic annulus area and diameter were smaller, and they were exposed to a smaller amount of contrast agent and radiation than the SPIRAL group. There was no statistically significant difference in primary clinical and safety endpoints between the two groups, including mechanical complications (such as annular rupture and valve malposition) and conduction disorders. Conclusions FLASH CT scan is a pragmatic and safe approach that potentially may replace spiral scan for the evaluation before TAVI procedure in the appropriate patients. Funding Acknowledgement Type of funding sources: None.