To Transcatheter Aortic Valve Replacement Research Articles

Balloon aortic valvuloplasty bridge to transcatheter aortic valve replacement is associated with worse in-hospital mortality

BackgroundBalloon aortic valvuloplasty (BAV) has gained renewed interest as a bridge to transcatheter aortic valve replacement (TAVR) for patients with aortic stenosis (AS). However, it is unclear whether they patients should undergo TAVR directly or receive a staged bridge to BAV before TAVR is unclear. We used a national database to examine the association between BAV and TAVR in patients with TAVR and its effect on in-hospital mortality. MethodsUsing the nationwide inpatient database of the Japanese registry of all cardiac and vascular diseases and the combination of the diagnosis procedure combination, we retrospectively analyzed 27,600 patients with AS who underwent TAVR between October 2013 and March 2021. Outcomes of the direct TAVR group (n = 27,387) were compared with those of the BAV bridge to TAVR group (n = 213), which received BAV at least 1 day before TAVR. ResultsThe median age was 85 (interquartile range: 82–88) years, with 33.3% (n = 9188) being male. Unplanned/emergent admissions increased with TAVR, whereas the use of BAV bridge to TAVR decreased. The in-hospital mortality rate was 1.3% and decreased over time. However, the BAV bridge to TAVR had a significantly higher in-hospital mortality than direct TAVR (5.6% vs. 1.3%; p < .0001). Factors associated with in-hospital mortality included age, body mass index, chronic renal disease, percutaneous coronary intervention, and BAV bridge to TAVR. ConclusionsIn unplanned/emergent and planned admission settings, the in-hospital mortality rate for BAV bridge to TAVR is worse than that for direct TAVR. Practical criteria for BAV bridge to TAVR should be proposed to improve outcomes.

Incidence and risk factors of acute kidney injury after transcatheter aorticvalve replacement.

Acute kidney injury (AKI) is a common early complication secondary to transcatheter aortic valve replacement (TAVR). Studies on the incidence and risk factors for AKI after TAVR surgery are limited to date. Here, we retrospectively analyzed the incidence and risk factors for AKI after TAVR surgery in our hospital. Patients who underwent TAVR surgery at our hospital from November 2017 to February 2023 were selected. AKI was defined using the 2012 KDIGO definition and staging criteria. The relevant data and information between the AKI group and the non-AKI group were compared and analyzed, and a binary logistic regression model was used to analyze the risk factors for AKI. A total of 75 patients who underwent TAVR surgery were included in the retrospective analysis. After TAVR, the incidence of AKI was 17.3% (13/75), of which 8 (61.5%) had stage 1 AKI, 2 (15.4%) had stage 2 AKI, 3 (23.1%) had stage 3 AKI, and 3 needed renal replacement therapy. After multivariate logistic analysis, contrast volume (OR = 1.024 (1.001, 1.047)) was found to be an independent risk factor for AKI, while patients with high estimated glomerular filtration rate (eGFR) (OR = 0.903 (0.826, 0.986)) have a reduced risk of AKI. A retrospective study revealed a 17.3% incidence of AKI after TAVR surgery in our hospital, most of which were stage 1 AKI. A low preoperative eGFR and contrast volume were found to be independent risk factors for AKI.

Radiological Parameters for the Detection of Pulmonary Hypertension in Severe Aortic Valve Stenosis and Their Influence on Mortality: Does Sex Matter?

Background: Echocardiography has long been established as the primary noninvasive method for diagnosing pulmonary hypertension (PH) prior to transcatheter aortic valve replacement (TAVR) in patients with severe aortic valve stenosis (AS). In recent years, radiological methods for diagnosing PH have been investigated. Measurements such as the computed tomography angiography (CTA)-derived pulmonary artery (PA) diameter and PA diameter/body surface area (PA/BSA) have shown promising results regarding their diagnostic strength. However, it has yet to be determined if a patient's sex has any impact on the effectiveness of these diagnostic measurements. Methods: In all, 271 patients (51.3% male, mean age 82.6 ± 4.8 years) with severe AS undergoing TAVR were separated into male and female groups. The cut-off values for the diagnosis of PH were calculated for the CTA-derived PA diameter and PA/BSA based on different systolic pulmonal artery pressure values (40-45-50 mmHg). Patients were then subclassified according to measurements above or below these PA diameters and PA/BSA cut-off values. A PA diameter ≥29.5 mm and PA/BSA ≥ 15.7 mm/m2 qualified for PH. The 1-5 year survival rate in these cohorts was further analyzed. Results: Patients with a PA diameter ≥29.5 mm showed a significantly higher 1 year mortality rate (p = 0.014). This observation could only be confirmed for the male sex (p = 0.018) and not for the female sex (p = 0.492). As for the PA/BSA, in patients over the cut-off value, no significant increase in mortality was noted in the overall cohort. However, the male patients showed increased 3 year (p = 0.048) and 5 year mortality rates (p = 0.033). Conclusions: The CTA-obtained PA diameter and PA/BSA are both useful in the diagnosis of PH and mortality risk stratification in patients with severe AS undergoing TAVR, especially in males. Male patients with PA ≥ 29.5 mm or PA/BSA ≥ 15.7 mm/m2 seem to be at a higher risk of death during follow-up after undergoing TAVR. In females, no such correlation was observed.

Evaluation of ECG-Gated, High-Pitch Thoracoabdominal Angiographies With Dual-Source Photon-Counting Detector Computed Tomography.

The aim of this study was to evaluate the radiation dose, image quality, and the potential of virtual monoenergetic imaging (VMI) reconstructions of high-pitch computed tomography angiography (CTA) of the thoracoabdominal aorta on a dual-source photon-counting detector-CT (PCD-CT) in comparison with an energy-integrating detector-CT (EID-CT), with a special focus on low-contrast attenuation. Consecutive patients being referred for an electrocardiogram (ECG)-gated, high-pitch CTA of the thoracoabdominal aorta prior to transcatheter aortic valve replacement (TAVR), and examined on the PCD-CT, were included in this prospective single-center study. For comparison, a retrospective patient group with ECG-gated, high-pitch CTA examinations of the thoracoabdominal aorta on EID-CT with a comparable scan protocol was matched for gender, body mass index, height, and age. Virtual monoenergetic imaging reconstructions from 40 to 120 keV were performed. Enhancement and noise were measured in 7 vascular segments and the surrounding air as mean and standard deviation of CT values. The radiation dose was noted and signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were calculated. Finally, a subgroup analysis was performed, comparing VMI reconstructions from 40 keV to 70 keV in patients with at least a 50% decrease in contrast attenuation between the ascending aorta and femoral arteries. Fifty patients (mean age 77.0±14.5 years; 31 women) were included. The radiation dose was significantly lower on the PCD-CT (4.2±1.4 vs. 7.2±2.2 mGy; p<0.001). With increasing keV, vascular noise, SNR, and CNR decreased. Intravascular attenuation was significantly higher on VMI at levels from 40 to 65, compared with levels of 120 keV (p<0.01 and p<0.005, respectively). On the PCD-CT, SNR was significantly higher in keV levels 40 and 70 (all p<0.001), and CNR was higher at keV levels 40 and 45 (each p<0.001), compared with scans on the EID-CT. At VMI ≤60 keV, image noise was also significantly higher than that in the control group. The subgroup analysis showed a drastically improved diagnostic performance of the low-keV images in patients with low-contrast attenuation. The ECG-gated CTA of the thoracoabdominal aorta in high-pitch mode on PCD-CT have significantly lower radiation dose and higher objective image quality than EID-CT. In addition, low-keV VMI can salvage suboptimal contrast studies, further reducing radiation dose by eliminating the need for repeat scans. ECG-gated CT-angiographies of the thoracoabdominal aorta can be acquired with a lower radtiation dose and a better image quality by using a dual-source photon-countinge detector CT. Furthermore, the inherent spectral data offers the possiblity to improve undiagnostic images and thus saves the patient from further radiation and contrast application.

CT annulus sizing prior to transcatheter aortic valve replacement (TAVR): evaluation of free-breathing versus breath-holding acquisition.

To assess feasibility and accuracy of aortic annulus measurements using cardiac computed tomography angiography (CTA) performed during free-breathing prior to transcatheter aortic valve replacement (TAVR). Sixty consecutive TAVR candidates underwent free-breathing wide-detector cardiac CTA, followed by a percutaneous valve replacement. For each, a theoretical valve size was suggested through CT measurements of the annulus, then compared to the size of the actual implanted transcatheter heart valve (THV). The procedural success and the 30-day outcomes were collected. Image quality of the annulus was also studied according to subjective and objective criteria. Data of a control group of 60 patients previously evaluated on breath-holding were also evaluated. A total of 120 patients (mean age, 83years ± 7, 60 men) were evaluated. All CT acquisitions provided sufficient image quality allowing precise annulus measurements. Mean attenuation (p < 0.001) and image noise (p = 0.01) were higher in the free-breathing group, while image quality was comparable (p = 0.36). The agreement rate between CT-suggested valve size and THV implanted size was comparable, estimated at 87% (κ = 0.79, 95%CI 0.566, 0.908) on free-breathing vs. 82% (κ = 0.78, 95%CI 0.634, 0.904) on breath-holding. The procedure was successful for all patients without increase in 30-day mortality or adverse events. Free-breathing cardiac CTA allows accurate aortic annulus measurements without compromising image quality or patients' outcome after TAVR. Elderly patients experiencing dyspnea, discomfort, or hearing loss that could prevent proper breath-holding should not be excluded from CT prior to TAVR. To decrease elderly patients' discomfort, MDCT evaluation prior to transcatheter aortic valve replacement (TAVR) may be performed on quiet breathing with no significant impact on the outcome. • Adhering to CT breathing commands can be challenging for patients with dyspnea, hearing impairment, agitation, or pulmonary diseases. • Free-breathing cardiac CT may be an alternative to breath-holding for patients unable to follow the breathing commands. • Wide-detector CT acquisition on free-breathing does not impair annulus measurements and prosthesis sizing in patients scheduled for TAVR.

AF in TAVR patients: double trouble means double care

Abstract Introduction Atrial fibrillation (AF) and aortic stenosis share multiple common risk factors and aortic valve stenosis itself is associated with higher rate of AF. Patients submitted to transcatheter aortic valve replacement (TAVR) are particularly frail and AF is associated with increased mortality, ischemic and hemorrhagic events. Thus, a thorough approach, especially in such frail population, is warranted to reduce morbi-mortality. Bearing this in mind, a risk assessment tool derived from ENVISAGE-AF trial was recently developed to stratify the mortality risk of AF patients after completion of successful TVR. Purpose To characterize a population of patients with AF who implanted TAVR and test a newly proposed mortality score to estimate prognosis in this population. Methods Single-center observational retrospective study including consecutive pts with AF who implanted TAVI from 2017 to 2021. Clinical data was collected at baseline and during follow-up. The AF mortality score groups pts in three crescent strata of severity (0-10; 11-16; &amp;gt;16) by summing seven variables: age, creatinine clearance, duration of AF, NYHA class, alcohol consumption, peripheral artery disease and prior major bleeding. Kaplan Meyer survival analysis was performed using SPSS statistics. Results For 5 years, 621 pts underwent TAVR, of which 189 (30,4%) had previously diagnosed AF. 102pts were female, mean age of 82,6± 6,1 years. More than half (53%) had permanent AF, 28% paroxysmal AF and 19% persistent AF. During a mean follow up of 953 days, 8 (4,2%) pts suffered a major hemorrhagic event, two pts had ischemic arterial events (peripheral and mesenteric) and no venous thrombotic events were observed. As anticipated, event rate was high: at 1 year follow-up, 27 were admitted for cardiovascular events (3 with acute myocardial infarction and 4 with stroke). 26 pts died after 1-year (13,7%) and 30 died during available FUP (15,8%). The aforementioned AF mortality score was applied to our pts at baseline, before TAVR: 63%, 17.5% and 8.5% of patients were categorized as low, moderate or high risk. Patients in the high risk group (score&amp;gt;16) had a significantly higher rate of events during follow-up – figure1. Lower and intermediate group failed to show a clear separation in terms of risk estimation between them, which may be attributed to the paucity of events in these two groups. Conclusion AF and aortic stenosis are both burdensome diseases and AF increases the risk of events in TAVR population. We showed that a newly proposed score that stemmed from ENVISGE-AF can effectively select pts at high risk of mortality, in whom close clinical surveillance should be particularly rigorous.

Trends and Predictors of Short Length of Stay Following Transcatheter Aortic Valve Replacement

BackgroundMinimalist approaches to Transcatheter aortic valve replacement (TAVR) have allowed for improved efficiency in care of patients. We hypothesized that improved efficiencies in care process may have led to increased adoption of a one night length of stay (LOS) in this patient group. ObjectivesThe authors aimed to study temporal trends in short length of stay following TAVR. MethodsThis is a nationwide temporal trends study using the 2016–2019 National In Patient Sample (NIS) registry. Short stay was defined as LOS of one night or less. Trends in proportion of patients with short stay were obtained. A multivariate model to identify predictors of short stay was built after adjusting for confounders. Secondary analysis of temporal trends was stratified by presence or absence of major complications (major bleeding requiring transfusion or pacemaker implantation [PPMI]). ResultsA total of 217,110 patients were included in the weighted sample. The proportion of patients with short stay significantly increased for those with and without complications (Ptrend < 0.001). The morbidity burden, as defined by the proportion of patients with a Charlson comorbidity index (CCI) score of ≥2 and rate of major complications decreased significantly. On multivariate analysis short stay was predicted by male sex, white ethnicity, Southern/Western regions and lower CCI score. Patients with major bleeding requiring transfusion or PPMI were less likely to have short stay (aOR 0.23 and aOR 0.12, p < 0.001 respectively). ConclusionThere is a national trend towards shorter LOS following TAVR. There is a decrease in major post procedural complication rates from 2016 to 2019.

Abstract 14964: Photon Counting Computed Tomography for Aortic Valve Calcium Scoring in Contrast Enhanced Datasets of the Heart

Introduction: The prognostic value of aortic valve calcification prior to transcatheter aortic valve replacement (TAVR) is well established. Its reliable quantification requires a non-contrast computed tomography (CT) of the heart (‘true non contrast’, TNC) which in this cohort is not regularly performed at all centers. Photon Counting Detector CT (PCD-CT) permits the routine derivation of ‘virtual non-contrast’ (VNC) and ‘virtual non-iodine’ (VNI) series from CT Angiography (CTA) acquisitions due to its intrinsic spectral sensitivity. These might render separate non-contrast acquisitions unnecessary. Hypothesis: We hypothetized that quantification of aortic valve calcification of VNC/ VNI series derived from CTA scans is feasable and correlates with calcium scores of TNC series. Methods: 45 consecutive patients underwent pre TAVR CT on a novel PCD-CT (NAEOTOM Alpha, Siemens Healthineers, Erlangen, Germany) comprising a non-contrast CT of the heart, followed by a CTA of the heart, aorta, and iliac arteries. VNC series were derived from CTA acquisitions and two readers independently quantified aortic valve calcium scores (Agaston score) and calcium volumes on VNC-, VNI- and TNC-series. Results: A total of 41 patients (41.46% female) were included in the study. In comparison with aortic valve calcium scores and volume scores derived from TNC series (i.e., 2800[2075-3681] vs. 2206[1645-2894] mm3), those derived from VNC (i.e., 752[390-1357] vs. 653.3[319.5-1052.3] mm3) and VNI (i.e., 1986[1270-3278] vs. 1515[971-2480] mm3) series were consistently lower but correlation was excellent for both, i.e., calcium and volume score, respectively (r’s: 0.96 and 0.96 for VNC; r’s: 0.92 and 0.91 for VNI, p&lt; 0.05). Conclusions: Our initial patient experience with TAVR planning CT on a novel PCD-CT showed signficant correlation of aortic valve calcium scores and volumes derived from VNC and VNI series, as compared with those derived from TNC series, thus rendering non-contrast acquisitions for TAVR planning redundant.

Abstract 15819: Longing for a Pacemaker, Association of Prolonged Qrs and Permanent Pacemaker in the Tavr Population

Background: The duration of the QRS carries valuable information regarding structural disease, conduction defects, or even ischemia. Studies have shown that a widened QRS (&gt;120) is associated with poor cardiovascular outcomes. In this study we investigated the impact of the presence of a widened QRS (wQRS )previous to Transcatheter Aortic Valve Replacement (TAVR) and clinical outcomes. Methods:: Retrospective analysis of electronic medical records from 2018-2020 at the University of Illinois Chicago identified TAVR patients. Patients were placed into two groups: a wQRS and a nQRS group. Those with pacemakers prior to procedure were excluded. Primary outcomes included PPM placement prior to discharge, composite MACE (all-cause mortality, MI, or CVA), and (LOS) at 6 and 12 months. Results: We included 149 patients in this analysis. There were 76.1% male, 57.1% non-white, and 74 ± 13 years old on average. A wQRS was found in 46 (30.9%) and 103 (69.1%) were found to have a nQRS. Of this group, 40.2% had a history of congestive heart failure (CHF). The average ejection fraction (EF) was 50% with 80% of patients having a normal (EF). The CoreValve was placed in 65.7% of patient compared to 34.3% of patients having the Sapian valve placed. There were no differences in age, sex, or race between the two groups. Of all patient’s in the study, those with a wQRS were more likely to have a PPM placed prior to discharge compared to those with nQRS (17.4% (8) vs 5.8% (6) , p=0.025). Though not significant, 14% (13)of patients with the CoreValve placed required PPM prior to discharge compared to 2.5%(1) in the Sapian valve group (p=.175). There was no statistically significant difference in composite MACE, LOS, or significant bleeding events in either groups at 6 or 12 months. Conclusion: Our results suggest that patients with a wQRS are more likely to receive a PPM placement post TAVR during index hospitalization compared to those with a nQRS. This study suggests further investigation into the predictive nature of EKG parameters on clinical outcomes be done.

Artificial intelligence-enabled phenotyping of patients with severe aortic stenosis: on the recovery of extra-aortic valve cardiac damage after transcatheter aortic valve replacement

ObjectiveA novel artificial intelligence-based phenotyping approach to stratify patients with severe aortic stenosis (AS) prior to transcatheter aortic valve replacement (TAVR) has been proposed, based on echocardiographic and haemodynamic data....

Large-bore arterial access closure after transcatheter aortic valve replacement: a systematic review and network meta-analysis.

AimsAs the indications to transcatheter aortic valve replacement (TAVR) expand to patients at increasingly lower risk, procedure-related vascular and bleeding complications events must be minimized. We aimed to evaluate the impact of different large-bore arterial access closure devices on clinical outcomes after TAVR.Methods and resultsWe searched for papers that reported outcomes according to the type of vascular closure device/technique used after TAVR and performed a Bayesian network meta-analysis (NMA). Fifteen studies involving 9259 patients who underwent access site closure using PROSTAR™ XL percutaneous vascular surgical system (Abbott Vascular, Santa Clara, CA, USA), Perclose ProGlide™ suture-mediated closure system (Abbott), or MANTATM vascular closure device (Teleflex, Morrisville, NC, USA) were included. NMA showed MANTA to have the highest likelihood of reducing a primary composite endpoint of intra-hospital death, major vascular complications, and major or life-threatening bleedings [surface under the cumulative ranking curve analysis (SUCRA) 94.8%], but this was mitigated when only randomized clinical trials and propensity-matched cohorts were included (SUCRA 56.1%). The ProGlide showed the highest likelihood to reduce major or life-threatening bleedings, especially with increasing procedural complexity, and the MANTA device to reduce major and minor vascular complications. The ProStar XL device performed poorly in all explored endpoints.ConclusionAvailable evidence summarized through a NMA shows that ProGlide and MANTA devices appear to be both valid vascular closure devices globally and to be the best options to minimize vascular complications and reduce bleeding in patients undergoing TAVR, respectively.

Changes to transcatheter aortic valve replacement (TAVR) services during the first wave of the COVID-19 pandemic: A single centre experience from United Kingdom tertiary hospital

AimsCOVID-19 had a devastating impact on patients with severe aortic stenosis (AS). Like many cardiac procedures, transcatheter aortic valve replacement (TAVR) services were suspended during the first wave of COVID-19. We took the opportunity to evaluate the clinical outcomes and identify any delays at different stages of the TAVR pathway during the COVID-19 pandemic. MethodsProspectively collected data on 210 consecutive TAVR patients between March 2019 and March 2021 were analysed. We compared the clinical outcomes and 30-day mortality rates of TAVR cases pre-pandemic and during the pandemic. We also looked to identify any time lags from the initial referral to respective stages of the TAVR workup. ResultsA total of 134 patients underwent TAVR prior to the national lockdown (March 2019-March 2020), compared to 76 patients during COVID-19 (April 2020–April 2021). Success rates of TAVR were similar (99% prior to the pandemic and 97.4% during COVID-19). The 30-day survival rates were 98.6% and 94.7%, respectively. Median length of stay post TAVR was 2 days during COVID-19 and 2.5 days prior to the pandemic (p = 0.064). Patients were seen quicker in clinic (median of 33 days) during COVID-19, compared to 51 days before COVID-19 (p = 0.044). No significant difference in times from referral to discussion at TAVR multidisciplinary team (MDT) meetings, CT Aortogram and TAVR implantation, in both groups. ConclusionsReconfiguring the patient pathway during COVID-19 allowed TAVR to be performed safely, with a similar success rate and no excess complications or increased 30-day mortality. There proved to be no delay in the respective stages of patient TAVR workup, during the pandemic.

Transcatheter aortic valve replacement in aortic stenosis and cardiac amyloidosis: a systematic review and meta-analysis.

Aortic stenosis (AS) and cardiac amyloidosis (CA) are typical diseases of the elderly. Up to 16% of older adults with severe AS referred to transcatheter aortic valve replacement (TAVR) have a concomitant diagnosis of CA. CA-AS population suffers from reduced functional capacity and worse prognosis than AS patients. As the prognostic impact of TAVR in patients with CA-AS has been historically questioned and in light of recently published evidence, we aim to provide a comprehensive synthesis of the efficacy and safety of TAVR in CA-AS patients. We performed a systematic review and meta-analysis of studies: (i) evaluating mortality with TAVR as compared with medical therapy in CA-AS patients and (ii) reporting complications and clinical outcomes of TAVR in CA-AS patients as compared with patients with AS alone. A total of seven observational studies were identified: four reported mortality with TAVR, and four reported complications and clinical outcomes after TAVR of patients with CA-AS compared with AS alone patients. In patients with CA-AS, the risk of mortality was lower with TAVR (n=44) as compared with medical therapy (n=36) [odds ratio (OR) 0.23, 95% confidence interval (CI) 0.07-0.73, I2 =0%, P=0.001, number needed to treat=3]. The safety profile of TAVR seems to be similar in patients with CA-AS (n=75) as compared with those with AS alone (n=536), with comparable risks of stroke, vascular complications, life-threatening bleeding, acute kidney injury, and 30day mortality, although CA-AS was associated with a trend towards an increased risk of permanent pacemaker implantation (OR 1.76, 95% CI 0.91-4.09, I2 =0%, P=0.085). CA is associated with a numerically higher rate of long-term mortality and rehospitalizations following TAVR in patients with CA-AS as compared with those with AS alone. TAVR is an effective and safe procedure in CA-AS patients, with a substantial survival benefit as compared with medical therapy, and a safety profile comparable with patients with AS alone except for a trend towards higher risk of permanent pacemaker implantation.

SCAI Position Statement on Best Practices for Clinical Proctoring of New Technologies and Techniques

The field of interventional cardiology continues to evolve with the introduction of new techniques and technologies. From the first angioplasty to transcatheter aortic valve replacement (TAVR), dissemination of new treatments has generally required a training program of didactics and observation, culminating in a hands-on experience with a patient. Trainees and facilities starting new programs often require support from outside experts, traditionally known as “medical proctors,” whose costs are typically borne by the medical device industry.

Harnessing feature extraction capacities from a pre-trained convolutional neural network (VGG-16) for the unsupervised distinction of aortic outflow velocity profiles in patients with severe aortic stenosis.

Hypothesizing that aortic outflow velocity profiles contain more valuable information about aortic valve obstruction and left ventricular contractility than can be captured by the human eye, features of the complex geometry of Doppler tracings from patients with severe aortic stenosis (AS) were extracted by a convolutional neural network (CNN). After pre-training a CNN (VGG-16) on a large data set (ImageNet data set; 14 million images belonging to 1000 classes), the convolutional part was employed to transform Doppler tracings to 1D arrays. Among 366 eligible patients [age: 79.8 ± 6.77 years; 146 (39.9%) women] with pre-procedural echocardiography and right heart catheterization prior to transcatheter aortic valve replacement (TAVR), good quality Doppler tracings from 101 patients were analysed. The convolutional part of the pre-trained VGG-16 model in conjunction with principal component analysis and k-means clustering distinguished two shapes of aortic outflow velocity profiles. Kaplan-Meier analysis revealed that mortality in patients from Cluster 2 (n = 40, 39.6%) was significantly increased [hazard ratio (HR) for 2-year mortality: 3; 95% confidence interval (CI): 1-8.9]. Apart from reduced cardiac output and mean aortic valve gradient, patients from Cluster 2 were also characterized by signs of pulmonary hypertension, impaired right ventricular function, and right atrial enlargement. After training an extreme gradient boosting algorithm on these 101 patients, validation on the remaining 265 patients confirmed that patients assigned to Cluster 2 show increased mortality (HR for 2-year mortality: 2.6; 95% CI: 1.4-5.1, P-value: 0.004). Transfer learning enables sophisticated pattern recognition even in clinical data sets of limited size. Importantly, it is the left ventricular compensation capacity in the face of increased afterload, and not so much the actual obstruction of the aortic valve, that determines fate after TAVR.

Patients with Atrial Fibrillation Benefit from SAVR with Surgical Ablation Compared to TAVR Alone.

IntroductionIn patients with preoperative atrial fibrillation (AF) undergoing aortic valve replacement, the addition of surgical ablation to surgical aortic valve replacement (SAVR-SA) is efficacious and a Class I guideline. We hypothesized that this subgroup may benefit from SAVR-SA compared to transcatheter aortic valve replacement (TAVR) alone.MethodsMedicare beneficiaries with persistent non-valvular AF who underwent SAVR-SA or TAVR alone between 2012 and 2018 were included. Patients with high-risk surgical comorbidities were excluded. Groups were matched using inverse probability weighting. The primary outcome was all-cause mortality. Secondary outcomes were stroke, transient ischemic attack, permanent pacemaker implantation, bleeding, rehospitalization for atrial arrhythmias, and rehospitalization for heart failure. Kaplan–Meier estimates and Cox proportional-hazards regression were used to compare outcomes. Outcomes were adjusted for variables with a standardized mean difference greater than 0.1.ResultsOf 439,492 patients who underwent aortic valve replacement, 2591 underwent SAVR-SA and 1494 underwent TAVR alone. Weighting resulted in adequately matched groups. Compared to TAVR alone, SAVR-SA was associated with a significant reduction in all-cause mortality (HR 0.65, 95% CI 0.53–0.79), permanent pacemaker implantation (HR 0.62, 95% CI 0.44–0.87), bleeding (HR 0.63, 95% CI 0.39–1.00), and rehospitalization for heart failure (HR 0.49 (0.36–0.65). There was no difference in the incidence of stroke (HR 1.07, 95% CI 0.74–1.54), transient ischemic attack (HR 1.05, 95% CI 0.75–1.47), or rehospitalization for atrial arrhythmia.ConclusionSelect patients with persistent non-valvular AF may benefit from SAVR-SA compared to TAVR alone.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40119-022-00262-w.

The Prognostic Utility of Invasive Right Heart Catheterization in Patients Prior to Transcatheter Aortic Valve Replacement.

Invasive right heart catheterization (RHC) provides valuable prognostic information in cases of severe aortic stenosis, but is not done routinely prior to transcatheter aortic valve replacement (TAVR). Therefore, we sought to investigate the prognostic utility of pre-TAVR RHC for assessing outcomes post TAVR. This is a single-center, retrospective study of patients who underwent RHC prior to TAVR between June 2011 and March 2019. We evaluated abnormalities in the following variables as predictors of poor outcomes post TAVR: pulmonary capillary wedge pressure (PCWP), systolic pulmonary artery pressure (PASP), mixed venous oxygen saturation (MVO2), right ventricular stroke work index (RVSWI), and right atrial pressure (RAP). Cox proportional hazard regression models were used to assess the primary composite outcome of all-cause mortality and hospitalization for heart failure. A total of 522 patients (mean age, 83.5 ± 4.5 years; 49.4% women) with complete invasive hemodynamic data were included. At a median follow-up of 529.5 days, there were 127 deaths and 59 heart failure hospitalizations. On multivariate analysis, PCWP ≥15 mm Hg (hazard ratio [HR], 1.48; 95% confidence interval [CI], 1.02-2.07), PASP ≥50 mm Hg (HR, 1.66; 95% CI, 1.17-2.36), MVO2 ≤60% (HR, 1.42; 95% CI, 1.01-1.98), RVSWI ≥12 g•m/m²/beat (HR, 1.40; 95% CI, 1.004-1.94), and RAP ≥10 mm Hg (HR, 1.66; 95% CI, 1.09-2.51) were independent predictors of death or heart failure hospitalization. Preprocedural invasive RHC provides useful prognostic information. A comprehensive invasive hemodynamic assessment should be considered for risk stratification in patients undergoing TAVR.

241 Transcatheter aortic valve replacement in aortic stenosis and cardiac amyloidosis: a systematic review and meta-analysis

Abstract Aims Aortic stenosis (AS) and cardiac amyloidosis (CA) are typical diseases of the elderly. Up to 16% of older adults with severe AS referred to transcatheter aortic valve replacement (TAVR) have a concomitant diagnosis of CA. CA-AS population suffers from reduced functional capacity and worse prognosis than AS patients. As the prognostic impact of TAVR in patients with CA-AS has been historically questioned and in light of recently published evidence, we aim to provide a comprehensive synthesis of the efficacy and safety of TAVR in CA-AS patients. Methods We performed a systematic review and meta-analysis of studies: 1) evaluating mortality with TAVR as compared to medical therapy in CA-AS patients, and 2) reporting complications and clinical outcomes of TAVR in CA-AS patients as compared to patients with AS alone. Results A total of 8 observational studies were identified, 4 of which reporting mortality with TAVR and 4 reporting complications and clinical outcomes after TAVR of patients with CA-AS compared with AS alone patients. In patients with CA-AS, the risk of mortality was lower with TAVR as compared to medical therapy (OR 0.23, 95% CI 0.07–0.73, I²=0%, P=0.001, number needed to treat=3). The safety profile of TAVR seems to be similar in patients with CA-AS as compared to those with AS alone, with comparable risks of stroke, vascular complications, life-threatening bleeding, acute kidney injury and 30-day mortality, although CA-AS was associated with a trend towards an increased risk of permanent pacemaker implantation (OR 1.93, 95% CI 0.91–4.09, I2=0%, P=0.085). CA is associated with a numerically higher rate of long-term mortality and rehospitalizations following TAVR in patients with CA-AS as compared to those with AS alone. Conclusions TAVR is an effective and safe procedure in CA-AS patients, with a substantial survival benefit as compared to medical therapy, and a safety profile comparable to patients with AS alone except for a trend towards higher risk of permanent pacemaker implantation.

The Prognostic Utility of Invasive Right Heart Catheterization in Patients Prior to Transcatheter Aortic Valve Replacement.

Invasive right heart catheterization (RHC) provides valuable prognostic information in cases of severe aortic stenosis, but is not done routinely prior to transcatheter aortic valve replacement (TAVR). Therefore, we sought to investigate the prognostic utility of pre-TAVR RHC for assessing outcomes post TAVR. This is a single-center, retrospective study of patients who underwent RHC prior to TAVR between June 2011 and March 2019. We evaluated abnormalities in the following variables as predictors of poor outcomes post TAVR: pulmonary capillary wedge pressure (PCWP), systolic pulmonary artery pressure (PASP), mixed venous oxygen saturation (MVO2), right ventricular stroke work index (RVSWI), and right atrial pressure (RAP). Cox proportional hazard regression models were used to assess the primary composite outcome of all-cause mortality and hospitalization for heart failure. A total of 522 patients (mean age, 83.5 ± 4.5 years; 49.4% women) with complete invasive hemodynamic data were included. At a median follow-up of 529.5 days, there were 127 deaths and 59 heart failure hospitalizations. On multivariate analysis, PCWP ≥15 mm Hg (hazard ratio [HR], 1.48; 95% confidence interval [CI], 1.02-2.07), PASP ≥50 mm Hg (HR, 1.66; 95% CI, 1.17-2.36), MVO2 ≤60% (HR, 1.42; 95% CI, 1.01-1.98), RVSWI ≥12 g•m/m²/beat (HR, 1.40; 95% CI, 1.004-1.94), and RAP ≥10 mm Hg (HR, 1.66; 95% CI, 1.09-2.51) were independent predictors of death or heart failure hospitalization. Preprocedural invasive RHC provides useful prognostic information. A comprehensive invasive hemodynamic assessment should be considered for risk stratification in patients undergoing TAVR.

Abstract 9220: Employing a Convolutional Neural Network Facilitates Unsupervised Clustering of Aortic Outflow Velocity Profiles from Patients With Severe Aortic Stenosis

Introduction: The aortic outflow velocity profile is key to diagnose severe aortic stenosis (AS), and its shape reflects both aortic valve obstruction and left ventricular contractility. Hypothesis: Hypothesizing that aortic outflow velocity profiles contain more valuable information than can be captured by the human eye, features of the complex geometry of Doppler tracings were extracted by a convolutional neural network (CNN) pre-trained on big data (transfer learning). Methods: After pre-training a CNN (VGG-16) on a large data set (ImageNet data set; 14 million images belonging to 1,000 classes), the convolutional part was employed to transform Doppler tracings to 1D arrays. Principal component analysis (PCA) and k-means clustering of those 1D arrays were performed, and association between cluster and 2-year all-cause mortality was hereinafter assessed. Among 366 eligible patients with pre-procedural echocardiography and right heart catheterization prior to transcatheter aortic valve replacement (TAVR) for severe AS, good quality Doppler tracings from 101 patients were analyzed. Results: Among 101 patients (mean age: 79.3 ± 6.78 years; 49 [48.5%] women), estimated 2-year survival was 83.0% (95% CI: 75.1-91.7%). The convolutional part of the pre-trained VGG-16 model in conjunction with PCA and k-means clustering distinguished 2 shapes of aortic outflow velocity profiles. Kaplan-Meier analysis revealed that mortality in patients from cluster 2 (n = 40 [39.6%]) was significantly increased (HR for 2-year mortality: 3 [95% CI: 1-8.9]). Apart from reduced cardiac output and mean aortic valve gradient (AVG mean ), patients from cluster 2 were also characterized by signs of pulmonary hypertension, impaired right ventricular function and right atrial enlargement. Conventional dichotomization according to AVG mean confirmed that patients with AVG mean &lt; 40 mmHg (n = 54 [53.5%]) decease earlier, but no statistical significance was reached (HR for 2-year mortality: 1.8 [95% CI: 0.59-5.2]). Conclusions: This is a proof-of-principle that transfer learning aids in agnostic interpretation of aortic outflow velocity profiles, thereby holding the promise to refine prognostic resolution for survival after TAVR.