Transcatheter Aortic Valve Implantation Operators Research Articles

Transcatheter Aortic Valve Therapy for Bicuspid Aortic Valve Stenosis.

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

Contemporary European practice in transcatheter aortic valve implantation: results from the 2022 European TAVI Pathway Registry.

A steep rise in the use of transcatheter aortic valve implantation (TAVI) for the management of symptomatic severe aortic stenosis occurred. Minimalist TAVI procedures and streamlined patient pathways within experienced Heart Valve Centres are designed to overcome the challenges of ever-increasing procedural volume. The 2022 European TAVI Pathway Survey aims to describe contemporary TAVI practice across Europe. Between October and December 2022, TAVI operators from 32 European countries were invited to complete an online questionnaire regarding their current practice. Responses were available from 147 TAVI centres in 26 countries. In 2021, the participating centres performed a total number of 27,223 TAVI procedures, with a mean of 185 TAVI cases per centre (median 138; IQR 77-194). Treatment strategies are usually (87%) discussed at a dedicated Heart Team meeting. Transfemoral TAVI is performed with local anaesthesia only (33%), with associated conscious sedation (60%), or under general anaesthesia (7%). Primary vascular access is percutaneous transfemoral (99%) with secondary radial access (52%). After uncomplicated TAVI, patients are transferred to a high-, medium-, or low-care unit in 28%, 52%, and 20% of cases, respectively. Time to discharge is day 1 (12%), day 2 (31%), day 3 (29%), or day 4 or more (28%). Reported adoption of minimalist TAVI techniques is common among European TAVI centres, but rates of next-day discharge remain low. This survey highlights the significant progress made in refining TAVI treatment and pathways in recent years and identifies possible areas for further improvement.

Operator preference and determinants of size selection when additional intermediate-size aortic transcatheter heart valves are made available

BackgroundAppropriate size selection of transcatheter heart valves (THVs) is fundamental to reduce transcatheter aortic valve implantation (TAVI) related complications, particularly paravalvular aortic regurgitation, new permanent pacemaker implantation, and annular rupture. We sought to investigate the frequency of operator selection of intermediate-size balloon-expandable Myval THVs (Meril Life Sciences Pvt. Ltd., India) for TAVI in a real-world dataset. MethodsIn this retrospective survey of patients treated with TAVI using the Myval THV, 20, 23, 26, and 29 mm are conventional-size THVs, 21.5, 24.5 and 27.5 mm are intermediate-size THVs, and 30.5 and 32 mm are extra-large THVs. Operator size selection for implantation was based on multislice computed tomography (MSCT) derived aortic-root dimensions. ResultsA total of 1115 patients underwent Myval THV implantation in 27 countries worldwide. The Myval intermediate-size THVs were used in 468 (42.0%) patients. MSCT data were available in 562 patients. There was no statistical difference between the Intermediate/Upsized and Appropriately sized groups or Intermediate/Downsized and Appropriately sized groups in terms of different variables measured with MSCT except for annular dimensions and degree of calcification. ConclusionsIntermediate-size Myval balloon-expandable THVs are used in nearly half of all cases in contemporary real-world TAVI practice, addressing the unmet need of TAVI operators for a more calibrated THV choice. Our hypothesis should be tested in randomized prospective studies currently initiated in Europe, including clinical outcomes of patients treated with both conventional- and intermediate-size THVs.

Management of access site vascular complications in transcatheter aortic valve implantation

Since its advent, transcatheter aortic valve implantation (TAVI) has experienced a continuous expansion, thanks to extraordinary clinical results and to the dramatic increase of safety, enabled by improvements of prosthesis and delivery systems, refinement of implantation techniques, increasing operator experience, and use of computed tomography scan for procedural planning. However, complications rates are still not negligible. As vascular complications, and, particularly, access-related complications are among the most frequent adverse events, all TAVI operators should know how to prevent and how to manage those potentially catastrophic situations. Here we provide an overview of the most frequent access site vascular complications and the respective treatment options.

Long-Term Follow-Up of Transcatheter Aortic Valve Implantation With Portico Versus Evolut Devices

New-generation devices such as Evolut and Portico have provided favorable results in patients who underwent transcatheter aortic valve implantation (TAVI) for aortic stenosis, but their comparative effectiveness remains debated, despite its relevance when envisioning TAVI in low-risk patients. We evaluated the safety and efficacy of 2 leading TAVI devices (Evolut and Portico) used by the same team of experienced TAVI operators, focusing on long-term outcomes, including major adverse events (i.e., the composite of death, stroke, myocardial infarction, major vascular complication, or major bleeding). Unadjusted and propensity score-adjusted analyses were carried out. A total of 233 patients were included, 119 (51.1%) receiving Evolut and 114 (49%) Portico. Baseline and procedural data showed significant between-device differences, including functional class, surgical risk, chronic obstructive pulmonary disease, renal function, transesophageal guidance, device size, postdilation, and procedural time (all p <0.05). Yet, acute and in-hospital outcomes were not significantly different (all p >0.05). Follow-up status was ascertained in 228 (98%) patients after 15.0 ± 7.6 months. Unadjusted analysis showed similar rates of major adverse events, as well as the individual risk of death, stroke, myocardial infarction, major vascular complication, major bleeding, and pacemaker implantation (all p >0.05). Even at propensity score-adjusted analysis outcomes were not significantly different with Evolut and Portico (all p >0.05). In conclusion, Evolut and Portico devices yield similarly favorable results at long-term follow-up when used by experienced TAVI operators.

Transcatheter Treatment of Bicuspid Aortic Valve Disease: Imaging and Interventional Considerations.

Patients with bicuspid aortic valve disease have systematically been excluded from large randomized clinical trials investigating transcatheter aortic valve implantation (TAVI) due to their younger age, lower surgical risk and complex aortic anatomy. The asymmetric nature of the bicuspid valve orifice often accompanied by heavy regional calcification has led to concerns regarding valve positioning and expansion. Bicuspid aortic valve disease patients are at heightened risk of TAVI-related complications including coronary occlusion, aortic dissection and annular rupture, as well as the known risks of progressive aortopathy in these patients. These unique anatomical characteristics pose challenges for TAVI operators. However, with recent and ongoing refinements in implantation technique, improvements in pre-procedural imaging and iterations in device design, TAVI is emerging as a safe and feasible treatment option in this population. Paravalvular aortic regurgitation and high pacemaker rates have been the Achilles Heel for TAVI in bicuspid valve patients, yet newer generation devices are yielding promising results. Further studies are required before TAVI ultimately emerges as a viable option in low and intermediate surgical-risk patients with bicuspid valve disease. This review comprehensively summarizes the epidemiology, pathology and current evidence for TAVI in patients with bicuspid aortic valve disease. We also outline some practical tips for performing TAVI in these patients.

Alternate Access for TAVI: Stay Clear of the Chest.

Transcatheter aortic valve implantation (TAVI) is currently performed through an alternative access in 15% of patients. The transapical access is progressively being abandoned as a result of its invasiveness and poor outcomes. Existing data does not allow TAVI operators to favour one access over another - between transcarotid, trans-subclavian and transaortic - because all have specific strengths and weaknesses. The percutaneous trans-subclavian access might become the main surgery-free alternative access, although further research is needed regarding its safety. Moreover, the difficult learning curve might compromise its adoption. The transcaval access is at an experimental stage and requires the development of dedicated cavo-aortic crossing techniques and closure devices.

Transcatheter aortic valve implantation operators - get involved in imaging!

Pre-procedural planning is the key element of transcatheter aortic valve implantation (TAVI). Multislice computed tomography of the chest, abdomen and pelvis with the ability to perform a 3-dimensional reconstruction has become the cornerstone of pre-procedural planning. We would like to encourage TAVI operators (interventional cardiologist and surgeons) to get involved in imaging. All TAVI operators should know how to assess the annulus, the annular root, and the iliofemoral access. We strongly believe that this will improve outcomes of this evolving procedure.

Impact of rapid ventricular pacing during TAVI on microvascular tissue perfusion

Rapid ventricular pacing (RVP) is an established technique to temporarily reduce left ventricular output during transcatheter aortic valve implantation (TAVI). The purpose of this study was to evaluate the impact of RVP on microvascular tissue perfusion (MTP) in patients undergoing TAVI. We studied 42 patients (mean age 81.8±6.9years, n=18 females. EuroSCORE 33±12%) during TAVI. MTP was analyzed using Sidestream-Darkfield imaging, of the sublingual microvasculature. Microvascular flow index (MFI) was continuously measured in small (10-25μm)- and medium (26-50μm)-sized vessels, starting 10s before and ending 12s after RVP. Further, perfused capillary density, total vessel density and the proportion of perfused vessels were assessed. After a mean RVP duration of 14.3s (range 6-29), mean arterial pressure decreased from 68±05 to 40±7mmHg (p<0.001). This was associated with a significant decrease of MFI in small- and medium-sized vessels from 2.29±0.64 and 2.36±0.6 to 0.87±0.66 (p<0.001) and 1.0±0.83 (p<0.001), respectively. MFI remained significantly below baseline values (small: 1.75±0.8, p=0.001 vs. baseline; medium: 1.77±0.85; p=0.005 vs. baseline) at 12s after end of RVP. The study demonstrates a time-dependent effect of RVP on microflow, leading to 50 and 25% of baseline at 8 and 18s of RVP, respectively. In a substantial proportion of patients, RVP is associated with microcirculatory arrest and a delayed recovery of microflow. Although the impact of these findings on outcome is yet unclear, TAVI operators should be aware of the potentially adverse effects of even short periods of RVP.

98 Lack of Consensus on Anti-thrombotic Therapy in Patients Undergoing Tavi – an Online Survey from Uk Tavi Operators

IntroductionThe incidence of cerebrovascular ischaemic events during and early after Trans-catheter Aortic Valve Implantation (TAVI) procedure remains a major concern. Peri-procedural events may be due to embolization of calcified material...

A method to determine suitable fluoroscopic projections for transcatheter aortic valve implantation by computed tomography

In transcatheter aortic valve implantation (TAVI), optimal selection of fluoroscopic projections that permit orthogonal visualization of the aortic valve plane is important but may be difficult to achieve. We developed and validated a simple method to predict suitable fluoroscopic projections on the basis of cardiac CT datasets. In 75 consecutive patients that underwent TAVI, angulations in which a 35-mm thick maximum intensity projection would render all aortic valve calcium into 1 plane were determined by manual interaction with contrast-enhanced dual-source CT datasets. TAVI operators used the predicted angulation for the first aortic angiogram and performed additional aortic angiograms if no satisfactory view of the aortic valve plane was obtained. Predicted angulations were compared with the angulation used for valve implantation. Radiation exposure and contrast use was compared between patients with accurate prediction of fluoroscopic angulations by CT and patients in whom CT failed to predict a suitable view. The mean difference between the predicted angulation according to CT and the angulation used for implantation was 3 ± 6 degrees. CT predicted a suitable angulation (<5-degree deviation) in 63 of 75 cases (84%). The mean number of aortic angiograms acquired in patients with correct prediction (1.02 ± 0.1) was significantly lower than in patients with incorrect prediction of the implantation angle by CT (3.0 ± 1.7; P < 0.001). Contrast agent required for the entire TAVI procedure was lower in patients with correct prediction (72 ± 36 mL vs 106 ± 39 mL; P = 0.001). CT permits prediction of suitable angulations for TAVI in most cases.

Transcatheter Aortic Valve Implantation: A Canadian Cardiovascular Society Position Statement

Patients with severe symptomatic aortic stenosis have a poor prognosis with medical management alone, and balloon aortic valvuloplasty has failed to provide durable clinical benefit. Open surgical replacement of the aortic valve can improve symptoms and survival. Recently, transcatheter aortic valve implantation (TAVI) has been demonstrated to improve survival, quality of life, and functional status in nonoperable patients and to be a viable option for patients in whom the risk of open surgical morbidity or mortality is high. This Canadian Cardiovascular Society position statement represents the consensus of a representative group of cardiologists and cardiac surgeons as to the current, but evolving, role of this less-invasive new therapy. Specific recommendations are provided for selection of patients for TAVI vs surgical aortic valve replacement for native valves and for bioprostheses, approaches to patient evaluation for TAVI, appropriate constitution of multidisciplinary teams involved in performing TAVI, essential facilities that are needed to perform TAVI safely and effectively, and training/qualifications for TAVI operators. Cost considerations, complication rates, and the quality of the available evidence are also discussed. It is hoped that this consensus document will prove to be a useful resource for health professionals, institutions, departments, and decision-making bodies dealing with this important and rapidly evolving therapy.

Abstract 17754: Accuracy of Dual Source Computed Tomography to Predict Suitable Angulations for Fluoroscopic Guidance During Transcatheter Aortic Valve Implantation (TAVI)

For Transcatheter Aortic Valve Implantation (TAVI), optimal selection of fluoroscopic projections is important and often requires multiple aortic angiograms in various angulations. We analyzed the ability of Dual Source CT (DSCT) to predict suitable angulations for fluoroscopy during the TAVI procedure, including influence on procedural parameters and contrast use. Methods: 75 consecutive patients who underwent TAVI using the Edwards-Sapien valve were evaluated. Possible angulations which would render an orthogonal view onto the aortic valve plane were determined by interactive evaluation of pre_procedural contrast-enhanced DSCT data sets acquired during i.v. injection of 40ml contrast agent. TAVI operators used a predicted angulation for the first aortic angiogram and performed additional aortic angiograms if no satisfactory view of the valve plane was obtained. Predicted angulations were compared to the angulation used for valve implantation. Differences of less than 5° (sum of LAO-RAO and CRAN-CAUD deviation) were considered as accurate prediction. Radiation exposure and contrast use was compared between patients with accurate prediction of fluoroscopic angulations by CT versus those in whom CT failed to predict a suitable view. Aortic valve calcifum was visually quantified in CT as mild, moderate, severe. Results: TAVI was successful in all 75 patients. The mean difference between the CT-predicted angulation and the angulation used for implantation was 3±6°. CT predicted a suitable angulation in 63/75 cases (84%). The number of aortic angiograms acquired in patients with correct prediction (1.02±0.1) was lower than in patients with incorrect prediction (3.0±1.7, p &lt; 0.001). Similarly, the amount of contrast agent required for the entire TAVI procedure was lower in patients with correct prediction (72±36ml vs. 106±39 ml, p = 0.001). Extensive calcifications of the aortic valve were associated with a lower frequency of correct prediction (100% for mild, 89% for moderate, and 71% for severe calcification, p = 0.03). Conclusion: CT allows prediction of suitable fluoroscopy angulations during TAVI in the majority of cases, which significantly reduces the required amount of contrast.