Transaortic Valve Implantation Research Articles

Outcomes of the Transaortic Valve Implantation Procedure in North Cyprus

Outcomes of the Transaortic Valve Implantation Procedure in North Cyprus

Multi-modality cardiac image computing: A survey.

Multi-modality cardiac imaging plays a key role in the management of patients with cardiovascular diseases. It allows a combination of complementary anatomical, morphological and functional information, increases diagnosis accuracy, and improves the efficacy of cardiovascular interventions and clinical outcomes. Fully-automated processing and quantitative analysis of multi-modality cardiac images could have a direct impact on clinical research and evidence-based patient management. However, these require overcoming significant challenges including inter-modality misalignment and finding optimal methods to integrate information from different modalities. This paper aims to provide a comprehensive review of multi-modality imaging in cardiology, the computing methods, the validation strategies, the related clinical workflows and future perspectives. For the computing methodologies, we have a favored focus on the three tasks, i.e., registration, fusion and segmentation, which generally involve multi-modality imaging data, either combining information from different modalities or transferring information across modalities. The review highlights that multi-modality cardiac imaging data has the potential of wide applicability in the clinic, such as trans-aortic valve implantation guidance, myocardial viability assessment, and catheter ablation therapy and its patient selection. Nevertheless, many challenges remain unsolved, such as missing modality, modality selection, combination of imaging and non-imaging data, and uniform analysis and representation of different modalities. There is also work to do in defining how the well-developed techniques fit in clinical workflows and how much additional and relevant information they introduce. These problems are likely to continue to be an active field of research and the questions to be answered in the future.

PO-03-021 HIS BUNDLE PACING SUCCESS AND ELECTRICAL PARAMETERS STABILITY REGARDLESS OF THREE-DIMENSIONAL TRANSTHORACIC ECHOCARDIOGRAPHY LEAD LOCALIZATION

His bundle pacing (HBP) is the most physiological form of ventricular pacing. Few prospective studies have analyzed lead localization using imaging techniques and its relationship with electrical parameters and capture patterns. To examine the correlation between electrical parameters and lead localization using three-dimensional transthoracic echocardiography (3D-TTE). This single-center, prospective, nonrandomized clinical research study (January 2018-June 2020) included patients with an indication of permanent pacing, in whom 3D-TTE was performed to define lead localization as supravalvular or subvalvular. A total of 92 patients were included: 56.5% of leads were supravalvular and 43.5% were subvalvular (Figure 1), which resembles previous anatomic descriptions of autopsied hearts of His bundle localization within the triangle of Koch (ToK). Most of our patients (98.9%) did not need a right ventricular backup lead in addition to the His lead. Only in one patient, with alternating BBB after transaortic valve implantation, we implanted a backup lead. R-wave sensing was higher when the His lead was localized subvalvular instead of supravalvular. His lead localization was not associated with HBP threshold or impedance differences, nor with the two different HBP patterns of capture (Table 1). HBP was attempted in 56 patients with baseline broad QRS, and we successfully corrected the baseline conduction disturbance in 45 patients (80.4%); lead localization was not associated with the ability of HBP to correct baseline BBB. The median HBP threshold at implantation was 1.25 V [0.75–2] @0.4ms, with no differences depending on lead localization. The thresholds remained stable during the follow-up visits at 1 and 6 months, regardless of His lead localization. R-wave sensing showed a significant change at follow-up, with higher - but no clinically relevant - R-wave sensing compared to that at baseline, which was mainly observed in the subvalvular His leads (4mV at baseline and 4.3mV at 6-months, p<0.001). However, lead impedances in both positions were decreased at follow-up (median difference -110 Ω). Clinically relevant p-wave oversensing was not observed. Lead localization in relation to the tricuspid valve did not influence the electrical performance of HBPs. Wide anatomical variations of the His bundle within the ToK explain our findings, reinforcing the idea that the technique for HBP should be fundamentally guided by electrophysiological and not anatomical parameters.

Aortic valve replacement using a polytetrafluoroethylene leaflet valve in patients with a history of the Bentall–De Bono procedure: a case series

Objective: To analyze outcomes of 4 transcatheter aortic valve replacements using a polytetrafluoroethylene leaflet valve in patients with a history of the Bentall–De Bono procedure.Methods: We retrospectively analyzed a series of 4 cases. From February 2019 to March 2022 in Federal Center for Cardiovascular Surgery (Penza, Russia), patients with a history of the Bentall–De Bono procedure underwent transaortic aortic valve implantation of the MedLAB-CT balloon-expandable valve under cardiopulmonary bypass and cardioplegia. Valve No. 25 was implanted in 3 patients, and 1 patient received valve No. 23.Results: According to echocardiography, valve hemodynamic performance improved in the postoperative period: mean and peak pressure gradients were 11.5 and 24 mm Hg, respectively; the median value of effective orifice area was 1.9 cm2, while mitral regurgitation in all cases did not exceed grade 1. Median cardiopulmonary bypass and myocardial ischemia times were 59 and 31 minutes, respectively. There was no immediate and remote mortality. No complications were reported in the postoperative period.Conclusion: The proposed replacement of the valved conduit’s compromised part after the Bentall–De Bono procedure can significantly reduce the extent of surgery, cardiopulmonary bypass and myocardial ischemia times, as well as simplify the procedure. Received 1 December 2022. Revised 10 February 2023. Accepted 16 February 2023. Informed consent: The patient’s informed consent to use the records for medical purposes is obtained. Funding: The study did not have sponsorship. Conflict of interests: The authors declare no conflict of interest. Contribution of the authorsLiterature review: V.A. Karnakhin, I.D. PotopalskiyDrafting the article: V.V. Bazylev, A.B. Voevodin, I.D. Potopalskiy, V.A. KarnakhinCritical revision of the article: A.A. Kuznetsova, M.P. PatelSurgical treatment: V.V. Bazylev, A.B. VoevodinFinal approval of the version to be published: V.V. Bazylev, A.B. Voevodin, I.D. Potopalskiy, V.A. Karnakhin, M.P. Patel, A.A. Kuznetsova

Fluoroscopically guided vascular and cardiac transcatheter procedures: a comparison of occupational and patient dose by anatomical region

X-ray guided procedures are being performed by an increasing variety of medical specialties. Due to improvements in vascular transcatheter therapies, there is an increasing overlap of imaged anatomy between medical specialties. There is concern that non-radiology fluoroscopic operators may not have sufficient training to be well informed of the potential implications of radiation exposure and mitigation strategies to reduce dose. This was a prospective, observational, single center study to compare occupational and patient dose levels when imaging different anatomical regions during fluoroscopically guided cardiac and endovascular procedures. Occupational radiation dose was measured at the level of the temple of 24 cardiologists and 3 vascular surgeons (n = 1369), 32 scrub nurses (n = 1307) and 35 circulating nurses (n = 885). The patient dose was recorded for procedures (n = 1792) performed in three angiography suites. Abdominal imaging during endovascular aneurysm repair (EVAR) procedures was associated with a comparatively high average patient, operator and scrub nurse dose despite additional table-mounted lead shields. Air kerma was relatively high for procedures performed in the chest, and chest + pelvis. Higher dose area product and staff eye dose were recorded during procedures of the chest + pelvis due to the use of digital subtraction angiography to evaluate access route prior to/during transaortic valve implantation. Scrub nurses were exposed to higher average radiation levels than the operator during some procedures. Staff should be cognizant of the potentially higher radiation burden to patients and exposed personnel during EVAR procedures and cardiac procedures using digital subtraction angiography.

Evaluation of the Effect of Transcatheter Aortic Valve Implantation on Left Ventricular Function by 4-Dimensional Echocardiography.

Bene���cial e���ects of transaortic valve implantation on left ventricular hemodynamics and prognosis of patients have been demonstrated. Although left ventricular systolic and diastolic function following transaortic valve implantation procedure have been examined in previous studies, 4-dimensional echocardiographic parameters have not been extensively studied, especially in patients with preserved ejection fraction aortic stenosis. In our study, we planned to evaluate the e���ect of transaortic valve implantation on myocardial deformation using 4-dimensional echocardiography. A total of 60 consecutive patients who underwent transaortic valve implantation for severe aortic stenosis with preserved ejection fraction were prospectively enrolled in the study. Standard 2-dimensional echocardiography and 4-dimensional echocardiography were performed in all patients before and 6 months after the transaortic valve implantation procedure. Six months after valve implantation, signi���cant improvement was observed in global longitudinal strain (P < 0.001), spherical circumferential strain (P = 0.022), global radial strain (P = 0.008), and global area strain (P < 0.001). In the regression analysis, global area strain and absence of diabetes mellitus were determined as independent predictors to show a 10% increase in the left ventricular ejection fraction. In patients with preserved ejection fraction who underwent transaortic valve implantation, left ventricle deformation parameters have improved after 6 months, especially by using 4-dimensional echocardiography. The use of 4-dimensional echocardiography should be more common in daily practice.

INCIDENCE AND PREDICTORS OF PERMANENT PACEMAKER IMPLANTATION AFTER TRANS AORTIC VALVE IMPLANTATION (TAVI) – A SINGLE CENTER EXPERIENCE

Objectives: The objective of the study is to evaluate the incidence and predictors of permanent pacemaker (PPM) implantation in patients undergoing transaortic valve implantation (TAVI). Methodology: This study was conducted at the “National Institute of Cardiovascular Diseases (NICVD) Karachi, Pakistan”. All the consecutive patients who underwent TAVI between July 2015 and February 2020 were included in the study. Patient data were extracted from Hospital TAVI Registry. We included patients with severe symptomatic aortic stenosis (AS) with moderate to high surgical risk as per “society of thoracic surgeon score (STS)” and “EURO II score”, underwent TAVI. Patients were stratified into two groups based on the implantation of PPM, demographic characteristics, clinical characteristics, co-morbid conditions, valve pathology, and procedural characteristics were compared between both groups. Results: Among 100 patients included only 22 patients (22%) underwent PPM implantation. The indication for implantation of PPM for all patients was complete heart block. Clinical characteristics which shows statistical significance for PPM implantation are preprocedural left ventricular dysfunction (p=0.015), right bundle branch block (RBBB) p&lt;0.001, and left anterior hemiblock (p&lt;0.001) noted on ECG and post-deployment valve area post-procedure (p&lt;0.001). Multivariate analysis showed that pre-procedure RBBB and large post-deployment valve area are independent predictors for PPM implantation in Post TAVI patients. Conclusion: The incidence of PPM implantation in patients who underwent TAVI at NICVD is 22%. Preprocedural left ventricular dysfunction, RBBB, and post-procedure large post-deployment valve area were noted to be significant predictors for PPM implantation.

209 A COMMON CASE OF AORTIC STENOSIS IN A UNIQUE QUADRICUSPID ANATOMY: MANAGEMENT IN REAL LIFE

Abstract A 85-year-old lady with severe dyspnea presented in emergency dept. of our institution in Reggio Emilia last July. Typical signs and symptoms of heart failure were associated with high voltage at ECG and echocardiographic findings show a reduced EF (40%) with trans-aortic mean gradient of 42 mmHg, aortic valvular area of 0.8 cm2 and moderate aortic regurgitation. At CT scan analysis, a dismorphic quadricuspid aortic valve (QAV) was detected. This is a rare congenital heart disease generally unrelated to other cardiac abnormalities and usually diagnosed incidentally. Due to QAV stenosis rarity, many considerations in Trans Aortic Valve Implantation (TAVI) in QAV are unclear. Some individuals with QAV develop aortic regurgitation and rarely other cardiovascular complications such as aortic aneurysm. Because of its infrequency, it is difficult to characterize these patients and standardize their management. Tailored therapy is more than ever necessary. Our patient also had bicameral pacemaker for grade II Mobitz 2 atrioventricular blockage. At coronarography angiography mild atheromasia was detected; AngioCT reconstructions in figure 1 panel A and B show the presence of QAV. Severe wall atheromasia along the entire course of the aorta was also detected. A few days later the patient underwent the TAVI procedure. A coronary guidewire was positioned in right coronary artery in order to protect its ostium that was slightly lower and, as known from literature, QAV has a longer leaflet height and a shallower cusp depth. After implantation of a Balloon Expandable Valve, a chimney stenting was also performed. An excellent final result was achieved with a safe deployment and a 90/10 final position (last aortography frame in Figure 2, where both coronary arteries are well visible). Post-procedural echo follow-up showed a well functioning aortic prosthesis (with mean gradient of 9 mmHg). The case presented is particularly interesting mainly for three reasons: Extreme rarity of this condition that can be challenging especially in the elderly people with calcific valve affected by stenosis and regurgitation;Paucity of procedural data in literature on QAV;It is a real life management example with subsequent successful implantation of the BEV and chimney stenting in QAV;

Apixaban and Valve Thrombosis After Transcatheter Aortic Valve Replacement: The ATLANTIS-4D-CT Randomized Clinical Trial Substudy.

Subclinical obstructive valve thrombosis after transcatheter aortic valve replacement (TAVR) is of uncertain frequency and clinical impact. The aim of this study was to determine the effects of apixaban vs standard of care on post-TAVR valve thrombosis detected by 4-dimensional (4D) computed tomography. The randomized ATLANTIS (Anti-Thrombotic Strategy to Lower All Cardiovascular and Neurologic Ischemic and Hemorrhagic Events After Trans-Aortic Valve Implantation for Aortic Stenosis) trial demonstrated that apixaban 5mg twice daily was not superior to standard of care (vitamin K antagonists or antiplatelet therapy) after successful TAVR and was associated with similar safety but with more noncardiovascular deaths. Three months after randomization, 4D computed tomography was proposed to all patients to determine the percentage of patients with≥1 prosthetic valve leaflet with grade 3 or 4 reduced leaflet motion or grade 3 or 4 hypoattenuated leaflet thickening (the primary endpoint) in the intention-to-treat population. Seven hundred sixty-two participants had complete multiphase datasets and were included in the 4D computed tomographic analysis. The primary endpoint occurred in 33 (8.9%) and 51 (13.0%) patients in the apixaban and standard-of-care groups, respectively. It was reduced with apixaban vs antiplatelet therapy (OR: 0.51; 95%CI: 0.30-0.86) but not vs vitamin K antagonists (OR: 1.80; 95%CI: 0.62-5.25) (Pinteraction=0.037). The composite of death, myocardial infarction, any stroke, or systemic embolism at 1 year occurred in 10.7% (n=9 of 84) and 7.1% (n=48 of 178) of patients with and without subclinical valve thrombosis at 90days, respectively (HR: 1.68; 95%CI: 0.82-3.44). Apixaban reduced subclinical obstructive valve thrombosis in the majority of patients who underwent TAVR without having an established indication for anticoagulation. This study was not powered for clinical outcomes. (Anti-Thrombotic Strategy After Trans-Aortic Valve Implantation for Aortic Stenosis [ATLANTIS]; NCT02664649).

Transcatheter aortic valve implantation via transaortic surgical access

We report a case of an 80-years&amp;ndash;old patient with a severe, symptomatic aortic valve stenosis and history of ischemic heart disease, previously treated by coronary artery bypass graft surgery. The patient was contraindicated for conventional surgical aortic valve replacement (SAVR) due to advanced age and underlying comorbidity, therefore transcatheter aortic valve implantation (TAVI) has been offered. The access options for the procedure were restricted by the underlying generalized atherosclerosis process causing peripheral vessel disease. We have chosen transaortic access for the patient which in that case was the only possible option. The transaortic valve implantation was successful with satisfactory hemodynamic results, improvement in functional class heart failure of the patient and preserving the function and anatomy of the coronary artery bypass graft. This case report demonstrates that the lack of favorable transfemoral access for TAVI should not be a limitation by itself for the procedure, rather than be stimulus for searching and using new and alternative access for it.

The predictive role of fully revascularized coronary artery disease in patients undergoing transaortic valve implantation

In the modern days and the era of the rapid development of medical technology, the introduction of innovative invasive methods of treatment is gradually displacing traditional conventional surgery. In 2002 was performed the fi rst transcatheter implantation of an aortic valve. Over the next twenty years, with the advancement of technology and the accumulation of experience in clinical centers, transcatheter aortic valve implantation has become the standard in adult and high-risk patients with high-grade Ao stenosis. In a large percentage of cases enrolled under the transcatheter aortic valve protocol a concomitant ischemic heart disease is detected or known. Globally, there is no signifi cant difference in overall mortality on the thirtieth day after TAVI in patients with ischemic heart disease. However, the overall mortality was signifi cantly higher in one &amp;ndash; year follow - up of patients after transcatheter aortic valve implantation with underlying coronary pathology. We conducted a study comparing the number of late and early adverse events in patients with concomitant fully revascularized ischemic heart disease and those with insignifi cant coronary atherosclerosis. Based on the data collected, analyzed and summarized in our clinical center, fully revascularized ischemic heart disease does not increase the percentage of major adverse events after transcatheter aortic valve implantation. It can be considered when assessing the risk of transcatheter aortic implantation, as part of the individual approach for each case.

Advantages and disadvantages of drug challenge during electrophysiological study in patients with new left bundle branch block after transaortic valve implantation.

AimsElectrophysiological study (EPS) is recommended in case of new-onset persistent left bundle branch block (NOP-LBBB) after transaortic valve implantation (TAVI) to identify patients at high risk of delayed atrioventricular block (D-AVB). We evaluated the added value of drug challenge, after normal baseline EPS, to predict D-AVB in such patients.MethodsWe conducted a comparative single-centre study of two successive periods, during which we used baseline EPS alone (first period) or drug challenge in case of normal baseline EPS (second period), for patients with NOP-LBBB after TAVI. The primary endpoint was a composite of pacemaker use, documented D-AVB, cardiac syncope, sudden death, or delayed pacemaker implantation.ResultsAmong 736 patients with TAVI implantation between January 2016 and September 2019, 64 with NOP-LBBB were included. During the first period, 4/22 (18.2%) presented with a positive baseline EPS. After a mean (standard deviation [SD]) of 15.6 (8.3) months, 7/22 (31.8%) reached the primary endpoint. During the second period, 19/42 (45.2%) presented with a positive EPS. After a mean (SD) of 12.8 (3.5) months, 8/42 (19.0%) reached the primary endpoint. There was a tendency to increased sensitivity (42.9–87.5%; P = 0.12) and negative predictive value (77.8–95.7%; P = 0.15) of the EPS, respectively during the first to the second period. However, the specificity decreased (93.3–64.7%; P = 0.04).ConclusionDiagnostic yield improved with drug challenge in case of normal baseline EPS. However, the decrease in specificity led to a high rate of unnecessary pacemaker implantation.

Direct transaortic transcather valve-in-valve implantation into a mechanical aortic valve prosthesis during left ventricular assist device implantation: description of a surgical technique.

The presence of a mechanical aortic valve prosthesis is considered a relative contraindication for left ventricular assist device implantation (LVAD) due to the occurrence of thromboembolic events. Five patients were operated on for LVAD implantation with status post mechanical aortic valve implantation (n = 3 with status post Bentall procedure). After removal of the leaflets, a transcatheter balloon-expandable valve was placed within the mechanical ring in all patients. Three patients were discharged from hospital with a maximum follow-up of 3.3 years. Transaortic transcatheter valve implantation into a mechanical aortic valve during LVAD implantation is a feasible option. It reduces operative times and might also prevent thromboembolic events.

Cardiac computed tomography: beyond ischemic heart disease and preTAVI studies. Experience during a year in a second level hospital

Abstract Funding Acknowledgements Type of funding sources: None. Background Cardiac disease is generally evaluated by non-ionizing imaging exams, as echocardiogram or magnetic resonance (MRI) and cardiac computed tomography (cCT) is seldom performed due to radiation concerns, but this exam has some advantages as better spatial resolution or better assessment of calcifications. Depending on different cardiac procedures, radiation exposure to the patients varies. Published values ranged from 4 mSv approx. for coronary angiography alone to 15 mSv approx. if stenting and ventriculography are added. Apart from coronary angiography, cCT is usually performed to plan transaortic valve implantation (TAVI) but other indications exit. Methods we reviewed cCT performed during a year and selected those not performed to assess coronary stenosis or previous to TAVI procedure. Results There were 18 exams, 50% women, mean age 62.8 years (range 17 to 82). There were no inconclusive exams. There were 10 exams with diagnostic purpose, not for measuring different structures. Among them, suspected diagnosis was confirmed in 2 cases. Reasons to choose cCT were: better assessment of calcium (6 cases), better spatial resolution (11), contraindications to MRI (3: 1 due to claustrophobia, 2 due to intracardiac device). 3 exams had 2 reasons (better spatial resolution+ assessment of calcium). 4 exams were performed without contrast, only to assess calcification: 1 case the pericardium, 3 cases the aortic valve. In the rest, contrast was used, assessing coronary anatomy as well in 5 of them. Among them, calcification was also assessed in other 2 cases (pericardium in constrictive pericarditis and mitral annulus in a woman with previous coronary artery by-pass grafting in whom a new mitral intervention was planned). Mean Radiation exposure was 5.5 mSv (range 0.3 to 15.3). There were 9 prospective cases (4 women), with a mean age of 61.6 years (17 to 82 years). Radiation exposure was 1.9 mSv (0.3 to 5.9). Mean age in retrospective studies was 63.8 years (53 to 81). 5 women underwent a retrospective study. Radiation exposure in retrospective studies was 8.7 mSv (3.9 to 15.3). There were no complications. We can see images from the prospective and retrospective studies in figures 1 and 2 respectively. Conclusions Although is seldom performed, cCT can be used safely to assess different cardiac structures. In different cases in which other imaging techniques is not enough, cCT is a good option to evaluate different structures or ventricular function. Several structures can be assessed in the same exploration.

Minimizing Population Health Loss in Times of Scarce Surgical Capacity During the Coronavirus Disease 2019 Crisis and Beyond: A Modeling Study

ObjectivesCoronavirus disease 2019 has put unprecedented pressure on healthcare systems worldwide, leading to a reduction of the available healthcare capacity. Our objective was to develop a decision model to estimate the impact of postponing semielective surgical procedures on health, to support prioritization of care from a utilitarian perspective. MethodsA cohort state-transition model was developed and applied to 43 semielective nonpediatric surgical procedures commonly performed in academic hospitals. Scenarios of delaying surgery from 2 weeks were compared with delaying up to 1 year and no surgery at all. Model parameters were based on registries, scientific literature, and the World Health Organization Global Burden of Disease study. For each surgical procedure, the model estimated the average expected disability-adjusted life-years (DALYs) per month of delay. ResultsGiven the best available evidence, the 2 surgical procedures associated with most DALYs owing to delay were bypass surgery for Fontaine III/IV peripheral arterial disease (0.23 DALY/month, 95% confidence interval [CI]: 0.13-0.36) and transaortic valve implantation (0.15 DALY/month, 95% CI: 0.09-0.24). The 2 surgical procedures with the least DALYs were placing a shunt for dialysis (0.01, 95% CI: 0.005-0.01) and thyroid carcinoma resection (0.01, 95% CI: 0.01-0.02). ConclusionExpected health loss owing to surgical delay can be objectively calculated with our decision model based on best available evidence, which can guide prioritization of surgical procedures to minimize population health loss in times of scarcity. The model results should be placed in the context of different ethical perspectives and combined with capacity management tools to facilitate large-scale implementation.

RETRACTED: Preoperative evaluation of tavi for aortic stenosis based on embedded system and dual-source CT large-pitch scanning

Trans Aortic Valve Implantation (TAVI) catheter veins in the upper bit of the legs and chest by embedding a catheter; it consolidates the aortic valve. By then, coordinate the catheter, which is used to ensure the replacement valve on top of the old. Reachability before CT imaging of the third through the aortic valve implanted in the (Dual-Source Computed Tomography) DSCT scanner age wide-show TAVI method is used to evaluate the precision of the image quality and contrast decline volume show. Computed Tomography (CT ) scanner called the wide show, and TAVI appraisal of the total amount of contrast pro channel shows and 50 ml. A visual score of 4 centers (4–1) will be used to survey the image's idea. Distinction decreasing worth and Contrast-To-Noise Ratio (CNR) is the aortic root, climbing/plunging aorta is assessed in the aorta of unusual levels, it has left the right level and femoral flexibly course. To evaluate the coronary passageway tree, it is differentiated and coronary angiography. Assessments of the aortic valve annulus, to break down, is the result of the latest frameworks. Creatinine of the patient is checked at design; it chipped away at the following 72 h.

NGAL in trans-catheter aortic valve implantation on and off RenalGuard

Introduction: Acute kidney injury (AKI) is a well-known complication post invasive cardiac procedures. RenalGuard system has been shown to reduce the risk of AKI in high-risk patients by evacuating iodine-based contrast material rapidly. Neutrophil gelatinase-associated lipocalin (NGAL) is a glycoprotein stored in granules of mature neutrophils and is released to the blood stream due to acute tubular damage. This report examined the biomarker as a sub study of the randomized sham control study REDUCE-AKI in the setting of Trans-Aortic Valve Implantation (TAVI). Methods: Venous blood was drawn from 27 patients. Blood was drawn at designated time intervals: before the procedure, after 12 hours and after 24 hours. Patients were randomly allocated to active versus sham RenalGuard activity. Results: There was no difference between baseline and 24 hours levels in NGAL values (ng/mL) in the sham group (median 70.3 IQ 21.5, 176.6) versus the active group (median 46.9, IQR 1.3, 127.7) (P = 0.259). There was also no association between NGAL and clinical complications. Conclusion: Forced diuresis with matched hydration does not prevent AKI in patients undergoing TAVI and measuring NGAL correlates with these findings.

Impact of mitral annular calcification associated mitral stenosis on clinical outcomes in patients undergoing transcatheter aortic valve implantation

Abstract Introduction Mitral annular calcification (MAC) is a common finding in patient undergoing transaortic valve implantation (TAVI) and can cause significant mitral stenosis (MS). Purpose To assess the impact of MAC associated with significant MS (MAC-MS) on clinical outcomes following TAVR. Methods Consecutive patients undergoing TAVI in our institution between January 2008 and May 2018, were evaluated. All echocardiogram exams before intervention were analysed to identify the presence of MAC and MAC was confirmed on computed tomography (CT) scans. Patients were included in the MAC group if there was any calcification on the mitral annulus on CT scan. Severe MAC was considered as calcification of the mitral annulus involving over 50% of the circumference. Patients with a mitral mechanical valve or bioprosthesis and without CT scan available to confirm MAC were excluded (n=62). MAC-MS was defined as the association of MAC and a mean transmitral gradient over 5 mmHg. Results Among 1177 consecutive finally included patients, 504 (42.8%) had MAC and 85 had a MAC-MS (7.2%, 16.9% among the MAC population). Compared to MAC without MS (MAC non-MS group) and non-MAC patients, patients with MAC-MS were more frequently women (p&amp;lt;0.0001), had a greater BMI (p=0.002), more previous pacemaker implantation (p=0.035), smaller indexed aortic valve area and left ventricular end systolic diameter (p=0.019 and p=0.038). At 30-days after TAVR, there were no differences in stroke, major vascular complication and pacemaker implantation between groups. However, MAC-MS patients had higher rates of tamponade [Odd Ratio adjusted 3.12, 95% confidence interval (CI) 1.08–9.07, p=0.036] and mortality [Adjusted hazard Ratio (HRa) 2.83, 95% CI 1.39–5.76, p&amp;lt;0.005] after adjustment on baseline characteristics. At 1 year, patients with MAC-MS had a higher risk of death [19 (22.1%) vs. 142 (13%); HRa 1.83, 95% CI 1.14–3.03, p=0.01] compared to MAC non-MS and non-MAC patients. Severe MAC was not a predictor of 1 year mortality. Conclusions Mitral stenosis due to mitral annular calcification is infrequent in patient undergoing TAVI but is associated with higher early and mid-term mortality. Funding Acknowledgement Type of funding source: None

Patients undergoing urgent trans-aortic valve implantation suffer from an increased mortality rate

Abstract Introduction Information on the outcome of urgent Transcatheter valve implantations (TAVI) is scarce, but available data suggest that it could be a reasonable option for the treatment of decompensated severe aortic valve stenosis. The prospects of an all-comer urgent population, however, are unknown. Here we report our experience with clinically indicated urgent TAVI implantation in an unselected patient population with severe aortic valve stenosis (AS). Purpose To compare the outcome of patients undergoing urgent or elective TAVI and to identify potential predictors of outcome. Methods A retrospective, single centre study of AS patients undergoing femoral or apical TAVI between 01. 01.2013 and 30.09.2018 was performed. Demographic information, medical history, clinical and procedural data were collected from the local electronic database. Urgent implantation was defined as accelerated, in-hospital patient preparation and urgent device placement following an acute admission. Survival was investigated with Kaplan-Meier survival analysis and log-rank test. Regression analysis was performed to identify possible predictors of mortality. Results During the study period TAVI was performed in 631 patients, of whom 53 (8.4%) underwent urgent TAVI. In the case of urgent procedures, the median admission-to-procedure time was 18 [10–29] days. Age, gender and the prevalence of diabetes mellitus, chronic obstructive lung disease (COPD) and a glomerular filtration rate of ≤30ml/min was comparable among the groups. Patients in the urgent group had a lower BMI (26 [23–28] vs. 27 [24–30]; p&amp;lt;0.05), had more frequently an ejection fraction &amp;lt;30% (30% vs 4%p&amp;lt;0.001) and a higher Euroscore II (5.3 [3.4–10.9]% vs 2.9 [1.7–4.5]%; p&amp;lt;0.001). The rate of apical implantation and post-operative stroke, pacemaker implantation and renal failure did not differ between the groups. Urgent patients, however, needed longer post-procedural hospitalization (6 [4–9] vs 4 [3–6] days; p&amp;lt;0.001) and had higher in-hospital (11.3% vs 3,1%; &amp;lt;0.001) and one-year mortality rates (28.3% vs 8.5%; p&amp;lt;0.001). Urgency was an independent predictor of overall one-year mortality (HR 3.0, p=0.001) and worsened the survival of the individuals who were discharged from the hospital (out-of-hospital mortality at one-year; HR 2.8, p=0.011), but had no effect on in-hospital mortality. In-hospital mortality was mainly determined by apical access (OR 3.1; p=0.016) and major post-operative stroke (OR 8.8.; p=0.006), with both worsening overall 1-year survival too (HR 1.8 for apical access and 4.8 for stroke; p&amp;lt;0.05). Mortality after a successful hospital discharge was increased not only by urgency (HR 2.8, p=0.011), but by COPD (HR 2.1; p=0.04) and prolonged post-operative hospitalization (HR 1.05/day; p=0.001) as well. Conclusion Stabilizing AS patients can mitigate the effect of urgency on peri-procedural survival. Urgency remains, however, an important determinant of one-year TAVI outcome. Funding Acknowledgement Type of funding source: None

Electrocardiographic and clinical predictors for permanent pacemaker requirement after transcatheter aortic valve implantation: a 10-year single center experience.

The aim of this study is to identify clinical, electrocardiographic (ECG) and procedural predictors for permanent pacemaker (PPM) requirement after transaortic valve implantation (TAVI). All consecutive patients with severe symptomatic aortic stenosis (SSAS) undergoing TAVI at our single center were included in the study and prospectively followed. All patients had standard 12-leads ECGs recordings before and after TAVI and continuous ECG monitoring during hospital stay. Primary endpoint was to identify electrocardiographic predictors of PPM implantation after TAVI; secondary endpoint was to ascertain other clinical or procedure-related predictive factors of PPM need. PPM implantation was further arbitrarily divided into early and late one (beyond the 3rd day). Among the 431 patients undergoing TAVI between 2008 and 2018, 77 (18%) needed PPM implantation; 47 (11%) had an early procedure, and 30 (7%) a late implant. Preoperative right bundle branch block (RBBB) implies more than five-fold increase of the risk of PPM implantation (OR 5.19, CI 1.99-13.56, P=0.001), whereas the use of a self-expandable prosthesis is associated with an almost three-fold increase of the risk (OR 2.60, CI 1.28-5.28, P=0.008). In the late PPM implantation subgroup, only the history of syncope retains a significant association with such an increased risk (OR 2.71, CI 1.09-6.75, P=0.032). The need of a PPM in the individual TAVI patient is hardly predictable. However, the finding of pre-existing RBBB, the use of self-expandable prosthesis and history of syncope can individuate patients at increased risk.