Transcatheter Aortic Valve Implantation For Aortic Stenosis Research Articles

Right ventricular to pulmonary artery coupling in patients with different types of aortic stenosis undergoing TAVI.

Right ventricular (RV) dysfunction in patients undergoing transcatheter aortic valve implantation (TAVI) for aortic stenosis (AS) has long been disregarded. We aimed to assess the predictive value of RV to pulmonary artery coupling (RV/PAc), defined as tricuspid annular plane systolic excursion to systolic pulmonary artery pressure, on mortality in different flow types of AS after TAVI. All patients undergoing TAVI for AS at our centre between 2018 and 2020 were assessed; 862 patients were analysed. The cohort was dichotomized using a ROC analysis (cut-off 0.512mm/mmHg), into 429 patients with preserved and 433 patients with reduced RV/PAc. Reduced RV/PAc was associated with male sex and a higher rate of comorbidities. Short-term VARC-3 endpoints and NYHA classes at follow-up were comparable. Reduced RV/PAc was associated with higher 2-year all-cause mortality (35.0% [30.3-39.3%] vs. 15.4% [11.9-18.7%], hazard ratio 2.5 [1.9-3.4], p < 0.001). Cardiovascular mortality was almost tripled. Results were consistent after statistical adjustment and in a multivariate model. Sub-analyses of AS flow types revealed lower RV/PAc in classical and paradoxical low-flow low-gradient AS, with the majority having reduced RV/PAc (74% and 59%). RV/PAc retained its predictive value in these subgroups. RV dysfunction defined by low RV/PAc is a strong mortality predictor after TAVI independent of flow group. It should be incorporated in future TAVI risk assessment.

The Prognostic Significance of Uric Acid/Albumin Ratio in Patients with Aortic Stenosis Following Transcatheter Aortic Valve Implantation for Major Adverse Cardiac and Cerebral Events.

Background: The goal of this study was to examine if the uric acid/albumin ratio (UAR) could predict major adverse cardiac and cerebral events (MACCEs) such as stroke, readmission, and short-term all-cause death in aortic stenosis (AS) patients, after transcatheter aortic valve implantation (TAVI). Material and Methods: A total of 150 patients who had TAVI for AS between 2013 and 2022 were included in our study, retrospectively. Before the TAVI, each patient's baseline uric acid/albumin was determined. The study's major endpoint was MACCEs, which included stroke, re-hospitalization, and 12-month all-cause death. Results: The UAR was found to be higher in TAVI patients who developed MACCEs than in those who did not develop them. Multivariate Cox regression analysis revealed that the UAR (HR: 95% CI; 2.478 (1.779-3.453) p < 0.01), was an independent predictor of MACCEs in AS patients after TAVI. The optimal value of the UAR for MACCEs in AS patients following TAVI was >1.68 with 88% sensitivity and 66% specificity (AUC (the area under the curve): 0.899, p < 0.01). We noted that the AUC of UAR in predicting MACCEs was significantly higher than the AUC of albumin (AUC: 0.823) and uric acid (AUC: 0.805, respectively). Conclusion: MACCEs in AS patients who received TAVI may be predicted by high pre-procedural uric acid/albumin levels. The uric acid/albumin ratio (UAR) can be used to determine MACCEs in such patients following TAVI because it is inexpensive and straightforward to calculate inflammatory parameters.

Supra-Annular Sizing for Prediction of THV Expansion in Bicuspid Aortic Valves: A MSCT Study

ABSTRACT Background Multislice computed tomography (MSCT) is the most common sizing method for transcatheter aortic valve implantation (TAVI) in the bicuspid aortic valve (BAV). It is unclear whether annular and supra-annular dimensions could predict final prosthesis diameter and expansion. This study aimed to identify baseline MSCT measurement that could predict the geometry of the transcatheter heart valve (THV) in BAV patients undergoing TAVI for symptomatic aortic stenosis (AS). Methods One hundred and two BAV patients undergoing TAVI for AS were included in this observational, retrospective, single-center study. Pre- and post-TAVI MSCT were compared. On pre and post MSCT, means of perimeter-derived diameter (PdD) and ellipticity indexes were measured at the annular plane and 4 mm and 8 mm above, and intercommissural distance (ICD) at 4 and 8 mm. Results Comparison of pre- and post-TAVI PdDs at 3 levels showed that pre-TAVI PdD at +4 mm was comparable to post-TAVI PdD at annulus (24.2 ± 2.6 mm vs. 24.0 ± 2.7 mm; p = 0.87; mean difference: 0.04; SD: 2.54; 95% CI: −0.46; 0.54) and at +4 mm (24.2 ± 2.6 mm vs. 23.7 ± 2.5 mm; p = 0.16; mean difference: 0.36; SD: 2.60; 95% CI: −0.15; 0.87). All other comparisons showed significant difference between pre and post dimensions, with reduction in post-TAVI THV dimensions, as compared to baseline measurements, suggesting underexpansion. Pre- and post-TAVI ellipticity indexes comparison showed significant reduction in post-TAVI ellipticity indexes at 3 levels, suggesting a more circular THV geometry. Conclusion In BAV, supra-annular PdD at 4 mm was comparable to post-TAVI THV PdDs. THV underexpansion and anatomical reshaping occurred after TAVI in BAV. Abbreviations AS, aortic stenosis; BAV, bicuspid aortic valve; ICD, intercommissural distance; MSCT, multislice computed tomography; PdD, perimeter-derived diameter; STS, Society of Thoracic Surgeons score; TAVI, transcatheter aortic valve implantation; THV, transcatheter heart valve.

Valve-in-valve transcatheter aortic valve implantation after failed surgically implanted aortic bioprosthesis versus native transcatheter aortic valve implantation for aortic stenosis: Data from a nationwide analysis

Valve-in-valve transcatheter aortic valve implantation (TAVI) has emerged as a treatment for aortic bioprosthesis failure in case of prohibitive risk for redo surgery. However, clinical evaluation of valve-in-valve TAVI remains limited by the number of patients analysed. To evaluate outcomes of valve-in-valve TAVI compared with native aortic valve TAVI at a nationwide level in France. Based on the French administrative hospital discharge database, the study collected information for all consecutive patients treated with TAVI for aortic stenosis or with isolated valve-in-valve TAVI for aortic bioprosthesis failure between 2010 and 2019. Propensity score matching was used for the analysis of outcomes. A total of 44,218 patients were found in the database. After matching on baseline characteristics, 2749 patients were analysed in each arm. At 30 days, no significant differences were observed regarding the occurrence of major clinical events (composite of cardiovascular mortality, all-cause stroke, myocardial infarction, major or life-threatening bleeding and conversion to open heart surgery) (odds ratio [OR] 0.83, 95% confidence interval [CI] 0.68-1.01; P=0.32). During follow-up (mean 516 days), the combined endpoint of cardiovascular death, all-cause stroke or rehospitalization for heart failure was not different between the valve-in-valve TAVI and native TAVI groups (RR 1.03, 95% CI 0.94-1.13; P=1.00). We observed that valve-in-valve TAVI was associated with good short- and long-term outcomes. No significant differences were observed compared with native valve TAVI regarding clinical follow-up.

Meta-analysis of impact of troponins on mortality after transcatheter aortic valve implantation.

To determine whether troponin (Tn) can predict mortality after transcatheter aortic valve implantation (TAVI), we performed a meta-analysis of currently available studies investigating impact of baseline and postprocedural Tn. MEDLINE and EMBASE were searched through April 2019 using PubMed and OVID. Studies considered for inclusion met the following criteria: the study investigating impact of baseline and postprocedural Tn on mortality; the study population was patients undergoing TAVI for aortic stenosis (AS); outcomes included early (30-day or in-hospital)/late (including early) mortality. For each study, data regarding early/late mortality in both high and low (defined in each study) level of baseline/postprocedural Tn groups were used to generate odds ratios (ORs) and 95% confidence intervals (CIs), or reported ORs and hazard ratios (HRs) with 95% CIs were directly extracted. Study-specific estimates were combined using inverse variance-weighted averages of logarithmic ORs/HRs in the random-effects model. We identified 19 eligible studies including a total of 7555 patients undergoing TAVI. Pooled analyses demonstrated associations of high levels of baseline Tn with statistically significant increases in both 30-day (P=0.002) and midterm mortality (P<0.00001), no correlation of high postprocedural Tn with 30-day mortality (P=0.13), and an association of high postprocedural Tn with a statistically significant increase in midterm mortality (P=0.002). High levels of baseline/postprocedural TnT predicted statistically significant increases in both 30-day (P=0.002/<0.0001) and midterm mortality (P<0.00001/0.0003). Both baseline and postprocedural Tn, especially TnT, may predict mortality after TAVI for AS.

A meta-analysis of impact of mitral stenosis on outcomes after transcatheter aortic valve implantation.

To determine whether concomitant mitral stenosis (MS) impairs outcomes after transcatheter aortic valve implantation (TAVI) in patients with severe aortic stenosis (AS), we performed a meta-analysis of currently available evidence. To identify all observational comparative studies of outcomes after TAVI for AS in patients with MS vs patients with no-MS, we searched databases (MEDLINE and EMBASE) using web-based search engines (PubMed and OVID). Studies meeting the following criteria were included; the design was an observational study; the study population was patients undergoing TAVI for AS; outcomes in patients with MS were compared with those in patients with no-MS. Study-specific estimates were then pooled using inverse variance-weighted averages of logarithmic odds and hazard ratios in the random-effects model. We identified six eligible studies including 111 621 patients undergoing TAVI. In pooled analyses, postprocedural incidence of ≥ moderate paravalvular aortic regurgitation (PAR) (P = .02), early all-cause mortality (P = .008), early incidence of myocardial infarction (MI) (P = .01), and midterm all-cause mortality (P = .03) after TAVI were significantly higher in patients with MS than in patients with no-MS. There were no significant differences in early incidence of stroke, major bleeding, acute kidney injury, and new permanent pacemaker implantation after TAVI between patients with MS and patients with no-MS. When the study for mitral annular calcification was excluded in the pooled analyses, no results except for MI were substantially altered but the significance for early incidence of MI disappeared (P = .10). Postprocedural incidence of ≥ moderate PAR, early all-cause mortality, early incidence of MI, and midterm all-cause mortality after TAVI are higher in patients with MS than in patients with no-MS.

Meta-Analysis of Impact of Baseline N-TerminalPro-Brain Natriuretic Peptide Levels on SurvivalAfter Transcatheter Aortic Valve Implantation for Aortic Stenosis

We performed a meta-analysis of currently available studies investigating impact of baseline N-terminal pro-brain natriuretic peptide (NT-proBNP) on mortality after transcatheter aortic valve implantation (TAVI) for aortic stenosis (AS). MEDLINE and EMBASE were searched through August 2018 using PubMed and OVID. Studies considered for inclusion met the following criteria: the design was a study researching impact of baseline NT-proBNP levels on survival; the study population was patients underwent TAVI for AS; outcomes included all-cause mortality. For each study, we directly extracted odds ratio (ORs) or hazard ratios (HRs) of mortality (for high vs low baseline NT-proBNP); and generated ORs using mortality rates in both patients with high and low levels of baseline NT-proBNP. Study-specific estimates were combined using inverse variance-weighted averages of logarithmic ORs/HRs in the random-effects model. We identified 16 eligible studies including a total of 3,679 patients who underwent TAVI for AS. Pooled analyses demonstrated that high levels of baseline NT-proBNP were associated with a statistically nonsignificant increase in early (30-day or 2-month) mortality (pooled OR, 1.60; 95% confidence interval, 0.84 to 3.04; p = 0.15) and a statistically significant increase in midterm (6-month to 4-year) mortality (pooled OR/HR, 1.88; 95% confidence interval, 1.54 to 2.28; p < 0.00001). Although funnel-plot asymmetry suggesting publication bias was detected, adjusting for funnel-plot asymmetry indicated an association of high levels of baseline NT-proBNP with a still significant increase in midterm mortality. In conclusion, high levels of baseline NT-proBNP predict increased midterm, not early, mortality after TAVI for AS.

Effect of body mass index on clinical outcome and all-cause mortality in patients undergoing transcatheter aortic valve implantation.

ObjectivesTo assess the effect of body mass index (BMI) on outcome among patients with severe aortic stenosis (AS) admitted for transcatheter aortic valve implantation (TAVI).BackgroundBeing overweight or obese is associated with improved outcome following certain medical treatments, suggesting the existence of a BMI paradox. However, the relationship between BMI and mortality after TAVI remains controversial.MethodsPatients were classified according to World Health Organisation criteria such as normal weight, overweight, or obesity according to their BMI (18.5 to 24.9 kg/m2, 25.0 to 29.9 kg/m2, and ≥30.0 kg/m2, respectively).ResultsA total of 549 consecutive patients (age: 80.2 ± 7.5 years; logistic European system for cardiac operative risk evaluation [EuroSCORE]: 17.3 ± 9.9%) who underwent TAVI for AS were included. Of these patients, 43% (n = 237) had normal weight, 36% (n = 200) were overweight, and 20% (n = 112) were obese. There were no differences in peri-operative bleeding or vascular complication rates between the groups. All-cause mortality after 30 days, and 1 year, were higher in normal weight patients compared with overweight and obese patients (7% vs. 5 and 4%, p = 0.383, and 19% vs. 9 and 10%, p = 0.006, respectively). After adjustment for several confounding factors, overweight was associated with a decreased 30-day and 1‑year all-cause mortality outcome (hazard ratio [HR] 0.69; 95% confidence interval [CI] 0.47–0.99, and HR 0.65; 95% CI 0.45–0.94, respectively).ConclusionsDespite the well-documented adverse effects of increased body weight on health, being overweight is associated with improved survival following TAVI when compared with normal weight.

Transcatheter aortic valve implantation in patients with small aortic annuli using a 20 mm balloon-expanding valve

BackgroundWhile transcatheter aortic valve implantation (TAVI) is established for treating high-operative risk surgical aortic valve replacement candidates, until recently the smallest transcatheter heart valve (THV) measured 23 mm, posing greater...

Coexisting Mitral Regurgitation Impairs Survival After Transcatheter Aortic Valve Implantation

It remains unclear whether coexisting and untreated mitral regurgitation (MR) affects survival after transcatheter aortic valve implantation (TAVI) for aortic stenosis (AS). To summarize contemporary evidence, we performed the first metaanalysis of adjusted observational studies reporting post-TAVI mortality in patients with various grades of MR. MEDLINE and EMBASE were searched until February 2015, with a bibliographic review of secondary sources. Eligible studies were observational studies enrolling patients undergoing TAVI for AS and reporting adjusted odds ratios (ORs), hazard ratios (HRs), or both for early (30-day or in-hospital) all-cause mortality, overall all-cause mortality, or both in patients with apparent (significant) versus unapparent (nonsignificant) MR as outcomes. Sixteen eligible studies enrolling a total of 13,672 patients undergoing TAVI for AS were identified and included. Pooled analyses of eight studies (representing 9,356 patients) and 14 studies (representing 7,405 patients) respectively demonstrated a statistically significant increase in early (OR 2.17; 95% confidence interval [CI] 1.50 to 3.14; p < 0.0001) and overall all-cause mortality (HR 1.81; 95% CI 1.37 to 2.40; p < 0.0001) in patients with apparent relative to unapparent MR. The exclusion of any single study from the analyses did not substantively alter the overall results of our analyses, and there was no evidence of significant publication bias. Coexisting and untreated apparent (usually moderate or severe) MR appears to be associated with an increase in both early and overall mortality after TAVI for AS.

Echocardiographic evaluation of cardiac function response to removal of aortic stenosis: Surgical and trans-catheter aortic valve implantation (TAVI)

&lt;p&gt;Aortic stenosis (AS) is the commonest valve disease in the&lt;/p&gt;&lt;p&gt;West, with a prevalence varying between 0.02% in adults&lt;/p&gt;&lt;p&gt;under 44 years and 3-9% in those over 80 years of age &lt;span&gt;1, 2&lt;/span&gt;. The&lt;/p&gt;&lt;p&gt;disease may remain “silent” and hence unnoticed for years,&lt;/p&gt;&lt;p&gt;particularly in the elderly with naturally limited exercise. With the&lt;/p&gt;&lt;p&gt;development of symptoms, patients may carry a mortality of&lt;/p&gt;&lt;p&gt;36-52%, 52-80% and 80-90% at 3, 5 and 10 years, respectively&lt;/p&gt;&lt;p&gt;if left untreated, with a potential high risk of sudden death &lt;span&gt;3&lt;/span&gt;.&lt;/p&gt;&lt;p&gt;Surgical aortic valve replacement (SAVR) used to be the only&lt;/p&gt;&lt;p&gt;effective treatment for severe AS, being the second indication&lt;/p&gt;&lt;p&gt;for open heart surgery after coronary artery bypass grafting&lt;/p&gt;&lt;p&gt;(CABG) &lt;span&gt;4&lt;/span&gt;. Trans-catheter aortic valve implantation (TAVI) is a&lt;/p&gt;&lt;p&gt;recently developed procedure which aims at non-surgical AVR&lt;/p&gt;&lt;p&gt;in patients with severe, symptomatic and calcified AS who&lt;/p&gt;&lt;p&gt;are at high surgical risk because of either poor left ventricular&lt;/p&gt;&lt;p&gt;(LV) function, ejection fraction (EF) &amp;lt;50%, or other significant&lt;/p&gt;&lt;p&gt;co-morbidities e.g. age &amp;gt;80 years, previous CABG surgery and/&lt;/p&gt;&lt;p&gt;or aorta or other heart valve surgery, impaired kidney function,&lt;/p&gt;&lt;p&gt;chronic obstructive pulmonary disease (COPD) or pulmonary&lt;/p&gt;&lt;p&gt;hypertension &lt;span&gt;5&lt;/span&gt;. Currently, this technique is not recommended&lt;/p&gt;&lt;p&gt;in bicuspid AS patients due to the risk of incomplete and&lt;/p&gt;&lt;p&gt;suboptimal deployment of the aortic prosthesis [6]. TAVI&lt;/p&gt;&lt;p&gt;avoids open heart surgery and hence is likely to protect&lt;/p&gt;&lt;p&gt;myocardial function. The purpose of this paper is to review the&lt;/p&gt;&lt;p&gt;echocardiographic evaluation of LV, right ventricular (RV), and&lt;/p&gt;&lt;p&gt;left atrial (LA) function response to SAVR and TAVI for AS.&lt;/p&gt;

Do Edwards SAPIEN valves fit to the annulus?

Congratulations to the authors for this valuable study [1]. In this paper, it was stated that it was controversial whether the measurements regarding the aortic annulus should be made from the virtual annulus or the coronal hinge-to-hinge while deciding on transcatheter aortic valve implantation (TAVI). As seen in Figure 1d, the prosthetic valve sits on the thick aortic leaflet in TAVI for aortic stenosis. This means that thick leaflets may obstruct the coronary orifices during deployment of the prosthetic valve after opening the valve in order to fit the annulus. Instead of measuring the annulus, one should take into consideration the orifice area, three-dimensional configuration of the aortic leaflets (including leaflet thickness), desired orifice area and from where the orifice area could be gained. The leaflet thickness is an important issue and as seen in Figure 2e, the right side of the valve stent is so close to the aortic wall that it may obstruct the coronary ostium. When five patients with paravalvular leak were investigated, it was found out that Edwards-Sapien valves were inserted in smaller sizes (26, 23, 23, 23 and 23-mm) than the measured virtual ring diameters (28.2, 27.4, 26.9, 25.8 and 26.8 mm). However, no paravalvular leak was observed in patients with maximum virtual ring diameters measured with multislice computed tomography (26.8, 28.5, 28.9, 29 and 27 mm) who received Edwards-Sapien valves of 26-mm. This finding supports our theory. This topic was investigated in the ‘Discussion’ section and it indicates the inappropriateness of the measurement method of calculated average annulus diameter (CAAD). The aortic orifice area increased from 0.7 to 3.6 cm with TAVI. The risk of leaflet rupture is high at the point of least firmness. This has nothing to do with aortic stenosis as seen in Figure 4b. The preand post-TAVI measurements in Table 2 showed no significant differences. Our opinion is that there is no correlation between the TAVI procedure and the measurement methods. We must clarify that the following CAAD measurement is wrong: