Transcatheter Aortic Valve Implantation Implantation Research Articles

Differences in circulating blood volume changes during emergence from general anesthesia in transcatheter aortic valve implantation and MitraClip implantation.

We aimed to compare changes in the circulating blood volume (CBV) during emergence from general anesthesia in patients undergoing transcatheter aortic valve implantation (TAVI) and MitraClip implantation. We included 97 patients who underwent TAVI or MitraClip implantation. The primary outcome was the rate of change in the estimated CBV associated with emergence from general anesthesia. The secondary outcomes were hemoglobin and hematocrit values before and after emergence from anesthesia for each procedure. Additionally, the independent factors associated with changes in the estimated CBV were assessed using multiple regression analysis. In the TAVI group, the hemoglobin concentration increased from 9.6g/dL before emergence from anesthesia to 10.8g/dL after emergence (P < 0.001; mean difference, 1.2g/dL, 95% confidence interval [CI] 1.1-1.3g/dL). Conversely, no statistically significant change was observed in the hemoglobin concentration before and after emergence from anesthesia in the MitraClip group. The mean rate of change in the estimated CBV was - 15.4% (standard deviation [SD] 6.4%) in the TAVI group and - 2.4% (SD, 4.7%) in the MitraClip group, indicating a significant decrease in the estimated CBV in the former than in the latter (P < 0.001; mean difference, 13.0%; 95% CI 9.9-16.1%). Emergence from general anesthesia increased the hemoglobin concentration and decreased the estimated CBV in patients undergoing TAVI but did not elicit significant changes in patients undergoing MitraClip implantation. These results may provide a rationale for minimizing blood transfusions during general anesthesia in patients undergoing these procedures.

Angulation and curvature of aortic landing zone affect implantation depth in transcatheter aortic valve implantation

In transcatheter aortic valve implantation (TAVI), final device position may be affected by device interaction with the whole aortic landing zone (LZ) extending to ascending aorta. We investigated the impact of aortic LZ curvature and angulation on TAVI implantation depth, comparing short-frame balloon-expanding (BE) and long-frame self-expanding (SE) devices. Patients (n = 202) treated with BE or SE devices were matched based on one-to-one propensity score. Primary endpoint was the mismatch between the intended (HPre) and the final (HPost) implantation depth. LZ curvature and angulation were calculated based on the aortic centerline trajectory available from pre-TAVI computed tomography. Total LZ curvature (kLZ,tot\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$${k}_{LZ,tot}$$\\end{document}) and LZ angulation distal to aortic annulus (αLZ,Distal\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$${\\alpha }_{LZ,Distal}$$\\end{document}) were greater in the SE compared to the BE group (P < 0.001 for both). In the BE group, HPost was significantly higher than HPre at both cusps (P < 0.001). In the SE group, HPost was significantly deeper than HPre only at the left coronary cusp (P = 0.013). At multivariate analysis, αLZ,Distal\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$${\\alpha }_{LZ,Distal}$$\\end{document} was the only independent predictor (OR = 1.11, P = 0.002) of deeper final implantation depth with a cut-off value of 17.8°. Aortic LZ curvature and angulation significantly affected final TAVI implantation depth, especially in high stent-frame SE devices reporting, upon complete release, deeper implantation depth with respect to the intended one.

Coronary Flow Reserve and Myocardial Resistance Reserve Changes After Transcatheter Aortic Valve Implantation in Aortic Stenosis

Aortic valve stenosis (AS) induces an alteration in hemodynamic conditions that are responsible for coronary microvasculature impairment. Relief of AS by transcatheter aortic valve implantation (TAVI) is expected to improve the coronary artery hemodynamic. We aimed to assess the midterm effects of TAVI in coronary flow reserve (CFR) and myocardial resistance reserve (MRR) by a continuous intracoronary thermodilution technique. At-rest and hyperemic coronary flow was measured by a continuous thermodilution technique in 23 patients with AS and compared with that in 17 matched controls, and repeated 6 ± 3 months after TAVI in 11 of the patients with AS. In patients with AS, absolute coronary flow at rest was significantly greater, and absolute resistance at rest was significantly less, than in controls (p <0.01 for both), causing less CFR and MRR (1.73 ± 0.4 vs 2.85 ± 1.1, p <0.01 and 1.95 ± 0.4 vs 3.22 ± 1.4, p <0.01, respectively). TAVI implantation yielded a significant 35% increase in CFR (p >0.01) and a 39% increase in MRR (p <0.01) driven by absolute coronary flow at rest reduction (p = 0.03). In patients with AS, CFR and MRR determined by continuous thermodilution are significantly impaired. At 6-month follow-up, TAVI improves these indexes and partially relieves the pathophysiologic alterations, leading to a partial restoration of CFR and MRR.

Mini-Aortic Valve Replacement versus Transcatheter Aortic Valve Implantation: A Propensity-Matched Study

Background. Total sternotomy for aortic valve replacement has been superseded by less invasive approaches such as mini-sternotomy or transcatheter procedures. There has been an exponential uptake in transcatheter aortic valve implantation (TAVI) in younger and lower risk patients following recent randomized trials. This study aims to compare the outcomes of patients with aortic stenosis treated with minimally invasive approaches: mini-sternotomy for aortic valve replacement (mini-AVR) and TAVI implantation. Methods. Between January 2015 and December 2021, a total of 1437 TAVI and 176 mini-AVR patients from 2 tertiary centers fulfilled the criteria and were included in the propensity matching model. Results. A total of 256 TAVIs and 146 mini-AVR were included in the matched cohort. There was no significant difference in 30-day mortality in the two groups (TAVI vs. mini-AVR 2.7% vs. 2.8%, p = 0.935 ). TAVI confers slightly lower gradients in the follow-up echo when compared with mini-AVR (peak gradient 20 ± 8.7 mmHg vs. 24.5 ± 10 mmHg, p &lt; 0.001 ; mean gradient 10.9 ± 5.6 mmHg vs. 13.2 ± 5.7 mmHg, p &lt; 0.001 ). On the other hand, mini-AVR exhibits remarkably lower rates of paravalvular leak (mild leak 8% vs. 41.5%, p &lt; 0.001 ; moderate leak 2.8% vs. 0%, p &lt; 0.001 ) and of need for permanent pacemaker implantation (2% vs. 12.2%, p &lt; 0.001 ). Unsurprisingly, TAVI has lower in-hospital stay 3 (2 to 6) days vs. 10 (8 to 13) days, p &lt; 0.001 ). Conclusions. For eligible aortic stenosis patients in the 7th decade of life, mini-AVR remains an excellent therapeutic option.

Early acute kidney injury after transcatheter aortic valve implantation: predictive value of currently available risk scores.

Acute kidney injury (AKI) after transcatheter aortic valve implantation (TAVI) is a frequent complication associated with adverse outcomes and mortality. Various scores have been developed to predict this complication in the coronary setting. However, none have ever been tested in a large TAVI population. This study aimed to evaluate the power of four different scores in predicting AKI after TAVI. Overall, 1535 consecutive TAVI patients from the observational multicentric "Magna Graecia" TAVI registry were included in the analysis. Of the study population, 235 (15.31%) developed AKI early. The Mehran, William Beaumont Hospital, CR4EATME3AD3, and ACEF scores were calculated retrospectively. The patients who developed TAVI-related AKI had significantly higher absolute values of all risk scores than those who did not. The receiver-operating characteristic analysis also showed a significant correlation between these four scores and AKI, but without a significant difference among all of them (p value=0.176). Nevertheless, based on their area under the curve values (≤0.604 for all), none had adequate diagnostic accuracy in predicting TAVI-related AKI. Importantly, multivariate analysis identified myocardial revascularization close to the TAVI procedure and implantation of self-expanding prostheses, as well as atrial fibrillation, low-osmolar contrast media administration, corrected contrast medium volume, and any transfusion (p value<0.05 for all) as independent risk factors for AKI. Although high values of current AKI risk scores are significantly associated with the development of this complication, these are not sufficiently accurate. Further studies are needed so that a TAVI-dedicated AKI risk score may be created.

Endovascular Technique for Ascending Aorta Repair Based on TEVAR and TAVI Procedures

Purpose: Ascending aorta (AAo) acute pathology still has an open-surgery indication with a high mortality rate associated to cardiopulmonary bypass and circulatory arrest. In these cases, the endovascular aortic approach could be an excellent option. The aim of the present study is to detail an optimized technique for the endovascular treatment of AAo diseases, based on thoracic endovascular aortic repair (TEVAR) and transcatheter aortic valve implantation (TAVI) procedures. Technique: The procedure implies the usual preparation for TEVAR and TAVI implants. A transient pacemaker lead is necessary to deliver the prosthesis under “rapid pacing.” As in the TAVI technique, a final high-support guidewire is placed at the left ventricle. The proximal landing zone is the sinotubular junction (zone 0B). Transesophageal echocardiography is essential to ensure aortic valve function and patency in coronary arteries during the delivery. To assess a potential occlusion of the brachiocephalic artery, a guidewire is positioned in the descending aorta from the axillary artery. Finally, a noncovered stent is implanted to stabilize the AAo prosthesis. Conclusion: The technique presented here can standardize a safe and reproducible procedure to endovascular repair of AAo diseases. However, new devices specifically designed for the AAo could facilitate the transcatheter approach. Clinical Impact Ascending aorta acute pathology still has an open-surgery indication with high mortality rate associated to cardiopulmonary bypass and circulatory arrest. Moreover, near 30% of patients are not considered suitable for surgery because of age, critical situation or the presence of severe comorbidities. The present study provides a detailed and optimized technique for the endovascular treatment of ascending aorta disease, based on TEVAR and TAVI procedures.

Eight-year single-center experience with transcatheter aortic valve implantation (TAVI)

The first TAVI implantation was performed in 2002 by Cribier and colleagues. From then, we have seen significant progress in technology, with the appearance of new generations &amp;ndash; lower-profile, longer-lasting and more stable during positioning TAVI prostheses. The present publication presents single-center results and experience with TAVI procedures over an eight-year period. During the period 2013 &amp;ndash; November 2022 a total of 354 TAVI procedures were performed in Acibadem City Clinical Cardiovascular Center. Two operating strategies are used &amp;ndash; standard and minimalist approach. From the first procedure in 2013 until mid-2018 the standard approach (surgical vascular access, general anesthesia, direct valve implantation where possible) was mostly used. Then, the minimalist approach (percutaneous access, no intubation anesthesia, mandatory valve predilation and use of rapid pacing) was introduced as a standard approach in the center.

Cost-effectiveness of transcatheter aortic valve implantation in patients with severe symptomatic aortic stenosis of intermediate surgical risk in Singapore

ObjectiveThe objective was to assess the cost-effectiveness of transcatheter aortic valve implantation (TAVI) in patients with severe aortic stenosis with intermediate surgical risk in Singapore.MethodsA de novo Markov model with three health states – stroke with long-term sequelae, no stroke, and death – was developed and simulated using Monte Carlo simulations with 10,000 iterations over a five-year time horizon from the Singapore healthcare system perspective. A 3% annual discount rate for costs and outcomes and monthly cycle lengths were used. By applying the longest available published clinical evidence, simulated patients received either TAVI or surgical aortic valve replacement (SAVR) and were at risk of adverse events (AEs) such as moderate-to-severe paravalvular aortic regurgitation (PAR).ResultsWhen five-year PARTNER 2A data was applied, base-case analyses showed that the incremental cost-effectiveness ratio (ICER) for TAVI compared to SAVR was US$315,760 per quality-adjusted life year (QALY) gained. The high ICER was due to high incremental implantation and procedure costs of TAVI compared to SAVR, and marginal improvement of 0.10 QALYs as simulated mortality of TAVI exceeded SAVR at 3.75 years post-implantation. One-way sensitivity analysis showed that the ICERs were most sensitive to cost of PAR, utility values of SAVR patients, and cost of TAVI and SAVR implants and procedures. When disutilities for AEs were additionally applied, the ICER decreased to US$300,070 per QALY gained. TAVI was dominated by SAVR when the time horizon increased to 20 years. Clinical outcomes projected from one-year PARTNER S3i data further reduced the ICER to US$86,337 per QALY gained for TAVI, assuming early all-cause mortality benefits from TAVI continued to persist. This assumption was undermined when longer term data showed that TAVI’s early mortality benefits diminished at five years.Limitations and conclusionTAVI is unlikely to be cost-effective in intermediate surgical-risk patients compared to SAVR in Singapore.

Acute Kidney Injury after Transcatheter Aortic Valve Implantation

Aim. The aim of the study was to evaluate the incidence and predictors of acute kidney injury (AKI) associated with transcatheter aortic valve implantation (TAVI).Material and methods. 50 patients (39 women, 11 men) aged 76 (71; 80) years who underwent TAVI were examined. One day after TAVI, blood creatinine level was determined by the Jaffe method and troponin I by a highly sensitive method (hs-cTnI). Acute kidney injury (AKI) was diagnosed according to the KDIGO criteria (2012). The following hospital complications were evaluated: cases of cardiac death, intraoperative myocardial infarction (MI), stroke and transient ischemic attack, permanent pacemaker implantation, recurrent paroxysms of atrial fibrillation.Results. History of MI had 22% of patients, percutaneous coronary intervention – 38%, hypertension – 98%, chronic kidney disease – 48%, diabetes mellitus – 24%, class II NYHA of chronic heart failure (CHF) – 52%, NYHA class III – 46%, NYHA class IV – 2%. The risk of operational mortality according to EuroSCORE II was 6.3±5.4%. AKI after TAVI was registered in 6 (12%) patients (1 grade AKI – 8%, 2 grade – 2%, 3 grade – 2%). Parameters associated with AKI after TAVI were higher CHF NYHA class (p=0,020), high hs-cTnI level (p=0,013), intraoperative MI (p=0.035). The predictor of AKI after TAVI was high hs-cTnI level (odds ratio 4.0, 95% confidence interval 1.0-16.1). Among patients with AKI after TAVI in compare with patients without AKI, the cumulative frequency of cardiac death, MI, strokes and transient ischemic attacks, implantation of a permanent pacemaker, the proportion of people with paroxysmal atrial fibrillation during the hospital stay was 5,8 times higher (66.7% vs 11.4% respectively, p=0.001).Conclusion. AKI after TAVI was present in 12% of patients. The predictor for AKI development was an increase in hs-cTnI level after TAVI implantation. The hospital prognosis after TAVI is worse in patients with postoperative AKI.

Occurrence and Persistency of Conduction Disturbances during Transcatheter Aortic Valve Implantation.

Background and Objectives: Conduction disturbances such as left bundle branch block (LBBB) and complete atrio-ventricular block (cAVB) are relatively frequent complications following trans-catheter aortic valve implantation (TAVI). We investigated the dynamics of these conduction blocks to further understand luxating factors and predictors for their persistency. Materials and Methods: We prospectively included 157 consecutive patients who underwent a TAVI procedure. Electrocardiograms (ECGs) were obtained at specific time points during the TAVI procedure and at follow-up until at least six months post-procedure. Results: Of the 106 patients with a narrow QRS complex (nQRS) before TAVI, ~70% developed LBBB; 28 (26.4%) being classified as super-transient (ST-LBBB), 20 (18.9%) as transient (T-LBBB) and 24 (22.6%) as persistent (P-LBBB). Risk of LBBB was higher for self-expandable (SE) than for balloon-expandable (BE) prostheses and increased with larger implant depth. During the TAVI procedure conduction disturbances showed a dynamic behavior, as illustrated by alternating kinds of blocks in 18 cases. Most LBBBs developed during balloon aortic valvuloplasty (BAV) and at positioning and deployment of the TAVI prosthesis. The incidence of LBBB was not significantly different between patients who did and did not undergo BAV prior to TAVI implantation (65.3% and 74.2%, respectively (p = 0.494)). Progression to cAVB was most frequent for patients with preexisting conduction abnormalities (5/34) patients) and in patients showing ST-LBBB (6/28). Conclusions: During the TAVI procedure, conduction disturbances showed a dynamic behavior with alternating types of block in 18 cases. After a dynamic period of often alternating types of block, most BBBs are reversible while one third persist. Patients with ST-LBBB are most prone to progressing into cAVB. The observation that the incidence of developing LBBB after TAVI is similar with and without BAV suggests that a subgroup of patients has a substrate to develop LBBB regardless of the procedure.

Alineamiento comisural preciso durante el TAVI con ACURATE neo. Prueba de concepto

Introduction and objectivesFinal position of the neo-commissures is uncontrolled during transcatheter aortic valve implantation (TAVI), potentially hindering coronary access and future procedures. We aimed to develop a standard method to achieve commissural alignment with the ACURATE neo valve. MethodsThe relationship between native and TAVI neo-commissures was analyzed in 11 severe aortic stenosis patients undergoing TAVI. Based on computed tomography analysis, an in silico model was developed to predict final TAVI commissural posts position. A modified implantation technique, accurate commissural alignment (ACA) and a dedicated delivery system were developed. TAVI implants were tested in 3-dimensional (3D) printed models and in vivo. Commissural misalignment and coronary overlap (CO) were analyzed. ResultsThe in silico model accurately predicted final position of commissural posts irrespective of the implantation technique performed (correlation coefficient, 0.994; 95%CI, 0.989-0.998; P<.001). TAVI implant with patient-specific rotation was simulated in 3D printed models and in 9 patients. ACA-oriented TAVI implants presented adequate commissural alignment in vivo (mean commissural misalignment of 7.7 ±3.9°). None of the ACA oriented implants showed CO, whereas in silico conventional implants predicted CO in 6 of the 9 cases. ConclusionsAccurate commissural alignment of the ACURATE neo device is feasible by inserting the delivery system with a patient-specific rotation based on computed tomography analysis. This is a simple and reproducible method for commissural alignment that can be potentially used for all kinds of TAVI devices.

Influence of aortic valve tilt angle on flow patterns in the ascending aorta

Transcatheter aortic valve implantation (TAVI) has become the alternative procedure to high-risk patients who are diagnosed with aortic valve stenosis. Differently from the traditional open-chest surgical procedure, a small variation on the prosthetic aortic valve deployment angle is expected with the TAVI procedure. The hemodynamic patterns of the blood flow in the ascending aorta are related to the development of many cardiovascular diseases. There are, however, few data available in the literature correlating the aortic valve tilt angle to hemodynamic effects. In this work, a 3D printed aorta model made of a transparent silicon resin was produced, based on the anatomy of a specific patient submitted to a TAVI procedure. The stereoscopic Particle Image Velocimetry technique was employed to measure three-component velocity fields at closely spaced cross-sectional planes, along the ascending aorta. The measurements were performed for a constant flow rate corresponding to the peak of the systolic phase of the cardiac cycle. Averaged velocity fields and turbulent quantities were determined for both, the base case, with no valve tilt, and for cases with an inclination of 4° and 8°, oriented at the four anatomical directions of the human body reference system, namely anterior, posterior, right and left. The results revealed the dominant flow patterns in the ascending aorta formed by a jet-like inlet flow impinging on the curved aorta right wall, inducing a significant eccentricity on the axial velocity profile. Regions of reverse flow were identified and linked to the abrupt area change associated with the typical reduced inlet diameter of TAVI implants. The impinging flow and wall curvature effects established circulation patterns defining a helical flow structure. The influence of the inlet flow orientation on the flow turbulent characteristics was assessed by the spatial evolution of the turbulent kinetic energy (TKE), Reynolds and viscous stresses. The maximum values of TKE were found around the inlet jet boundaries and concentrated in the neighborhood of the right aorta wall where the eccentric axial flow prevailed. Spatial distributions of the maximum Reynolds stresses were similar to the TKE distributions and presented maximum stresses typically one order of magnitude higher than the maximum average viscous shear stresses. Maximum average viscous stress distributions were revealed at the jet-like flow boundaries and in the vicinity of the right wall, displaying moderate stress levels that, according to the literature, can be sufficient to produce cell damage and platelet activation. The complex nature of the flow field was revealed by streamlines obtained from the measured flow fields, allowing the identification of the influence of the inlet flow orientation and tilt angle on the position of the stagnation point on the aorta right wall, as well as the angle of incidence of the jet-like flow on the wall. A simple model based on momentum balance was used to estimate the pressure increment on the wall due to flow impingement. The model captured the influence of the inlet flow orientation, indicating that pressure increases of the order of 40% in relation to the base case condition were obtained for the 8°, left inlet flow orientation.

Accurate commissural alignment during ACURATE neo TAVI procedure. Proof of concept

Introduction and objectivesFinal position of the neo-commissures is uncontrolled during transcatheter aortic valve implantation (TAVI), potentially hindering coronary access and future procedures. We aimed to develop a standard method to achieve commissural alignment with the ACURATE neo valve. MethodsThe relationship between native and TAVI neo-commissures was analyzed in 11 severe aortic stenosis patients undergoing TAVI. Based on computed tomography analysis, an in silico model was developed to predict final TAVI commissural posts position. A modified implantation technique, accurate commissural alignment (ACA) and a dedicated delivery system were developed. TAVI implants were tested in 3-dimensional (3D) printed models and in vivo. Commissural misalignment and coronary overlap (CO) were analyzed. ResultsThe in silico model accurately predicted final position of commissural posts irrespective of the implantation technique performed (correlation coefficient, 0.994; 95%CI, 0.989-0.998; P<.001). TAVI implant with patient-specific rotation was simulated in 3D printed models and in 9 patients. ACA-oriented TAVI implants presented adequate commissural alignment in vivo (mean commissural misalignment of 7.7 ±3.9°). None of the ACA oriented implants showed CO, whereas in silico conventional implants predicted CO in 6 of the 9 cases. ConclusionsAccurate commissural alignment of the ACURATE neo device is feasible by inserting the delivery system with a patient-specific rotation based on computed tomography analysis. This is a simple and reproducible method for commissural alignment that can be potentially used for all kinds of TAVI devices.

Frailty is associated with chronic inflammation and pro-inflammatory monocyte subpopulations.

Frail patients with high grade aortic valve stenosis (AS) undergoing Transcatheter Aortic Valve Implantation (TAVI) have an increased mortality. A connection between frailty and inflammation has been suggested. Monocyte subpopulations are associated with both cardiovascular diseases and chronic inflammatory diseases. This study investigates the association of frailty with monocyte subpopulations and systemic inflammatory parameters in elderly patients undergoing TAVI. A total of 120 patients with symptomatic AS was examined. Before TAVI implantation, frailty was assessed by a bedside evaluation (eyeball test). In all patients a flow cytometry analysis has been performed. Monocyte subpopulations were defined as follows: classical (CD14++CD16-), intermediate (CD14++CD16+) and non-classical (CD14+CD16++). Expression of CD11b was measured as a marker for monocyte activation. Pro-inflammatory cytokines such as interleukin IL-8, as well as CRP were measured with Cytometric Bead Array or standard laboratory methods. 28 out of 120 patients were frail. These patients showed both, signs of elevated chronic systemic inflammation reflected by elevated CRP (3.7 (1.4-5.4) vs. 5.9 (3.7-29.1), p=0.001) and an elevated level of intermediate monocytes (37 (24-54) vs. 53 (47-63), p=0.001). At 6months after TAVI, 19 of 120 patients died, primarily without relevant dysfunction of the implanted aortic valve. Mortality was significantly higher in the frail as compared with non-frail patients (9 of 28 frail patients vs. 10 of 92 non frail patients, p<0.001). A binary logistic regression analysis validated frailty and intermediate monocytes as independent predictors for early mortality after TAVI. Chronic systemic inflammation and increased levels of intermediate monocytes are associated with frailty in old patients with severe aortic valve stenosis. Both the syndrome of frailty and elevated intermediate monocytes showed an association with early mortality after TAVI.

18F-Sodium fluoride PET/CT detects transcatheter aortic valve degeneration

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by the British Heart Foundation, London, United Kingdom Background Early detection of transcatheter aortic valve implantation (TAVI) degeneration is challenging and only feasible when advanced haemodynamic valve dysfunction is apparent. Purpose We tested whether 18F-sodium fluoride (18F-NaF) positron emission tomography and computed tomography (PET/CT) could detect structural TAVI degeneration and haemodynamic valve dysfunction. Methods After TAVI implantation, patients underwent baseline echocardiography, CT angiography and 18F-NaF PET/CT (Figure). We assessed for morphological changes, stenosis or regurgitation on Doppler echocardiography, CT (hypoattenuated leaflet thickening [HALT] or spotty calcification) and PET (18F-NaF uptake; maximum target-to-background ratio, TBRmax). We categorised structural valve degeneration (SVD) according to the standardised definition for surgical and transcatheter bioprosthetic valves, as proposed in a recent consensus statement. Results We recruited 47 patients (81 ± 6 years old, 79% male) 1 month (n = 9), 2 years (n = 22) or 5 years (n = 16) after TAVI: 25 (53%) had received a balloon expanded bioprosthesis and 22 (47%) a self-expanding valve. There was moderate valve dysfunction on Doppler echocardiography in 3 (6%) patients, HALT on CT in 6 (13%) patients, spotty calcification in one patient and 18F-NaF uptake in 7 patients (15%) (TBRmax range: 1.59-5.88); all enrolled 5 years post-TAVI. All patients with increased 18F-NaF uptake (TBRmax ≥1.59) demonstrated either SVD without haemodynamic valve dysfunction (stage 1, n = 4) or structural valve dysfunction with moderate valve dysfunction and mean transprosthetic pressure gradients &amp;gt;20 mmHg (stage 2, n = 3). In patients without increased 18F-NaF uptake there was no evidence of structural valve degeneration (n = 40). Within the increased 18F-NaF uptake (n = 7) group, patients with stage 2 SVD (n = 3) demonstrated higher uptake compared to patients with stage 1 SVD (TBRmax 4.3 [3.02-5.88] versus 1.8 [1.59-2.28]). Patients with stage 2 SVD (n = 3) had over 3 times higher TBRmax than those without SVD (n = 40) (4.30 [3.02, 5.88] versus 1.31 [1.21, 1.46]; p &amp;lt; 0.001); Figure). Conclusion 18F-NaF PET/CT detects patients with SVD and potentially identifies those at risk of valve failure. Abstract Figure.

Transcatheter Aortic Valve Implantation During the COVID-19 Pandemic

Transcatheter aortic valve implantation (TAVI) outcomes during the coronavirus disease 2019 (COVID-19) pandemic have not been fully evaluated and some structural programs in the world have been suspended during this period. We sought to evaluate and compare clinical outcomes in patients undergoing TAVI in pandemic versus nonpandemic era. In a single center, we compared 198 TAVI patients performed during 2019 to 59 patients performed during the COVID-19 pandemic period (March 1st to June 30th, 2020). Primary outcome was procedural success according to VARC criteria and 30-day mortality rates. VARC-defined procedural success was high in both groups (93.3% vs 96.6%; p = 0.53). There were no differences in any vascular complications (26% vs 19%; p = 0.3), permanent pacemaker implantation (11.8% vs 15.3%; p = 0.63), and length of hospital stay (5.2 vs 4.2 days; p = 0.29). Thirty-day mortality was similar (3% vs 3.4%; p = 1.0). We had no documented COVID-19 disease in our patients during follow up. In conclusion, TAVI procedures can be performed effectively and safely during the COVID-9 pandemic, using a minimalist approach, early discharge, and by maintaining proper use of personal protective equipment.

Predictors of 1-year survival in South African transcatheter aortic valve implant candidates.

Transcatheter aortic valve implantation (TAVI) has undergone rapid expansion internationally over the past 15 years. In view of resource constraints in developing countries, a major challenge in applying this technology lies in identifying patients most likely to benefit. The development of a risk prediction model for TAVI has proved elusive, with a reported area under the curve (AUC) of 0.6 - 0.65. The available models were developed in a First-World setting and may not be applicable to South Africa (SA). To evaluate novel indicators and to develop a TAVI risk prediction model unique to the SA context. The current work represents the important initial steps of derivation cohort risk model development and internal validation. Seven-year experience with 244 successive TAVI implants in three centres in Western Cape Province, SA, was used to derive risk parameters. All outcomes are reported in accordance with the Valve Academic Research Consortium definitions. Multiple preprocedural variables were assessed for their impact on 1-year survival using univariate and multivariate models. Factors found not to correlate with 1-year survival included age, renal function and aortic valve gradients. The commonly used surgical risk prediction models (Society of Thoracic Surgeons score and EuroSCORE) showed no correlation with outcomes. Factors found to correlate best with 1-year survival on multivariate analysis were preprocedural body mass index (BMI) (favouring higher BMI), preprocedural left ventricular end-diastolic dimension (LVED) and ejection fraction (EF) (favouring smaller LVED and higher EF), absence of atrial fibrillation, and three novel parameters: independent living, ability to drive a car, and independent food acquisition/cooking. Discriminant analysis of these factors yielded an AUC of 0.8 (95% confidence interval 0.7 - 0.9) to predict 1-year survival, with resubstitution sensitivities and specificities of 72% and 71%, respectively. Apart from existing predictors, we identified three novel risk predictors (independent living, ability to drive a car, and independent food acquisition/cooking) for 1-year survival in TAVI candidates. These novel parameters performed well in this early evaluation, with an AUC for predicting 1-year survival higher than the AUCs for many of the internationally derived parameters. The parameters are inexpensive and easy to obtain at the initial patient visit. If validated prospectively in external cohorts, they may be applicable to other resource-constrained environments.

Right ventricle assessment in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation.

Limited data are available regarding the evaluation of right ventricular (RV) performance in patients with aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). To evaluate the prevalence of RV dysfunction in patients with severe AS undergoing TAVI and long-term changes. Consecutive patients with severe AS undergoing TAVI from January 2016 to July 2017 were included. RV anatomical and functional parameters were analyzed: RV diameters, fractional area change, tricuspid annular plane systolic excursion (TAPSE), S-wave tissue Doppler of the tricuspid annulus (RV-S'TDI), global longitudinal strain (RV-GLS), and free wall strain (RV-FWS). Preprocedure and 1-year echo were analyzed. Final population included 114 patients, mean age 83.63±6.31years, and 38.2% women. The prevalence of abnormal RV function was high, variable depending on the parameter that we analyzed, and it showed a significant reduction 1year after TAVI implantation: 13.9% vs 6.8% (TAPSE<17mm), P=.04; 26.3% vs 20% (fractional area change<35%), P=.048; 41.2% vs 29.2% (RV-S'TDI<9.5cm/s), P=.04; 48.7% vs 39.5% (RV-GLS>[20]), P=.049; and 48.7% vs 28.9% (RV-FWS>[20]), P=.03. Significant differences were noted between patients with low-flow (LF) vs normal-flow (NF) AS in RV dysfunction prevalence as well as in RV function recovery which is less evident in LF compared with NF patients. RV dysfunction is high among symptomatic AS patients undergoing TAVI, with variable prevalence depending on the echocardiographic parameter used.

New-Onset Left bundle branch block after TAVI has a deleterious impact on left ventricular systolic function

Transcatheter aortic valve implantation (TAVI) has revolutionized the management of severe aortic stenosis. The development of new-onset complete left bundle branch block (LBBB) is, however, a frequent complication. The objective of the present study was to assess the impact of new-onset LBBB after TAVI on the evolution of left ventricular ejection fraction (LVEF). Forty consecutive patients were included following the development of new-onset LBBB after TAVI implantation and were matched for age and LVEF with 40 patients implanted during the same period who did not develop LBBB. The primary endpoint was evolution of the LVEF measured by echocardiography prior to implantation and between 6-12 months after TAVI. The development of a LBBB was associated with a 5-point decrease in LVEF [− 12.5–2.5], contrary to the non-LBBB group (1.5 [− 6.5–9.5], P = 0.007) at 8 months, with the persistence of the LBBB ( n = 23) exacerbating this decrease (− 7 [− 13; 2], P = 0.009). When left ventricular dysfunction (LVEF <50%) was present prior to TAVI, the appearance of LBBB was associated with a reduction in LVEF (− 2 [− 8 – 2]) contrary to the non-LBBB group (20 [9–22]), P = 0.02. The appearance of new-onset LBBB after TAVI has a pejorative impact on left ventricular systolic function, particularly in patients with an initial LVEF < 50%, due to a lack of recovery of the latter, thereby potentially affecting their prognosis.

Cardiology update 2020 first quarter

This review covers the end of 2019 and the beginning of 2020 and includes treatment of asymptomatic aortic stenosis, role of antisense oligonucleotides, rivaroxaban in transcatheter aortic valve implantation (TAVI), complete revascularization after myocardial infarction (MI) proving superior, study of colchicine in MI, and update of NOBLE trial showing that percutaneous coronary intervention in left main interventions is inferior to coronary artery bypass graft. There were also a number of trials highlighting various aspects of the outcomes of TAVI implants.