Transcatheter Aortic Valve Implantation Procedure Research Articles

Spanish cardiac catheterization and coronary intervention registry. 31st official report of the Interventional Cardiology Association of the Spanish Society of Cardiology (1990-2021)

Introduction and objectivesThe Interventional Cardiology Association of the Spanish Society of Cardiology (ACI-SEC) presents its annual activity report for 2021. MethodsAll Spanish centers with catheterization laboratories were invited to participate. Data were collected online and were analyzed by an external company, together with the members of the ACI-SEC. ResultsA total of 121 centers participated (83 public and 38 private). Compared to 2020, both diagnostic coronary angiograms and percutaneous coronary interventions (PCI) increased by 11,4% and 10,3%, respectively. The radial approach was the most used access (92,8%). Primary PCI also increased by 6.2% whereas rescue PCI (1,8%) and facilitated PCI (2,4%) were less frequently conducted. Transcatheter aortic valve implantation was one of the interventions with the most relevant increase. A total of 5720 transcatheter aortic valve implantation procedures were conducted with an increase of 34,9% compared to 2020 (120 per million in 2021 and 89,4 per million in 2020). Other structural interventions like transcatheter mitral or tricuspid repair, left atrial appendage occlusion and patent foramen oval closure also experienced a significant increase. ConclusionsThe 2021 registry demonstrates a clear recovery of the activity both in coronary and structural interventions showing a relevant increase compared to 2020, the year of the COVID-19 pandemic.

Re-hospitalisation after transcatheter aortic valve implantation: the HOSPITAVI study

Abstract Background Previous studies have shown increased re-hospitalisation rates for patients treated with transcatheter aortic valve implantation (TAVI) within the first post-procedural year. Most of these may be due to pre-existing co-morbidities, periprocedural complications, or suboptimal post-discharge plan. However, data on re-hospitalisation causes and associations with the TAVI procedure are limited. Purpose The aims of this study were to assess the incidence and cause of re-hospitalisation in patients with severe, symptomatic aortic stenosis treated with TAVI. Methods All patients who underwent TAVI at our centre between 2016 and 2020 were followed at patient-level during the first year after index admission. The risk of re-hospitalisation was calculated after discharge from index admission. All patients' medical records were reviewed to validate the cause of re-hospitalisation and mortality according to The Valve Academic Research Consortium 3 definitions. Results In total, 1,482 consecutive patients had undergone TAVI from 2016 to 2020, of whom 79 patients were excluded due to aortic regurgitation, conversion to surgical aortic valve replacement during index admission or residing abroad. Thus, the total study population consisted of 1,403 patients with a median age of 80 years (IQR: 75–84 years). Median length of stay for the post-procedural index admission was 2 days (IQR: 1–3 days). The total rate of all-cause re-hospitalisation per 100 patient years was 2.7 within the first 30 days, 1.1 from day 31 to 90, and 0.8 from day 91 to the first-year post-discharge. Within the first post-discharge year, 48.6% of the patients were re-hospitalized at least once, of which 26.2% (CI: 23.9–28.5%) of the first re-hospitalisations were of cardiovascular cause compared to 22.4% (CI: 20.2–24.6%) of non-cardiovascular cause. Median length of stay for the first re-hospitalisation was 3 days (IQR: 2–7 days). The most common cardiovascular causes were arrhythmias (28.1% of which 40.6% led to permanent pacemaker implantation), heart failure (14.4%), and neurological events (14.4%). The most common non-cardiovascular causes were infectious diseases (18.3% with pneumonia accounting for 40.4% of these admissions). The first re-hospitalisation was elective in 14.8% of the admissions, primarily due to percutaneous left atrial appendage closure, cancer, or osteoarthritis. Conclusion Almost half of the patients treated with TAVI between 2016 and 2020 were re-hospitalized within the first year after the index admission. First post-procedural re-hospitalisation was more often due to cardiovascular than non-cardiovascular cause with arrhythmias accounting for approximately 30% of cardiovascular re-hospitalisations. Further work is needed to explore whether the rate and causes of hospitalisations differ in the general population and to potentially establish a risk model to predict patients at high-risk of re-hospitalisation. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Boston ScientificAbbott

Short- and long-term impact of nutrition in a large cohort of patients undergoing transcatheter aortic valve implantation: prognostic value of GNRI

Abstract Background Nutritional status, as measured by Geriatric Nutritional Risk Index (GNRI), an easy-to-use tool combining both clinical and laboratory parameters, was shown to predict short-term survival in patients with aortic stenosis undergoing transcatheter aortic valve implantation (TAVI) by our group and others, and this has been extensively confirmed later on. However, data on the long-term impact of nutritional indexes on TAVI outcomes are still lacking. Purpose We aimed at confirming our previous short-term findings in a large population and to investigate the prognostic impact of GNRI in the long-term. Methods All consecutive patients who underwent TAVI between Oct. 2015 and Dec. 2021 at our centre were selected. Baseline nutritional parameters were consistently recorded. An up-to-6-year prospective follow-up was performed. Patients with missing albumin values or with no follow-up available were excluded. Taking into account the old age of patients usually being treated with TAVI, the geriatric version of NRI (GNRI for age>65) was used, and the very few patients younger than 65 years were excluded. GNRI was calculated as described by Bouillanne et al using the following formula: Geriatric (G) NRI = (1.489)×Albumin (g/L) + [(41.7×(present weight/ideal weight)]. The primary endpoint was long-term all-cause mortality. Patients were divided into: GNRI>98 (no risk of malnutrition) and ≤98 (risk of malnutrition). Kaplan-Meier curves were plotted and impact on prognosis was calculated using Cox regression analyses. Results A total of 1084 patients, median (IQR) age 82.2 (78.5–85.5) years, 44.4% female, were included. Median (IQR) BMI was 26.6 (24.2–30.0) kg/m2, corresponding to a slightly overweight population. Median (IQR) GNRI at baseline was 113.7 (106–120.2). 8.6% of patients showed risk of malnutrition (GNRI ≤98). Kaplan-Meier curves showed a significant impact on long-term mortality in patients with risk of malnutrition compared to those with no malnutrition risk, with curves starting to diverge in the first weeks after the procedure. The effect of nutritional status measured by GNRI increased with time. A significant association was shown in univariate analyses (HR 2.3 [95% CI 1.7–3.1], p<0.001) and also in multivariate analyses after adjusting for potential confounding factors (including age, sex and Euroscore II, among others) (HR 1.7 [95% CI 1.2–2.5], p<0.002). According to area under curve for ROC curves, GNRI showed a better predictive value than the widely used BMI. Conclusion This study confirmed the negative impact of the malnutrition risk status, as measured by GNRI, on short-term mortality after TAVI, and showed an even more pronounced effect in the long-term. GNRI could be easily recorded on admission, before TAVI procedure, and considered for heart team decisions. Further studies may be warranted to identify potential mechanisms for nutritional effects and to investigate the potential use of nutrition-improving measures in selected patients. Funding Acknowledgement Type of funding sources: None.

Transcatheter aortic valve implantation without contrast media technique in chronic kidney disease population – pilot study

Abstract Background/Introduction Acute Kidney Injury (AKI) is frequently observed after Transcatheter aortic valve implantation (TAVI), with rates ranging from 3% to 50%. In the Brazilian TAVI Registry, the incidence of AKI following TAVI was 18%, with 4.5% requiring dialysis. Its occurrence is associated with an increase in 3-fold all-cause and cardiac death. Since AKI is related to the volume of contrast media, avoiding contrast during TAVI procedure is advisable, especially in chronic kidney disease (CKD) patients. Purpose The aims of the proposed study are to: (1) evaluate the feasibility and safety of a zero-contrast technique for CKD patients undergoing TAVI and (2) define the role of each of the non-contrast imaging modalities in the preoperative assessment for TAVI and (3) evaluate the incidence of AKI post-TAVI in this population. Methods Patients with severe symptomatic aortic stenosis (AS) and CKD stage ≥3a where evaluated for TAVI with four preoperative exams: transesophageal echocardiogram (TEE), cardiac magnetic resonance, contrast and noncontrast computed tomography (MDCT) and aortoiliac co2 angiography. After safety measures of transfemoral (TF) viability and aortic valve favorable anatomy, patients were submitted to TF-TAVI with self-expandable Evolut R/Pro. The contrast MDCT was blinded to the operators and it is checked before the procedure, at a safety checkpoint, to exclude high-risk conditions not detected by non-contrast methods. During the procedure, another safety checkpoint was accomplished. Clinical and echocardiographic outcomes were assessed at 30 days. Results Between december 2020 to december 2021, a total of 25 patients underwent TF TAVI with zero-contrast technique. Mean age of 79.9±6.1 years, 52% male, 18 patients (72%) NYHA functional class III or IV, mean STS-PROM 3.0±1.5%, 12% had severe systolic dysfunction (left ventricle ejection fraction <35%) and mean creatinine clearance of 49.1±7 mL/min. Self-expandable Evolut R was implanted in 80% of patients and Evolut Pro in 20% of them, the most frequent THV size was 29 mm (52%) and the mean implant depth was 6 mm in fluoroscopy and 4.5 mm in TEE. The mean procedural time was 138±56 minutes, with a median radiation dose of 6.6 mGy/cm2 [IQR, 2–6 mGy]. Definitive pacemaker was implanted in 17% of patients and AKI was seen in 6 patients (24%), with stage I (20%), stage II (4%) and no case needed hemodialysis. At 30 days, 84% were at functional class I, there was no death, one embolization requiring a second valve and the rate of device success (VARC-2) was 92%. Conclusion The proposed pilot study for transfemoral TAVI in CKD population with zero contrast technique was safe, with promising results and similar rates of success and complication, compared with the conventional TAVI approach. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): MedtronicAngiodroid

Large comprehensive evaluation of new- vs. old-generation ACURATE neo self-expanding valve during TAVI procedures: a decrease in paravalvular leakage with an increase in post-procedural gradients?

Abstract Background Contemporary data comparing new- versus old-generation transcatheter heart valve (THV) devices are lacking regarding several THV devices. We aimed to compare the safety and efficacy of old-generation device (OGD) ACURATE neoTM versus the newer generation device (NGD) ACURATE neo2TM THVs (Boston Scientific) in patients undergoing transcatheter aortic valve implantation (TAVI). Methods An analysis of patients undergoing transfemoral TAVI with old-generation device ACURATE neoTM versus newer generation device ACURATE neo2TM from 2016 to 2021. The primary end-point was early safety events at 30-days post-valve implantation. Significant post-implantation paravalvular leakage (PVL) was considered as ≥moderate. Results A total of 249 patients were included in the evaluation; mean age was 81±7.2, and 95 (38.2%) were males. Of the total population 87 (35%) underwent TAVI with the NGD. Early safety events occurred in 21.8% NGD versus 19.1% in OGD (RR= 0.67, P=0.13). Permanent pacemakers were implanted within 30 days in 4.6% versus 6.2% in NGD versus OGD respectively (RR=1.343, P=0.77). Major vascular complications occurred in 5.7% in NGD versus 9.4% in OGD 9.4% (RR=1.6, P=0.46). More than mild PVL occurred significantly more often in OGD (P<0.0001). Echocardiographic mean gradient post-procedure was 9 mmHg± 5 in OGD versus 11±4 mmHg in the NGD (P=0.0159). Conclusion New-generation ACURATE neo2TM devices were associated with less significant PVL. However, this new generation valve was also associated with higher residual gradients. This trend of decrease in PVL with an increase in gradients will be further studied. Funding Acknowledgement Type of funding sources: None.

Transcatheter aortic valve implantation (TAVI) with zero contrast in patients with impairment of renal function. A single centre experience

Abstract Transcatheter aortic valve implantation (TAVI) represents nowaday a safe and effective alternative to traditional surgery for patients with high and intermediate surgical risk. However, the risk of contrast induced nephropathy still remains a major concern and a real challenge in patients with baseline chronic kidney disease (CKD). Aim of our new approach, has been to find a solution capable to reduce or contain the incidence of acute renal damage after TAVI caused by the use of contrast dye in CKD patients. In the last twelve months, out of 85 patients admitted to our Center for severe symptomatic aortic stenosis, addressed to TAVI, 18 patients (mean age: 81.8 years, NYHA class III) presented CKD with mean creatinine value: 2.39 mg/dl; GFR: 24.46 ml/min/1.73 m2. Three patients had previously undergone surgical revascularization with coronary artery bypass graft and in 3 cases we performed a valve-in-valve procedure for degeneration of valvular bioprostheses.They were selected for our zero contrast protocol; all these patients underwent pre-procedural chest and abdomen CT scan without dye, together with a Lower Limb Eco-Color Doppler scan.Coronary angiography had been carried out in a previous hospitalization. The valve size choice was determined after measurements of the CT scan and echo images (both two- and three-dimensions) were compared. Data obtained (valve perimeter, area and the two main valve diameters) were strongly similar with the two techniques, without significant differences. The new valve deployment was monitored under constant fluoroscopy and transesophageal (TOE) visualization. A single pig tail catheter was placed in the non coronary sinus to facilitate valve annulus localization on fluoroscopy. The TOE selected view for TAVI deployment was the mid esophageal long axis. Proper prosthesis positioning was determined by measuring the protruding portion through the left ventricle outflow tract, and prevent possible impairment of diastolic mitral valve movement. In 17 cases a transfemoral percutaneous approach was used and only in one case surgical isolation of the right carotid artery was necessary due to the occlusion of every other peripheral access. Four patients needed a post implant dilatation for significant residual left ventricle/aortic gradient. All patients underwent the TAVI procedure successfully. In the post-TAVI phase, two patients underwent definitive PM implantation for third degree atrioventricular block despite adequately high implantation of the valve.At discharge, mean creatinine value was 1.9 mg/dl and mean GFR was 32.2 ml/min/1.73 m2. All patients survived the procedure and were discharged alive, after a further mean Hospital stay of four days. In conclusion, TAVI zero contrast is a safe, feasible and winning procedure to consider in patients with severely impaired renal function. Funding Acknowledgement Type of funding sources: None.

Intravascular lithotripsy to facilitate transfemoral TAVI: a single-center experience

Abstract Introduction Transfemoral is considered the approach of choice for transcatheter aortic valve implantation (TAVI) and improves clinical outcomes such as death or stroke compared to transaortic or transapical access. Intravascular lithotripsy (IVL) has enabled modification of calcified intimal and medial lesions to increase vascular wall compliance which might facilitate the transfemoral TAVI approach. Purpose To present a single-center experience with intravascular lithotripsy facilitating transfemoral TAVI approach. Methods A peripheral IVL catheter was used to perform lithotripsy of calcified iliofemoral stenosis. A 0.014" guidewire was used to guide the lithotripsy catheter with a balloon diameter of 5.0 or 6.0 mm. Inflating the balloon with 4–6 atm of pressure enabled apposition with the arterial wall and several cycles of 30 pulses have been performed at various locations of the iliofemoral arteries. IVL was planned in advance as primary strategy in case of ring or as baillout strategy in case of ring or excentric calcified periferial artery stenosis, respectively. The IVL was immediately followed by transfemoral TAVI. Retrograde data were collected for the purpose of this abstract. Results From December 2019 to December 2021 433 TAVI procedures were performed in the University Medical Centre Ljubljana. In 13 of the procedures (3%) IVL was used to facilitate the transfemoral approach. The mean minimal diameter of iliofemoral arteries was 5,2 mm with calcifications affecting at least three-quarters of arterial circumference in 92% and circular calcifications in 62% of cases. In all cases, IVL was performed in a common iliac artery or aortic bifurcation, while external iliac (15%) or femoral (8%) arteries were treated less often. A 5 mm IVL balloon was used in 2 (15%), and a 6 mm balloon in 9 (69%) cases, while a combination of 5 and 6 mm balloons was used in 2 (15%) cases. IVL and subsequent TAVI were successful in all the cases. No hospital mortality or major bleeding was observed. One patient needed one unit of blood transfusion due to loss during planned surgical preparation and closure of the puncture site. The puncture site was closed using a 2 Proglide technique and no conversion from percutaneous to surgical puncture site closure was needed. A self-expanding aortic prosthesis (Evolut R, Medtronic) was used in 11 (85%) and a balloon-expandable (Sapien 3, Edwards Lifesciences) in 2 (15%) cases. Conclusion In our experience IVL of iliofemoral arteries is a safe and effective method to facilitate transfemoral approach in TAVI, especially in cases of circular calcifications affecting the majority of arterial wall circumference. Funding Acknowledgement Type of funding sources: None.

USE OF A DIGITAL APPLICATION TO OPTIMIZE THE CLINICAL TRAJECTORY OF PATIENTS IN A TAVI PROGRAM

USE OF A DIGITAL APPLICATION TO OPTIMIZE THE CLINICAL TRAJECTORY OF PATIENTS IN A TAVI PROGRAM

Registro español de hemodinámica y cardiología intervencionista. XXXI informe oficial de la Asociación de Cardiología Intervencionista de la Sociedad Española de Cardiología (1990-2021)

Introduction and objectivesThe Interventional Cardiology Association of the Spanish Society of Cardiology (ACI-SEC) presents its annual activity report for 2021. MethodsAll Spanish centers with catheterization laboratories were invited to participate. Data were collected online and were analyzed by an external company, together with the members of the ACI-SEC. ResultsA total of 121 centers participated (83 public and 38 private). Compared to 2020, both diagnostic coronary angiograms and percutaneous coronary interventions (PCI) increased by 11,4% and 10,3%, respectively. The radial approach was the most used access (92,8%). Primary PCI also increased by 6.2% whereas rescue PCI (1,8%) and facilitated PCI (2,4%) were less frequently conducted. Transcatheter aortic valve implantation was one of the interventions with the most relevant increase. A total of 5720 transcatheter aortic valve implantation procedures were conducted with an increase of 34,9% compared to 2020 (120 per million in 2021 and 89,4 per million in 2020). Other structural interventions like transcatheter mitral or tricuspid repair, left atrial appendage occlusion and patent foramen oval closure also experienced a significant increase. ConclusionsThe 2021 registry demonstrates a clear recovery of the activity both in coronary and structural interventions showing a relevant increase compared to 2020, the year of the COVID-19 pandemic.

Impacto clínico de la extensión del miocardio en riesgo en pacientes sometidos a intervención percutánea de la válvula aórtica

Introduction and objectivesCoronary artery disease (CAD) is found in 30%-50% of patients with severe aortic stenosis (AS) undergoing treatment. The best management of CAD in AS patients undergoing transcatheter aortic valve implantation (TAVI) is still unclear. We investigated the clinical impact of the extent of jeopardized myocardium in patients with concomitant CAD and severe AS treated by TAVI. MethodsConsecutive patients who underwent TAVI procedures at our hospital were identified. In the presence of CAD, the myocardium jeopardized before TAVI was graded using the British Cardiovascular Intervention Society (BCIS) jeopardy score (JS). The study population was divided in 3 groups: patients without concomitant CAD (no-CAD), patients with CAD and BCIS-JS ≤ 4 (CAD BCIS-JS ≤ 4) and patients with concomitant CAD and BCIS-JS> 4 (CAD BCIS-JS> 4). The primary study endpoint was major adverse cardiovascular and cerebrovascular events (MACCE). ResultsA total of 403 patients entered the study: 223 no-CAD, 94 CAD BCIS-JS ≤ 4 and 86 CAD BCIS-JS> 4. At> 3 months of follow-up [range 104–3296 days], patients without CAD and CAD patients with BCIS-JS ≤ 4 had better survival free from MACCE compared with those with less extensive revascularization (BCIS-JS> 4) (P=.049). This result was driven by a significant reduction in death (P=.031). On multivariate analysis, residual BCIS-JS ≤ 4 and NYHA class III-IV independently predicted MACCE. ConclusionsIn patients with concomitant CAD and severe AS, the extent of jeopardized myocardium before TAVI impacts on clinical outcomes.

Preprocedural muscle strength and physical performance and the association with functional decline or mortality in frail older patients after transcatheter aortic valve implementation: a systematic review and meta-analysis.

BackgroundA significant number of older patients planned for transcatheter aortic valve implantation (TAVI) experience a decline in physical functioning and death, despite a successful procedure.ObjectiveTo systematically review the literature on the association of preprocedural muscle strength and physical performance with functional decline or long-term mortality after TAVI.MethodsWe followed the PRISMA guidelines and pre-registered this review at PROSPERO (CRD42020208032). A systematic search was conducted in MEDLINE and EMBASE from inception to 10 December 2021. Studies reporting on the association of preprocedural muscle strength or physical performance with functional decline or long-term (>6 months) mortality after the TAVI procedure were included. For outcomes reported by three or more studies, a meta-analysis was performed.ResultsIn total, two studies reporting on functional decline and 29 studies reporting on mortality were included. The association with functional decline was inconclusive. For mortality, meta-analysis showed that low handgrip strength (hazard ratio (HR) 1.80 [95% confidence interval (CI): 1.22–2.63]), lower distance on the 6-minute walk test (HR 1.15 [95% CI: 1.09–1.21] per 50 m decrease), low performance on the timed up and go test (>20 s) (HR 2.77 [95% CI: 1.79–4.30]) and slow gait speed (<0.83 m/s) (HR 2.24 [95% CI: 1.32–3.81]) were associated with higher long-term mortality.ConclusionsLow muscle strength and physical performance are associated with higher mortality after TAVI, while the association with functional decline stays inconclusive. Future research should focus on interventions to increase muscle strength and physical performance in older cardiac patients.

Ascending Aorta Pseudoaneurysm as a Rare, Late Complication after Valve-in-Valve Transcatheter Aortic Valve Implantation Procedure.

Ascending Aorta Pseudoaneurysm as a Rare, Late Complication after Valve-in-Valve Transcatheter Aortic Valve Implantation Procedure.

Changes in treatment of aortic valve diseases for acute and elective indications during the COVID-19 pandemic: A retrospective single-center analysis from 2019 to 2020.

Coronavirus disease 2019 (COVID-19) pandemic had an impact on the quality of healthcare services and led to many changes in the treatment of cardiac pathologies. To assess the differences in the clinical manifestations, management and outcomes of patients with aortic valve diseases (AVDs) treated invasively before and during the pandemic. This retrospective single-center study involved patients with AVDs treated by means of balloon aortic valvuloplasty (BAV), transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR) in 2019 and 2020. They were divided into groups with respect to the year of intervention (2019 compared to 2020) and the priority of admission (urgent compared to elective). Preoperative characteristics, early outcomes and probability of annual survival were compared between the groups. The number of patients admitted urgently increased from 37 in 2019 to 54 in 2020, with a higher prevalence of men in 2020 (83.3% compared to 56.8%, respectively). Elective cases, on the other hand, declined from 279 in 2019 to 256 in 2020. Among the latter, more subjects had manifestations of heart failure (p < 0.001), coronary artery disease (CAD; p = 0.002), hypertension (p = 0.006), as well as had a history of a stroke (p = 0.002). In the meantime, more TAVI and fewer SAVR procedures were performed in 2020 (86 compared to 127 and 192 compared to 125, respectively; p < 0.001). In 2020, TAVI individuals had risk of death (according to the EuroSCORE scale) than in 2019 (p < 0.001). The probability of annual survival was comparable (p = 0.769) among AVD patients treated before and during the coronavirus pandemic (91.3% compared to 88.3%, respectively). Although during the COVID-19 pandemic more nonelective and higher-risk AVD individuals received interventional treatment, the outcomes were comparable to the pre-pandemic era (2019). Our findings support highly valuable, less invasive therapeutic methods for treating aortic pathologies during the pandemic.

The Evolution of Pulmonary Hypertension and Its Prognostic Implications Post-TAVI-Single Center Experience.

Background and Objectives: Since the first transcatheter aortic valve implantation (TAVI) procedure was performed in 2002, advances in technology and refinement of the method have led to its widespread use in patients with severe aortic stenosis (AS) and high surgical risk. We aim to identify the impact of TAVI on the clinical and functional status of patients with severe AS at the one-month follow-up and to identify potential predictors associated with the evolution of pulmonary hypertension (PH) in this category of patients. Materials and Methods: We conducted a prospective study which included 86 patients diagnosed with severe AS undergoing TAVI treatment. We analyzed demographics, clinical and echocardiographic parameters associated with AS and PH both at enrolment and at the 30-day follow-up. Results: In our study, the decrease of EUROSCORE II score (p < 0.001), improvement of angina (p < 0.001) and fatigue (p < 0.001) as clinical benefits as well as a reduction in NYHA functional class in patients with heart failure (p < 0.001) are prognostic predictors with statistical value. Regression of left ventricular hypertrophy (p = 0.001), increase in the left ventricle ejection fraction (p = 0.007) and improvement of diastolic dysfunction (p < 0.001) are echocardiographic parameters with a prognostic role in patients with severe AS undergoing TAVI. The pulmonary artery acceleration time (PAAT) (p < 0.001), tricuspid annular plane systolic excursion (TAPSE) (p = 0.020), pulmonary arterial systolic pressure (PASP) (p < 0.001) and the TAPSE/PASP ratio (p < 0.001) are statistically significant echocardiographic parameters in our study that assess both PH and its associated prognosis in patients undergoing TAVI. Conclusions: PAAT, TAPSE, PASP and the TAPSE/PASP ratio are independent predictors that allow the assessment of PH and its prognostic implications post-TAVI.

Aortic valve replacement rates in Australia from 2004 to 2019.

Several surgical and percutaneous treatments are available for patients with aortic valve disease. To establish whether trends in aortic valve replacements (AVR) in Australia reflect recent evidence. Using the Australian Institute of Health and Welfare data, this study calculated all AVR and balloon aortic valvuloplasty (BAV) procedures conducted in all Australian hospitals from 2004 to 2019. Linear regression analysis was performed to determine whether age-adjusted rates had changed over the study period. There were 80 883 AVR performed. Of these, 66% were men and 64% were aged >70 years. Absolute rates of AVR increased from 3631 to 7277 with a significant 22% age-adjusted rise seen (1.9% increase per year (+0.26 per 100 000 per year; 95% confidence interval 0.19-0.34); P < 0.001). This trend was more pronounced in men than women and in those aged >80 years (+0.23 per 100 000 per year; P < 0.001). Proportion of mechanical AVR implanted fell from 38.4% to 8.6% (P < 0.001). A total of 2683 transcatheter aortic valve implantation (TAVI) procedures was performed in 2019, representing a 52% annual increase from 2014. BAV increased from 66 procedures in 2004 to 862 in 2019. Rates of AVR have increased significantly over the past 16 years, particularly in the elderly. Despite international guideline recommendations, fewer mechanical AVR are being used in younger cohorts. The uptake in TAVI rates might reflect evidence that suggests it is a safe alternative, at least in the medium term. BAV has also seen a resurgence during this time period.

Adiponectin serum level is an independent and incremental predictor of all-cause mortality after transcatheter aortic valve replacement.

BackgroundQuantifiable biomarkers may be useful for a better risk and frailty assessment of patients referred for transcatheter aortic valve implantation (TAVI).HypothesisTo determine if adiponectin serum concentration predicts all‐cause mortality in patients undergoing TAVI.Methods77 consecutive patients, undergoing TAVI, were analyzed. The CT axial slices at the level of the fourth lumbar vertebra were used to measure the psoas muscle area, and its low‐density muscle fraction (LDM (%)). To assess the operative risk, the STS (Society of Thoracic Surgeons Predicted Risk of Mortality) score, Log. Euroscore, and Euroscore II were determined. A clinical frailty assessment was performed. ELISA kits were used to measure adiponectin serum levels. We searched for a correlation between serum adiponectin concentration and all‐cause mortality after TAVI.ResultsThe mean age was 80.8 ± 7.4 years. All‐cause mortality occurred in 22 patients. The mean follow‐up was 1779 days (range: 1572–1825 days). Compared with patients with the lowest adiponectin level, patients in the third tertile had a hazards ratio of all‐cause mortality after TAVI of 4.155 (95% CI: 1.364–12.655) (p = .004). In the multivariable model, including STS score, vascular access of TAVI procedure, LDM (%), and adiponectin serum concentration, serum adiponectin level, and LDM(%) were independent predictors of all‐cause mortality after TAVI (p = .178, .303, .042, and .017, respectively). Adiponectin level was a predictor of all‐cause mortality in females and males (p = .012 and 0.024, respectively).ConclusionAdiponectin serum level is an independent and incremental predictor of all‐cause mortality in patients undergoing TAVI.

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.

Algorithm for systematic valve-crossing in transcatheter aortic valve implantation.

The retrograde valve-crossing of a stenotic aortic valve is a crucial step in the transcatheter aortic valve implantation procedure. In addition to being time-consuming and associated with an increased stroke risk, inappropriate valve-crossing may cause devastating complications. This tutorial review summarizes systematic and detailed techniques to cross the aortic valve. First, the main challenges in retrograde valve-crossing are depicted. Next, a step-by-step guidance on valve-crossing is provided, along with an in-depth description of the three-dimensional anatomy under a two-dimensional fluoroscopy view. Finally, modified techniques for different anatomies are described.

Transcatheter aortic valve implantation and frailty.

Over the last decade, transcatheter aortic valve implantation (TAVI) has emerged as a treatment option for patients with severe aortic stenosis. With exponential increase in the number of TAVI procedures, frailty assessments have been considered important for patients undergoing TAVI, and a number of studies have indicated a relationship between the frailty and post-TAVI outcomes. In this review, using studies searched systematically in the PubMed database, we review important frailty assessment tools that can be used as prognostic factors for patients before TAVI. The assessment tools were categorized as quantitative single marker, semi-quantitative single marker, or quantitative combined marker. Studies were further stratified by whether they used frailty markers to predict patients' prognosis pre-TAVI or to evaluate frailty improvement post-TAVI. The Clinical Frailty Scale (CFS), a semi-quantitative assessment, is one of the frailty assessment tools discussed. It may be easily used even in an outpatient consultation room. The CFS classifies patients' activity into nine categories, based on a simple interview and the patient's appearance. Gait speed and serum albumin levels were considered as qualitative frailty assessment tools. Compared to other methods, the Essential Frailty Toolset had the highest inter-rater reliability for accuracy in predicting mortality, thereby allowing better identification of vulnerable old age people and optimization of outcomes. A few studies have also focused on changes in frailty pre- and post-TAVI. Serum albumin-level measurements are important for assessing the frailty improvement in the chronic phase. Each frailty assessment tool had its own characteristics, strengths, and weaknesses, and therefore, these tools need to be selected based on where they are being used and the patient's condition.

Valve embolization during transcatheter aortic valve implantation: Incidence, risk factors and follow-up by computed tomography.

BackgroundIn most cases of transcatheter valve embolization and migration (TVEM), the embolized valve remains in the aorta after implantation of a second valve into the aortic root. There is little data on potential late complications such as valve thrombosis or aortic wall alterations by embolized valves.AimsThe aim of this study was to analyze the incidence of TVEM in a large cohort of patients undergoing transcatheter aortic valve implantation (TAVI) and to examine embolized valves by computed tomography (CT) late after TAVI.MethodsThe patient database of our center was screened for cases of TVEM between July 2009 and July 2021. To identify risk factors, TVEM cases were compared to a cohort of 200 consecutive TAVI cases. Out of 35 surviving TVEM patients, ten patients underwent follow-up by echocardiography and CT.Results54 TVEM occurred in 3757 TAVI procedures, 46 cases were managed percutaneously. Horizontal aorta (odds ratio [OR] 7.51, 95% confidence interval [CI] 3.4–16.6, p < 0.001), implantation of a self-expanding valve (OR 4.63, 95% CI 2.2–9.7, p < 0.01) and a left ventricular ejection fraction < 40% (OR 2.94, 95% CI 1.1–7.3, p = 0.016) were identified as risk factors for TVEM. CT scans were performed on average 26.3 months after TAVI (range 2–84 months) and detected hypoattenuated leaflet thickening (HALT) in two patients as well as parts of the stent frame protruding into the aortic wall in three patients.ConclusionTVEM represents a rare complication of TAVI. Follow up-CT detected no pathological findings requiring intervention.