Transcatheter Aortic Valve Implantation Valve Research Articles

Transcatheter aortic valve implantation in lower-risk patients: what is the perspective?

In the last decade, transcatheter aortic valve implantation (TAVI), a disruptive technology, has revolutionized the therapy of symptomatic severe aortic stenosis, and current guidelines state that the recommendations for TAVI and surgical aortic valve replacement (SAVR) are equivalent in patients at high-risk. Increased operator experience, technical advances in the new generation of transcatheter heart valves (THV) and excellent TAVI results in recently published randomized controlled trials have led to the expansion of TAVI indication as an alternative to SAVR in intermediate-risk subjects, given appropriate patient selection. The time is opportune to examine the role of TAVI in low-risk patients, currently the objective of on-going randomized trials. This review aims to summarize the available knowledge on TAVI in low- to intermediate-risk patients and to discuss the potential advantages and pitfalls TAVI will face in this clinical setting.

Transcatheter Aortic Valve Implantation (TAVI) in Left Ventricular Assist Device (LVAD) Patients with Aortic Valve Insufficiency: A Word of Caution

Objectives: Transcatheter aortic valve implantation (TAVI) is a well-accepted therapy for severe aortic valve stenosis in a population at high-risk for conventional operation. Some TAVI valves can be used in aortic valve insufficiency, too. However, the overall experience of TAVI valves in patients with aortic valve insufficiency is limited. Especially, in patients with acquired aortic valve insufficiency after long-term left ventricular assist devices (LVAD) implantation.

Wir machen zu viele TAVI – Kontra

Transcatheter aortic valve implantation (TAVI) is an established and approved procedure with an increasing implantation rate, whilst the number of surgical aortic valve replacements (SAVR) remained unchanged (AQUA data). This demonstrates that more patients who were unsuitable for SAVR were treated with TAVI. First randomized trials have shown a significant survival benefit for TAVI compared to conservative therapy (PARTNER B) and non-inferiority to SAVR in high-risk patients (PARTNER A). The US pivotal trials demonstrated even a significant survival benefit in TAVI patients compared to SAVR. The current 5-year data of the PARTNER trials demonstrate a long-term durability of the TAVI valves, which even have superior hemodynamic parameters. Increasing experience, optimization and evolution of the TAVI systems lead to better results and lower rates of complications and mortality, as was shown by the "real world data" from the German aortic valve registry (GARY). The analysis of the subgroups and also the Nordic aortic valve intervention (NOTION) study showed equivalent results for TAVI and SAVR in patients with intermediate and low risk. There is a trend to expand the indications to patients with intermediate risk and the currently ongoing large prospective and randomized trials SURTAVI and PARTNER II could provide greater clarity.

A Novel Method for Optical High Spatiotemporal Strain Analysis for Transcatheter Aortic Valves In Vitro.

The transcatheter aortic valve implantation (TAVI) valve is a bioprosthetic valve within a metal stent frame. Like traditional surgical bioprosthetic valves, the TAVI valve leaflet tissue is expected to calcify and degrade over time. However, clinical studies of TAVI valve longevity are still limited. In order to indirectly assess the longevity of TAVI valves, an estimate of the mechanical wear and tear in terms of valvular deformation and strain of the leaflets under various conditions is warranted. The aim of this study was, therefore, to develop a platform for noncontact TAVI valve deformation analysis with both high temporal and spatial resolutions based on stereophotogrammetry and digital image correlation (DIC). A left-heart pulsatile in vitro flow loop system for mounting of TAVI valves was designed. The system enabled high-resolution imaging of all three TAVI valve leaflets simultaneously for up to 2000 frames per second through two high-speed cameras allowing three-dimensional analyses. A coating technique for applying a stochastic pattern on the leaflets of the TAVI valve was developed. The technique allowed a pattern recognition software to apply frame-by-frame cross correlation based deformation measurements from which the leaflet motions and the strain fields were derived. The spatiotemporal development of a very detailed strain field was obtained with a 0.5 ms time resolution and a spatial resolution of 72 μm/pixel. Hence, a platform offering a new and enhanced supplementary experimental evaluation of tissue valves during various conditions in vitro is presented.

Prosthesis–Patient Mismatch After Transcatheter Aortic Valve Implantation

We reviewed currently available studies that investigated prosthesis-patient mismatch (PPM) in transcatheter aortic valve implantation (TAVI) with a systematic literature search and meta-analytic estimates. To identify all studies that investigated PPM in TAVI, MEDLINE and EMBASE were searched through August 2015. Studies considered for inclusion met the following criteria: the study population included patients undergoing TAVI and outcomes included at least post-procedural PPM prevalence. We performed three quantitative meta-analyses about (1) PPM prevalence after TAVI, (2) PPM prevalence after TAVI versus surgical aortic valve replacement (SAVR), and (3) late all-cause mortality after TAVI in patients with PPM versus patients without PPM. We identified 21 eligible studies that included data on a total of 4,000 patients undergoing TAVI. The first meta-analyses found moderate PPM prevalence of 26.7%, severe PPM prevalence of 8.0%, and overall PPM prevalence of 35.1%. The second meta-analyses of six studies, including 745 patients, found statistically significant reductions in moderate (p = 0.03), severe (p = 0.0003), and overall (p = 0.02) PPM prevalence after TAVI relative to SAVR. The third meta-analyses of five studies, including 2,654 patients, found no statistically significant differences in late mortality between patients with severe PPM and patients without PPM (p = 0.44) and between patients with overall PPM and patients without PPM (p = 0.97). Overall, moderate, and severe PPM prevalence after TAVI was 35%, 27%, and 8%, respectively, which may be less than that after SAVR. In contrast to PPM after SAVR, PPM after TAVI may not impair late survival.

Incidence, treatment, and outcome of acute aortic valve regurgitation complicating percutaneous balloon aortic valvuloplasty.

To evaluate the incidence, treatment, and outcomes of acute aortic regurgitation (ARR) complicating BAV. In the transcatheter aortic valve implantation (TAVI) era, there is an increase of percutaneous balloon aortic valvuloplasty (BAV) procedures with different indications. From the prospective BAV registry of the University of Bologna, which has enrolled patients between the year 2000 and the present, we selected those who suffered intraprocedural AAR with overt hemodynamic instability. Worsening of baseline aortic insufficiency without hemodynamic collapse, treatment of degenerated biological valve prosthesis, and BAV performed within a planned TAVI procedure were excluded. The main endpoints were in-hospital and 30-day mortality. Out of 1517 BAVs, we identified 26 cases of AAR (1.7%). This complication occurred in 80.8% of cases after one or two balloon inflations. Mean transaortic gradient decreased from 50.6±19.3 to 26.0±14.4 mmHg (p<0.01). In 8(30.8%) patients, AAR spontaneously resolved within few minutes; in 18 cases, the operators had to perform a rescue maneuver to reposition a valve leaflet got stuck in the opening position (this maneuver was successful in 13/18 of the cases, 72.2%). Out of 5 persistent AAR, 3 were managed with emergency TAVI or surgery, while 2 were unresolved. In-hospital mortality was 15.4% (n=4), whereas no more deaths occurred up to 30 days. AAR is a fearsome complication of BAV and portends a grim prognosis. In some cases, it can be resolved with appropriate technical maneuvers; in others, a rescue TAVI or surgical valve replacement may be necessary. © 2015 Wiley Periodicals, Inc.

Valve in valve implantation to prevent acute prosthetic valve migration in Transcatheter Aortic Valve Implantation (TAVI)

This case demonstrates the importance of accurate sizing of aortic annulus prior to TAVI. There was migration of first valve after deployment and therefore to prevent further migration to the left ventricle, a new TAVI valve was deployed jailing the first valve.

USE OF ST. JUDE MEDICAL PORTICO VALVE: THE CANADIAN EXPERIENCE

Transcatheter aortic valve implantation (TAVI) is an alternative treatment to surgical aortic valve replacement in patients with severe aortic stenosis who are high-risk surgical candidates. While results following this technique have continued to improve, technical challenges remain in terms of avoiding paravalvular leaks, conduction abnormalities requiring pacemaker and coronary perfusion compromise. These common complications may potentially be reduced by a valve that is self expanding, resheathable and recapturable. The Portico Valve (St. Jude Medical, Minneapolis, Minnesota) fulfills these objectives in that it permits recapture and repositioning at up to 80% deployment. The objective of this study was to describe procedural outcomes in the first Canadian series of patients who underwent TAVI with the Portico Valve. The Portico Valve was implanted in 25 consecutive patients with severe aortic stenosis at 2 institutions using trans-femoral, trans-axillary or trans-aortic approaches. Patients underwent transthoracic echocardiography before and after TAVI. Clinical outcomes were evaluated at 6 weeks following surgery. Average age was 80.2 yrs ±7.3 yrs and 72.0% (n=18) of patients were female. Preoperative echocardiographic evaluation showed a mean aortic valve area of 0.7cm2 ±0.4cm2, aortic valve gradient of 43.4mmHg ±21.1mmHg, and an ejection fraction of 52.7% ±16%. Device implantation was successful in all patients. Access was obtained via the femoral artery in 19 patients (76%), the axillary artery in 4 patients (16%), and trans-aortically in 2 patients (8%). Valve recapture and repositioning took place in 9 (36%) patients, 4 (16%) of whom required recapturing and repositioning twice. Following implantation of the Portico Valve, mean aortic gradients were 8.8mmHg ±4.5mmHg. Additionally, 9 patients (36%) had no paravavlular leaks, while 6 (24%) had trivial, 7 (36%) had mild, and 3 (12%) had moderate paravalvular leaks. One patient (4%) required a pacemaker insertion. No patients suffered a peri-operative myocardial infarction. Of the 19 patients who had 6 week follow up, 3 (16%) required readmission and all were alive. We report the first Canadian series of successful implantation of the Portico Valve in patients requiring TAVI. The innovative feature that allows this valve to be recaptured and repositioned was used in nearly one third of patients, resulting in adequate positioning in all patients with low rates of aortic insufficiency and pacemaker requirements. Further research will be needed to compare the Portico valve to other TAVI valves with regards to clinical outcomes.

Durability of devices: long-term results and clinical outcomes.

Over the last decade, transcatheter aortic valve implantation (TAVI) has emerged to become the treatment of choice for inoperable patients and the preferred alternative for high-risk patients with severe, symptomatic aortic stenosis (AS). Questions about the long-term durability of TAVI valves were raised early in the history of the procedure. Although there has not yet been a significant signal of early structural valve deterioration (SVD), these concerns remain important today, especially if TAVI is to be considered for use in lower-risk and younger patients with longer life expectancy. Durability expectations for TAVI to some degree parallel those of surgical bioprostheses, but the different tissue, mounting design and crimping of TAVI devices might adversely influence long-term results. The experience with surgical bioprostheses has shown that deterioration of these valves is a slow and gradual process. Thus, despite promising midterm results of many surgical bioprostheses at five to seven years, design faults with higher failure rates have become manifest eight to 10 years after implantation. Similarly, although the initial five-year outcomes of TAVI are promising, these results cannot yet be extrapolated to predict long-term durability with any firm degree of assuredness, especially in younger patient populations. Thus, a high degree of caution is necessary when considering TAVI in intermediate-risk and younger patients until more evidence of durability equivalent to that of surgical bioprostheses is forthcoming.

Balloon aortic valvuloplasty--ups and downs--are we facing a procedure comeback?

Recently, there has been renewed interest in balloon aortic valvuloplasty (BAV). To analyse the indications and short-term outcome of BAV since transcatheter aortic valve implantation (TAVI) was launched in our institution. Between September 2010 and September 2014, 25 consecutive patients (19 female, 6 male) underwent BAV. The mean age was 72 ± 11.4 years, mean EuroScore II was 10.4 ± 11.7%, mean logistic EuroScore 23.5 ± 23.6%, mean Society of Thoracic Surgeons mortality risk score was 21.8 ± 13.6%. The indications for BAV were: advanced haemodynamically unstable heart failure (HF) including cardiogenic shock or pulmonary oedema (n = 7), co-morbidities requiring urgent non-cardiac surgery (n = 8), palliative treatment (n = 6), and an intention to bridge to TAVI or aortic valve replacement in patients with severe HF (n = 4). In-hospital mortality was 20% (n = 5) and occurred in patients who underwent BAV in the setting of haemodynamically unstable HF. Other major complications included pacemaker implantation (n = 2), major vascular complications (n = 4), and cardiac tamponade (n = 1). There were no patients who required conversion to cardiac surgery. The mean peak aortic transvalvular gradient decreased from 96.9 ± 29.5 to 60.3 ± 15.5 mm Hg (p = 0.0001) after BAV. We did not observe significant aortic regurgitation. Treatment of advanced and haemodynamically unstable aortic stenosis, bridge to non-cardiac surgery and palliative therapy are the main reasons for BAV in recent years. BAV as a bridge to TAVI or aortic valve replacement may be an option for some patients. Short-term results are good with relatively low mortality and morbidity related to the procedure. Mortality in haemodynamically unstable patients presenting with cardiogenic shock or pulmonary oedema treated with BAV is very high.

Activity and outcomes for aortic valve implantations performed in England and Wales since the introduction of transcatheter aortic valve implantation.

The first transcatheter aortic valve implantation (TAVI) in England and Wales was performed in 2007. This study presents the subsequent national activity and outcomes for both TAVI and aortic valve replacement (AVR). Data for all AVR and TAVI procedures between January 2006 and December 2012 in England and Wales were included. The number of procedures, patient characteristics, in-hospital and 30-day mortality, postoperative length of stay (PLOS) and survival were analysed separately for: isolated AVR; AVR + coronary artery bypass graft (CABG) surgery; AVR + other surgery and TAVI. The number of TAVIs increased from 66 in 2007 (0.8% of all implants) to 1186 in 2012 (10.9% of all implants). AVR activity also increased over the study period. TAVI patients were older and had a higher mean logistic EuroSCORE than all AVR groups. The 30-day mortality rates were 2.1% for isolated AVR, 3.9% for AVR + CABG, 7.7% for AVR + other surgery and 6.2% for TAVI. In-hospital mortality has significantly improved for all groups. The 5-year survival rates were 82.6% for isolated AVR, 81.7% for AVR + CABG, 74.5% for AVR + other surgery and 46.1% for TAVI. The median PLOS after TAVI was similar to that of isolated AVR but shorter than that of the other AVR groups. Since the introduction of TAVI, there has been an increase in both TAVI and AVR activity. TAVIs now represent over 10% of all aortic valve implants. There are distinct differences between procedural groups with respect to patient risk factors. Outcomes for all procedural groups have improved, but long-term TAVI results are required before its role in the treatment of aortic stenosis can be fully defined.

Comparison of Frequency, Risk Factors, and Time Course of Postoperative Delirium in Octogenarians After Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement

Postoperative delirium (PD) after transcatheter aortic valve implantation (TAVI) remains to be explored. We sought to (1) determine the incidence of PD in octogenarians who underwent TAVI or surgical aortic valve replacement (SAVR), (2) identify its risk factors, and (3) describe possible differences in the onset and course of PD between treatment groups. A prospective cohort study of consecutive patients aged ≥80 years with severe aortic stenosis who underwent elective TAVI or SAVR (N = 143) was conducted. The incidence of PD was assessed for 5 days using the Confusion Assessment Method (CAM). Risk factors for PD were studied with logistic regression. Patients treated with TAVI were older (p ≤0.001), had lower cognitive scores (p = 0.007), and more co-morbidities (p = 0.003). Despite this, significantly fewer (p = 0.013) patients treated with TAVI (44%) experienced PD compared to patients treated with SAVR (66%). Undergoing SAVR (p = 0.02) and having lower cognitive function (p = 0.03) emerged as risk factors for PD, whereas gender, activities of daily living, frailty, atrial fibrillation, and postoperative use of opioids and anxiolytics did not. Patients treated with TAVI and without PD during the first 2 postoperative days were unlikely to experience PD on subsequent days. The onset of PD after SAVR could occur at any time during the postoperative evaluation. In conclusion, SAVR in octogenarian patients with aortic stenosis might be considered as a predisposing factor for PD. Our data also suggest that the onset of PD was more unpredictable after SAVR.

Change in quality of life after transcatheter aortic valve implantation and aortic valve replacement surgery in Australian patients aged ≥ 75 years: the effects of EuroSCORE and patient operability.

ObjectiveTo determine the extent to which differences in generic quality of life (QOL) between transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (AVR) patients explained by EuroSCORE and heart-team operability assessment.MethodsA total of 146 high-risk patients with EuroSCORE > 6 and aged ≥ 75 years underwent TAVI (n = 80) or aortic valve replacement (n = 66) between February 2010 and July 2013. A total of 75 patients also completed preoperative and six month SF-12 QOL measures. Analyses examined incident major morbidity, compared six month QOL between groups adjusted for EuroSCORE and operability, and quantified rates of clinically significant QOL improvement and deterioration.ResultsThe AVR group required longer ventilation (> 24 h) (TAVI 5.0% vs. AVR 20.6%, P = 0.004) and more units of red blood cells [TAVI 0 (0–1) vs. AVR 2 (0–3), P = 0.01]. New renal failure was higher in TAVI (TAVI 5.0% vs. AVR 0%, P = 0.06). TAVI patients reported significantly lower vitality (P = 0.01) by comparison to AVR patients, however these findings were no longer significant after adjustment for operability. In both procedures, clinically significant QOL improvement was common [range 25.0% (general health) – 62.9% (physical role)] whereas deterioration in QOL occurred less frequently [range 9.3% (physical role) – 33.3% (mental health)].ConclusionsClinically significant improvement and deterioration in QOL was evident at six months in high risk elderly aortic valve replacement patients. Overall QOL did not differ between TAVI and AVR once operability was taken into consideration.

Initial Experience With Transcatheter Aortic Valve Implantation in Montenegro

Background: Transcatheter aortic valve implantation (TAVI) has emerged as an alternative treatment to classic aortic valve replacement (cAVR) for selected, high risk patients with severe aortic stenosis. Objectives: In our study, we compared preoperative parameters and postoperative outcomes in patients with TAVI and classic aortic valve replacement. Patients and Methods: From March 2011 to December 2013, 18 patients received TAVI and 143 patients underwent cAVR. We compared preoperative Euro SCORE, 30 day mortality, complications after six month and echocardiography findings. Results: Patients received TAVI were older than patients underwent cAVR (72.7 ± 2.7: 65.3 ± 2.9; P < 0.001). Euro SCORE was higher in TAVI group (8.0%: 5.6%; P = 0.43). There were no statistically significant differences in 30-day (0.0%: 2.8%; P = 0.932) and 6-month mortality (5.5%: 3.5%; P = 0.822) as well in stroke incidence (11.1%: 2.8%; P = 0.822). Pacemaker implantation is more frequent in TAVI than in cAVR group (22.0%: 2, 1%; P < 0.001). Conclusions: High risk patients needing AVR are optimal candidates for transcatheter aortic valve implantation. TAVI is a valuable solution for high risk patients needing AVR. Obtained results are comparable to results in transthoracic AVR in standard candidates for aortic valve implantation.

Emergent cardiac surgery during transcatheter aortic valve implantation (TAVI): insights from the Edwards SAPIEN Aortic Bioprosthesis European Outcome (SOURCE) registry

Transcatheter aortic valve implantation (TAVI) carries the risk of intraprocedural complications that may ultimately require emergent cardiac surgery (ECS). However, few data exist on the incidence, reasons and outcomes of patients needing ECS during TAVI. We analysed data from 2,307 TAVI patients, prospectively enrolled in the multicentre Edwards SAPIEN Aortic Bioprosthesis European Outcome (SOURCE) registry. Twenty-seven (1.2%) of 2,307 patients required ECS. The rates of ECS were similar for patients undergoing transapical TAVI compared with transfemoral TAVI (1.1% vs. 1.2%). The leading causes for ECS were embolisation/migration of the TAVI valve prosthesis (9/27, 33%) and procedure-related aortic injury (n=7, 26%). Thirty-day mortality of ECS was high (51.9%) and showed cause-specific differences, with 100% mortality in patients with aortic rupture or cardiac tamponade, 0% death in those with acute aortic regurgitation and intermediate risk of death or intermediate mortality in those with aortic injury or valve embolisation/migration. Rates of ECS during TAVI were low (1.2%). Although ECS was performed without time delay, emergent surgery was associated with a 30-day mortality of 52%. Complications with dramatic acute consequences (annular rupture, aortic injury) had higher mortality than those with less acute deterioration (aortic regurgitation). Prevention of complications requiring ECS during TAVI appears to be of critical importance, focusing on less traumatic, more flexible delivery catheter systems and retrievable valves to reduce the risk of aortic injury and valve embolisation, the two most common causes of ECS.

Early effects of transcatheter aortic valve implantation and aortic valve replacement on myocardial function and aortic valve hemodynamics: Insights from cardiovascular magnetic resonance imaging

There remains a paucity of mechanistic data on the effect of transcatheter aortic valve implantation (TAVI) on early left and right ventricular function and quantitative aortic valve regurgitation. We sought to assess and compare the early effects on myocardial function and aortic valve hemodynamics of TAVI and aortic valve replacement (AVR) using serial cardiovascular magnetic resonance (CMR) imaging and echocardiography. A prospective comparison study of 47 patients with severe aortic stenosis undergoing either TAVI (n = 26) or high-risk AVR (n = 21). CMR (for left ventricle/right ventricle function, left ventricular mass, left atrial volume, and aortic regurgitation) was carried out before the procedure and early postprocedure (<14 days). Groups were similar with respect to Society of Thoracic Surgeons score (TAVI, 7.7 vs AVR, 5.9; P = .11). Preoperative left ventricular (TAVI, 69% ± 13% vs AVR, 73% ± 10%; P = .10) and right ventricular (TAVI, 61% ± 11% vs AVR, 59% ± 8%; P = .5) ejection fractions were similar. Postoperative left ventricular ejection fraction was preserved in both groups. In contrast, decline in right ventricular ejection fraction was more significant in the TAVI group (61%-54% vs 59%-58%; P = .01). Postprocedure aortic regurgitant fraction was significantly greater in the TAVI group (16% vs 4%; P = .001), as was left atrial size (110 vs 84 mL; P = .02). Further analysis revealed a significant relationship between the increased aortic regurgitant fraction and greater left atrial size (P = .006), and a trend toward association between the decline in right ventricle dysfunction and increased postprocedure aortic regurgitation (P = .08). There was no significant difference in early left ventricular systolic function between techniques. Whereas right ventricle systolic function was preserved in the AVR group, it was significantly impaired early after TAVI, possibly reflecting a clinically important pathophysiologic consequence of paravalvular aortic regurgitation.

Why is a new journal dedicated to echocardiography required?

Why is a new journal dedicated to echocardiography required?

Experience of a high-risk aortic valve clinic in Ireland

The advent of transcatheter aortic valve implantation (TAVI) has broadened the management options for severe aortic stenosis. The indications for TAVI are narrow. Selecting those that will benefit most from this intervention warrants careful consideration and input from cardiologists, anaesthetists and cardiac surgeons familiar with TAVI and surgical aortic valve replacement (SAVR). The aims of this paper were to assess the feasibility of establishing a high-risk aortic clinic in Ireland, and report stratification of the referred group into those suitable for SAVR, TAVI and conservative management. Patient data was prospectively collected by a dedicated clinical nurse specialist. ANOVA was used to assess variance in means between groups. Analyses were performed using IBM SPSS v20 (Armonk, NY: IBM Corp.). A total of 105 patients were assessed. Eighty-five patients were deemed suitable for TAVI, 9 (10.5 %) died awaiting the procedure and a further 6 (7 %) declined intervention. Eleven (10.5 %) underwent conventional SAVR, 1 (0.9 %) a balloon valvuloplasty, 4 (3.8 %) entered surveillance and 4 (3.8 %) were declined treatment. Establishment of a high-risk aortic clinic is feasible in the Irish context. The advent of TAVI has reduced the proportion of patients denied intervention to a minority. Despite being considered high risk, a number of patients were suitable candidates for SAVR. Measuring frailty continues to provide a challenge; a TAVI-specific frailty assessment tool would be advantageous to patient stratification.

Anesthetic Management in Aort Valve Surgery with Infective Endocarditis Following Transcatheter Aortic Valve Implantation

Anesthetic Management in Aort Valve Surgery with Infective Endocarditis Following Transcatheter Aortic Valve ImplantationIntroduction: Transcatheter aortic valve implantation (TAVI) has emerged as an alternative curative therapy in patients with severe calcific aortic stenosis in aging population, in which there is high operative risk rate with surgery due to significant co-morbidities. However, problems during and after procedure can seriously complicate the success of TAVI. We wanted to present the anesthetic management of a patient with infective endocarditis, undergoing aortic valve replacement surgery following TAVI.Case Report: A 75-year-old woman who had undergone TAVI five months before was readmitted to hospital with complaints of palpitation, breathlessness and fever. The blood culture was positive for Enterococcus faecalis, so antimicrobial therapy was started with a diagnosis of infective endocarditis. She was intubated due to acute lung edema and acidosis; and also underwent dialysis therapy. Transesophageal echocardiography (TEE) showed vegetation on right coronary cusp of the implanted aortic valve. The patient was scheduled for cardiac surgery for removal and replacement of the infected and malfunctioning TAVI valve. At the end of the surgical procedure, she was transferred to the intensive care unit (ICU) on inotropic support. However, in ICU, hemodynamic instability, including rhythm disturbance, persisted and intra-aortic balloon pump was implanted. Postoperative course was complicated with low cardiac output syndrome and organ failure. Unfortunately, the patient died at 10th postoperative hour in spite of all supportive management.Conclusion: The reported incidence of prosthetic valve endocarditis after TAVI patients is 0.5%. However, ¬its mortality rates vary from 30% to 50% and urgent open heart surgery with meticulous anesthesiological planning is required.

Effect of severe left ventricular systolic dysfunction on hospital outcome after transcatheter aortic valve implantation or surgical aortic valve replacement: Results from a propensity-matched population of the Italian OBSERVANT multicenter study

Despite demonstration of the superior outcomes of transcatheter aortic valve implantation (TAVI) versus optimal medical therapy for severe left ventricular systolic dysfunction, studies comparing TAVI and surgical aortic valve replacement (AVR) in this high-risk group have been lacking. We performed propensity matching for age, gender, baseline comorbidities, previous interventions, priority at hospital admission, frailty score, New York Heart Association class, EuroSCORE, and associated cardiac diseases. Next, the 30-day mortality and procedure-related morbidity of 162 patients (81 TAVI vs 81 AVR) with severe left ventricular systolic dysfunction (ejection fraction ≤ 35%) were analyzed at the Italian National Institute of Health. The 30-day mortality was comparable (P = .37) between the 2 groups. The incidence of periprocedural acute myocardial infarction (P = .55), low output state (P = .27), stroke (P = .36), and renal dysfunction (peak creatinine level, P = .57) was also similar between the 2 groups. TAVI resulted in significantly greater postprocedural permanent pacemaker implantation (P = .01) and AVR in more periprocedural transfusions (P < .01) despite a similar transfusion rate per patient (2.8 ± 3.7 for TAVI vs 4.4 ± 3.8 for AVR; P = .08). The postprocedural intensive care unit stay (median, 2 days after TAVI vs 3 days after AVR; P = .34), intermediate care unit stay (median, 0 days after both TAVI and AVR; P = .94), and hospitalization (median, 11 days after TAVI vs 14 days after AVR; P = .51) were comparable. In patients with severe left ventricular systolic dysfunction, both TAVI and AVR are valid treatment options, with comparable hospital mortality and periprocedural morbidity. Comparisons of the mid- to long-term outcomes are mandatory.