Transcatheter Aortic Valve Intervention Research Articles

Abstract 13551: Non-Invasive Assessment of Systemic Microvascular Function in Patients With Severe Aortic Stenosis Pre- and Post- Transcatheter Aortic Valve Intervention

Background: Aortic stenosis (AS) is associated with pathophysiological changes in both left ventricular and coronary microvascular structure and function. The treatment of AS with transcatheter aortic valve replacement (TAVR) has been associated with improvements in invasive indices of coronary microvascular function. This study sought to address whether systemic microvascular dysfunction was present in patients with AS and if microvascular function was altered by treatment of aortic stenosis with TAVR. The conjunctival microcirculation was used as the site for the non-invasive assessment of systemic microvascular function. Methods: Patients undergoing TAVR for the treatment of severe AS were compared to a cohort of age- and sex-matched controls without valvular heart disease. Conjunctival vascular imaging was performed in all subjects using a previously validated combination of a smartphone and slit-lamp biomicroscope. This technique allowed measurement of vessel diameter and other indices of microvascular function by tracking erythrocyte motion. Conjunctival hemodynamics were compared pre- and post-TAVR, in addition to between the severe AS and control cohorts. Results: A total of 165 patients were included (90 severe AS and 75 controls). Baseline characteristics were well matched between groups. In comparison to the control cohort, arteriole axial (Va) and cross-sectional velocity (Vcs) were significantly lower in females with AS (Va severe AS 0.53 ± 0.11mm/s vs control 0.59 ± 0.12mm/s, p=0.047; Vcs severe AS 0.38 ± 0.07mm/s vs control 0.41 ± 0.08mm/s, p=0.043), but not in males (Va severe AS 0.61 ± 0.11mm/s vs control 0.58 ± 0.10mm/s, p=0.19; Vcs severe AS 0.43 ± 0.08mm/s vs control 0.41 ± 0.07mm/s, p=0.20). Arteriole Va and Vcs significantly increased following TAVR in females (Va Pre-TAVR 0.52 ± 0.16mm/s vs post-TAVR 0.59 ± 0.15mm/s, p<0.001; Vcs Pre-TAVR 0.37 ± 0.11mm/s vs post-TAVR 0.42 ± 0.11mm/s, p<0.001). Conclusion: This study highlights sex-specific differences in conjunctival microvascular function in patients with severe AS. In this study TAVR resulted in significant improvements in conjunctival arteriolar V a and V cs . These findings are consistent with severe AS being a reversible cause of systemic microvascular dysfunction.

Segmentation of human aorta using 3D nnU-net-oriented deep learning.

Computed tomography angiography (CTA) has become the main imaging technique for cardiovascular diseases. Before performing the transcatheter aortic valve intervention operation, segmenting images of the aortic sinus and nearby cardiovascular tissue from enhanced images of the human heart is essential for auxiliary diagnosis and guiding doctors to make treatment plans. This paper proposes a nnU-Net (no-new-Net) framework based on deep learning (DL) methods to segment the aorta and the heart tissue near the aortic valve in cardiac CTA images, and verifies its accuracy and effectiveness. A total of 130 sets of cardiac CTA image data (88 training sets, 22 validation sets, and 20 test sets) of different subjects have been used for the study. The advantage of the nnU-Net model is that it can automatically perform preprocessing and data augmentation according to the input image data, can dynamically adjust the network structure and parameter configuration, and has a high model generalization ability. Experimental results show that the DL method based on nnU-Net can accurately and effectively complete the segmentation task of cardiac aorta and cardiac tissue near the root on the cardiac CTA dataset, and achieves an average Dice similarity coefficient of 0.9698 ± 0.0081. The actual inference segmentation effect basically meets the preoperative needs of the clinic. Using the DL method based on the nnU-Net model solves the problems of low accuracy in threshold segmentation, bad segmentation of organs with fuzzy edges, and poor adaptability to different patients' cardiac CTA images. nnU-Net will become an excellent DL technology in cardiac CTA image segmentation tasks.

Natural history of severe aortic stenosis in elderly heart failure patients who declined transcatheter aortic valve implantation

Abstract Background Transcatheter aortic valve implantation (TAVI) is an established minimally invasive treatment for elderly patients with severe aortic stenosis (AS). Although it is a relatively minimally invasive procedure, many elderly patients cannot undergo TAVI due to advanced age, advanced dementia, significantly impaired ADL, or because the patient or family does not wish to undergo TAVI. In general, severe AS patients died 5 years after an angina attack, 3 years after syncope symptoms, and 2 years after heart failure symptoms. However, few studies have investigated the prognosis of elderly patients with severe AS who declined TAVI. Purpose This study aimed to comprehend the natural history of elderly severe AS patients who declined aortic valve intervention and identify risk factors for death in the TAVI era. Methods We retrospectively reviewed 2,786 echocardiographic data from our hospital between 2017 and 2021. We identified 504 patients with AS in the echocardiography database. The severe AS was defined by the following echocardiography parameters: peak aortic flow velocity ≥4.0 m/s, aortic valve mean gradient ≥40 mmHg, aortic valve area (AVA)<1.0 cm2, or AVA index<0.6 cm2/m2. Patients with mild and moderate AS and patients who underwent surgical or transcatheter aortic valve intervention were excluded. Eventually, 82 patients fulfilled the study criteria and were analyzed in this study. Clinical events were investigated, and Cox proportional hazards analysis was performed to elucidate risk factors for mortality. Results The mean age was 89±6 years, and 63 (77%) were women. AHA/ACC classification was Stage A/B/C/D: 0%/52.4%/39.0%/8.5%. As event occurrence, we detected 34 (41.5%) all-cause deaths, 41 (50.0%) major adverse cardiovascular events, 32 (39.0%) development of heart failure, 13 (15.9%) chest pain attacks, and 3 (3.7%) syncope. The time from diagnosis of severe AS to all-cause death was 227±273 days, and the 1-, 2-, and 3-year survival rates were 61.5%, 46.2%, and 36.9%, respectively. Of the heart failure-onset population, 16 (50.0%) were found to have severe AS on initial heart failure admission. The incidence of heart failure at 1, 2, and 3 years after diagnosis of severe AS was 60.1%, 56.7%, and 45.4%, respectively. The time from heart failure to death was 107±147 days. Cox proportional hazards analysis adjusted with age, sex, comorbidities revealed that dementia (HR 4.5, P=0.014) and Katz index <5 (HR7.8, P=0.009) were independent risk factors for mortality. Conclusions Compared to the comprehension of the natural history of AS patients, the prognosis in severe AS patients who declined TAVI was extremely poor. Although the elderly patients did not have a high rate of angina attacks or syncope symptoms, probably due to their reduced ADL, the results suggest that dementia prevention and maintenance of exercise tolerance are essential since dementia and reduced ADL (Katz<5) are independent risk factors for mortality. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Clinical Research Promotion Foundation Reiwa 2 Michinari Hieda

Prognostic value of right ventricle to pulmonary artery coupling in transcatheter aortic valve implantation recipients

To investigate the impact of the right ventricle to pulmonary artery (RV-PA) coupling on the outcome of patients undergoing transcatheter aortic valve intervention (TAVI), and to describe changes in right ventricular function, pulmonary hypertension, and their ratio after TAVI. Three hundred and seventy-seven patients from the Italian ClinicalService Project, who underwent TAVI between February 2011 and August 2020, were included. Tricuspid annular plane systolic excursion/pulmonary artery systolic pressure (TAPSE/PASP) ratio was retrospectively calculated as a surrogate of RV-PA coupling. The population was stratified according to TAPSE/PASP using a cut-off of 0.36 mm/mmHg derived from a receiving operating characteristic (ROC) curve. The primary end point was 6-month all-cause death. Compared with patients with a TAPSE/PASP ratio ≥0.36 mm/mmHg (81%), those with TAPSE/PASP ratio <0.36 mm/mmHg (19%) had more comorbidities and were more symptomatic.Moreover, they were more likely to receive general anesthesia and an old generation device. Device success was similar between the two groups. A TAPSE/PASP ratio <0.36 mm/mmHg was associated with a higher risk of all-cause death at 6-months (17.3% versus 5.3%; adjusted HR 2.66; P = 0.041). The prognostic impact of the TAPSE/PASP ratio was stronger than the impact of TAPSE and PASP as separate parameters and was independent of the surgical risk score. Both TAPSE, PASP, and their ratio improved from baseline to 1 month and 6 months after TAVI. A TAPSE/PASP ratio <0.36 mm/mmHg is strongly associated with an increased risk of mortality after TAVI. Providing a left ventricle unloading, TAVI is associated with improvement of both TAPSE, PASP, and their ratio.

Clinical impact of the extent of jeopardized myocardium in patients undergoing transcatheter aortic valve intervention

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.

Transcatheter Aortic Valve Replacement in High-Risk Surgical Patient with Severe Aortic Insufficiency

Background: Transcatheter aortic valve replacement (TAVR) is approved by the FDA for severe aortic stenosis (AS) in patients of all surgical risk categories but has yet to be studied for its utility in aortic insufficiency (AI), despite the need for a safe alternative to surgery for prohibitive surgical risk patients. Case Report: We describe a case of a female patient who presented with acute decompensated congestive heart failure (CHF) with New York Heart Association (NYHA) Class IV symptoms. She was found to have severe AI leading to acute decompensation. Two years prior to this, she had aortic valve endocarditis that had potentially resulted in severe AI. Considering her underling comorbidities including diabetes mellitus, hypertension, morbid obesity and multiple myeloma on active chemotherapy at the time of evaluation, the patient was a high-risk surgical candidate for surgical aortic valve repair (SAVR) in view of elevated risk of mortality, infection, and poor wound healing. After critical and comprehensive assessment, transcatheter aortic valve intervention was considered to be an appropriate choice of treatment. TAVR was successfully performed that resulted in immediate improvement of aortic valve function. On subsequent follow-ups, she demonstrated markedly improved symptoms and reduced status to NYHA Class II HF symptoms. Conclusion: TAVR is a potential treatment modality for patients with severe AI who are poor surgical candidates for SAVR. We hope our case contributes to the growing pool of studies investigating the utility of TAVR procedure in patients with severe AI.

Updates on the Role of Interventional Radiology in Ischemic Patients Undergoing Aortic Valve Replacement: Systematic Review

Recent recommendations state that considerable coronary artery disease (CAD) should be treated before the index procedure in patients with severe aortic stenosis who have a transcatheter aortic valve implant. However, the data supporting this suggestion is still limited. We aimed to assess the recent updates on percutaneous coronary intervention (PCI) among patients undergoing transcatheter aortic valve interventions. A search was performed on the PubMed, Web of Science, Science Direct, EBSCO, S

508 Incidence and determinants of prosthesis-patient mismatch after transcatheter aortic valve replacement using predicted indexed effective orifice area

Abstract Aims A small effective orifice area (EOA) by body surface area (BSA), defined as prosthesis–patient mismatch (PPM), is associated with elevated transprosthetic pressure gradients, less ventricular remodelling, and a worse prognosis. Calculating PPM by dividing the normal reference value of EOA for the model and size of the prosthetic valve (predicted PPM), instead of using the continuity equation has been recently confirmed as more accurate after trans catheter aortic valve intervention (TAVI), providing a stronger association with post-procedural haemodynamic outcomes. However, current evidence using this new definition is still limited, thus impairing generalizability. Accordingly, this analysis aims to extend such evidence providing incidence, and determinants of predicted PPM (PPMp) in an all-comers population undergoing TAVR with a high prevalence of self-expandable devices. Methods 395 patients who underwent TAVI at our Institution from September 2008 to November 2020 were included in this analysis. PPMp was then classified as moderate if ≤ 0.85 cm2/m2 and severe if ≤ 0.65 cm2/m2 as well as moderate if ≤ 0.70 cm2/m2 and severe if ≤ 0.55 cm2/m2 for patients with a body mass index &amp;gt; 30, as recommended by the Valve Academic Research Consortium-3 definition. The independent association between baseline clinical and procedural variables and the presence of moderate or severe PPMp was investigated with cross-sectional logistic regression analysis. Results 11 patients (2.78%) had severe and 33 (8.35%) moderate PPMp. Patients with moderate or severe PPMp (m/s PPMp) were younger, female, with a higher prevalence of hypercholesterolaemia, prior aortic valve implantation and balloon expandable device and lower prevalence of chronic obstructive disease (COPD). Post-procedural mean gradient was higher in patients with m/s PPMp. The independent clinical and procedural correlates associated with higher likelihood of m/s PPMp were valve in valve procedure (ViV) and the use of a balloon-expandable device. Conclusions Moderate or severe PPMp was observed only in a small part of patients underwent TAVI, leading, however, a higher post-procedural mean gradient compared to those without PPMp. Balloon expandable devices and ViV were the strongest determinant of moderate or severe PPM.

690 Acute post-implantation enlargement of transcatheter self-expandable valve: insights from a single-centre prospective registry

Abstract Aims Transcatheter implantation of a balloon-expandable aortic valve is associated with an acute stent recoil . Conversely, the acute effects of nitinol-based stent frame- self expandable valve on post-deployment dimensions have not been reported. Accordingly, the aim of this study was to assess the occurrence and degree of acute prosthetic dimension changes after Evolute R valve implantation. Methods A total of 58 consecutive patients undergoing transcatheter aortic valve intervention (TAVI) with a widely used nitinol based self-expandable device (Evolute R, Medtronic, Minneapolis, USA) were included in this study. We measured valve diameters at three different sections: a) distal (aortic) level, b) central (annulus) level, and c) proximal (ventricular) level. Valve expansion was calculated as the difference between the diameters calculated immediately after valve deployment (A) and at the end of the procedure (B). The absolute and relative acute stent recoil were defined as B-A and (B-A)/B*100, respectively. A linear regression model was performed to test the association between the degree of valve extension, with baseline, as well as procedural characteristics. Results Final stent diameters were significantly higher compared to those achieved immediately after valve implantation in proximal (20.87±3.20 mm versus 20.37±3.27 mm, P &amp;lt;0.001), central (19.58±1.63 mm versus 19.12±1.75 mm, P &amp;lt;0.001) as well as distal (26.99±1.53 mm versus 26.41±1.57 mm, P &amp;lt;0.001) segments. The mean absolute and relative enlargement of the valve was respectively 0.50±0.51 mm and 2.48±2.57% in the proximal, 0.46±0.57 mm and 2.39±2.96% in the central and 0.58±0.59 mm and 2.14±2.14% in the distal segment. Among baseline and procedural characteristics assessed in the logistic regression model no association was observed between pre-dilation and valve expansion across all the segments (proximal: r2=0.004, P=0.885, central: r2=0.004, P=0.637, and distal r2=0.05, P=0.10). Of interest, post dilation affected only the expansion of the central segment (r2=0.241, P&amp;lt;0.001), while no association was observed for the proximal (r2=0.059, P=0.065) and distal (r2=0.0002, P=0.916) parts. The expansion of the proximal segment was associated with higher maximum/minimum diameter ratio measured by CT (r2=0.08, P=0.045), while no association was observed for the central (r2= 0.020; P=0.992) and distal (r2=1.111, P=0.683) segments. Conclusions This is the first study that documented a significant degree of post-deployment recoil of the Evolute R self-expandable valve, that was consistent across all the segments. The stent-valve expansion of the proximal segment was associated with a greater annulus dissymmetry reported by the maximum and minimum diameter ratio assessed by CT scan. However, further studies are required to assess the short and long-term time-course of self-expandable valve enlargement and the clinical relevance of this finding.

628 Long-term clinical impact of permanent pacemaker implantation in patients undergoing transcatheter aortic valve intervention: a systematic review and meta-analysis

Abstract Aims As compared with surgery, transcatheter aortic valve implantation (TAVI) is associated with increased need for permanent pacemaker implantation (PPMI). The clinical impact of PPMI post-TAVI has not been fully established. To assess by an updated meta-analysis the clinical outcomes related to PPMI after TAVI at long-term (≥12 months) follow-up (LTF). Methods and results A comprehensive literature research was performed on PubMed and EMBASE. The primary endpoint was all-cause death. Secondary endpoints were rehospitalization for heart failure, stroke, and myocardial infarction. A subgroup analysis was performed according to Society of Thoracic Surgeon—Predicted Risk of Mortality (STS-PROM) score. A total of 31 studies were identified, providing data on 51 069 patients. The mean duration of follow-up was 22 months. At LTF, PPMI post-TAVI was associated with a higher risk of all-cause death [22.9% vs. 19.6%; risk ratio (RR), 1.18, 95% confidence interval (CI), 1.10–1.25; P &amp;lt; 0.001] and rehospitalization for heart failure (16.6% vs. 15.1%; RR, 1.32; 95% CI, 1.13–1.52; P &amp;lt; 0.001). In contrast, risks of stroke and myocardial infarction were not affected. Among the 20 studies that reported surgical risk, the association between PPMI and LTF all-cause death risk was statistically significant only in studies enrolling patients with high STS-PROM score (RR, 1.25; 95% CI, 1.12–1.40), although there was a similar trend in those at medium and low-risk. Conclusions Patients necessitating PPMI after TAVI have higher long-term risk of all-cause death and rehospitalization for heart failure as compared to those who do not receive PPMI. Thus, strategies aimed at reducing need for PPMI might improve survival after TAVI.

Distressed Communities Index in Patients Undergoing Transcatheter Aortic Valve Implantation in an Affluent County in New York

Background The clinical impact of the distressed communities index (DCI), a composite measure of economic well-being based on the U.S. zip code, is becoming increasingly recognized. Ranging from 0 (prosperous) to 100 (distressed), DCI's association with cardiovascular outcomes remains unknown. We aimed to study the association of the DCI with presentation and outcomes in adults with severe symptomatic aortic stenosis (AS) undergoing transcatheter aortic valve intervention (TAVR) in an affluent county in New York. Methods The study population included 286 patients with severe symptomatic AS or degeneration of a bioprosthetic valve who underwent TAVR with a newer generation transcatheter heart valve (THV) from December 2015 to June 2018 at an academic tertiary medical center. DCI for each patient was derived from their primary residence zip code. Patients were classified into DCI deciles and then categorized into 4 groups. The primary and secondary outcomes of interest were 30-day, 1-year, and 3-year mortality, respectively. Results Among 286 patients studied, 26%, 28%, 28%, and 18% were categorized into DCI groups 1–4, respectively (DCI <10: n = 73; DCI 10–20: n = 81; DCI 20–30: n = 80; DCI >30: n = 52). Patients in group 4 were younger with worse kidney function compared to patients in groups 1 and 2. They also had smaller aortic annuli and were more likely to receive a smaller THV. No significant difference in hospital length of stay or distribution of in-hospital, 30-day, 1-year, and 3-year mortality was demonstrated. Conclusions While the DCI was associated with differences in the clinical and anatomic profile, it was not associated with differences in clinical outcomes in this prospective observational study of adults undergoing TAVR suggesting that access to care is the likely discriminator.

Ventral calcification in the common femoral artery: A risk factor for major transcatheter aortic valve intervention access site complications.

We aimed to identify risk factors for major transcatheter aortic valve intervention (TAVI) access site complications based on detailed analysis of the preprocedural computed tomography angiogram (CTA). Transfemoral TAVI has become the treatment of choice for severe aortic stenosis in elderly patients, especially with increased perioperative risk. Frailty, however, favors complications at the vascular access site due to the large bore vascular sheath devices necessary for valve deployment. In this monocentric study, we retrospectively analyzed the preprocedural CTA of 417 consecutive patients that received transfemoral TAVI between 2015 and 2019 to quantify vessel diameter, calcification volume and calcified plaque location in detail within 10cm proximal to the femoral bifurcation. The mean age of the study cohort was 81.4 ± 6.5 years with a STS of 8 ± 5.2 representing a population at increased periprocedural risk. 54.4% of patients were female. Major vascular access site complications occurred in 8.2% of patients. Major vascular complications correlated statistically with a sheath-to-vessel diameter (SFAR) when measured 1cm proximal to the femoral bifurcation using a line-derived diameter and ventral calcification within the first 5cm proximal to the bifurcation. In contrast, overall calcification volume had no influence. Transfemoral TAVI harbors a considerable risk for vascular access site complications especially if vessel diameter is too small to comfortably host the sheath diameter at the area of the femoral bifurcation. For preprocedural TAVI planning and risk assessment, location of calcification, especially if located ventrally, seems to be more relevant than consideration of overall calcification alone.

Patient-Tailored Aortic Valve Replacement.

Contemporary surgical and transcatheter aortic valve interventions offer effective therapy for a broad range of patients with severe symptomatic aortic valve disease. Both approaches have seen significant advances in recent years. Guidelines have previously emphasized ‘surgical risk’ in the decision between surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR), although this delineation becomes increasingly obsolete with more evidence on the effectiveness of TAVR in low surgical risk candidates. More importantly, decisions in tailoring aortic valve interventions should be patient-centered, accounting not only for operative risk, but also anatomy, lifetime management and specific co-morbidities. Aspects to be considered in a patient-tailored aortic valve intervention are discussed in this article.

Reintroduction of elective cardiac interventions in the era of COVID-19: the Barts experience

BackgroundThe response to COVID-19 has required cancellation of all but the most urgent procedures; there is therefore a need for the reintroduction of a safe elective pathway.MethodsThis was a study...

Patient selection, procedural planning and interventional guidance for transcatheter aortic valve intervention.

Transcatheter aortic valve replacement (TAVR) is an established treatment for severe aortic stenosis across a broad spectrum of patient risk profiles. Preprocedural planning using multislice computed tomography (MSCT) is a fundamental component to ensure acute and long-term procedural success. MSCT can establish the procedural feasibility, the type vascular of approach as well as the device which is more likely to give a good result. Moreover, MSCT is a key tool to estimate the risk of potentially life-threatening complications. In this review, the role of MSCT for preprocedural TAVR planning will be discussed providing a panoramic overview of the key elements that should be considered when performing TAVR. Additionally, the adjunctive role of fluoroscopy and echocardiography to plan and guide a TAVR procedure will also be discussed.

Self-navigated versus navigator-gated 3D MRI sequence for non-enhanced aortic root measurement in transcatheter aortic valve intervention

Abstract Funding Acknowledgements Type of funding sources: None. Background Preprocedural transcatheter aortic valve intervention (TAVI) evaluation requires reliable aortic root measurements for correct valve sizing. Purpose To prospectively compare image-quality, reliability and graft sizing of a prototype self-navigated and a navigator-gated non-contrast three dimensional (3D) whole-heart magnetic-resonance-angiography (MRA) sequence with computed-tomography-angiography (CTA) for planning transcatheter-aortic-valve-intervention (TAVI). Methods Self- and navigator-gated 1.5T MRA were performed in 27 patients (aged 83 ± 5 years, 41% male) for aortic root sizing and coronary ostia height measurements; 15 (56%) patients underwent additional CTA. Subjective-image quality was graded on a 4-point Likert scale, objective MRA image-quality was assessed by signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR). Continuous MRA and CTA measurements were analyzed with regression and Bland-Altman analysis, valve sizing by kappa statistics. Results Median image-quality as rated by two observers was 1.5 [interquartile range (IQR) 1-3] for self-navigated MRA and 1 [IQR 1-2] for navigator-gated MRA (p = 0.059). SNR and CNR were comparable between MRA sequences (p = 0.471 and 0.445, respectively). Acquisition time was shorter for self-navigated MRA compared to navigator-gated MRA (5.5 ± 1 minutes vs, 6.5 ± 2 minutes, p = 0.029). Inter-observer correlation of aortic root measurements was high to very high for both self- and navigator-gated MRA (r = 0.75 to 0.94 and r = 0.85 to 0.96, respectively, all p &amp;lt; 0.0001). Theoretical prosthetic valve sizing of self-navigated MRA and CTA was equivalent (κ=1). However, in four patients (15%) one coronary ostium each (right coronary artery 3, left main artery 1) was not clearly definable on self-navigated MRA. Conclusion Self-navigated MRA enables aortic annulus TAVI measurements without significant difference to navigator-gated MRA at shortened acquisition time. Prosthesis sizing by self-navigated MRA measurements is equivalent to navigator-gated MRA and CTA-based choice. Abstract Figure.

Interaction of stroke volume and myocardial phenotype in patients with severe aortic stenosis referred for intervention: outcome data from the BSCMR AS700 study

Abstract Funding Acknowledgements Type of funding sources: None. onbehalf The BSCMR Valve Consortium Background Patients with low-flow aortic stenosis (LF-AS) have higher mortality than those with high-flow severe AS. The conventional echocardiographic definition of LF-AS is an indexed stroke volume (SVi) &amp;lt;35ml/m2. Whether this cut-off translates to cardiac magnetic resonance (CMR), and how CMR SVi associates with myocardial remodelling (volume/function/scar) and survival is unclear. Purpose To determine the association between CMR SVi, myocardial remodelling and survival in severe symptomatic AS. Methods In a multi-centre longitudinal outcome study of patients with severe AS listed for either surgical (SAVR) or transcatheter aortic valve intervention (TAVI) at six cardiothoracic centres, survival was assessed and stratified by SVi. Patients underwent preprocedural echocardiography and CMR between January 2003 and May 2015. Standardised core-lab analyses on pre-procedural CMR for biventricular volumes, function and scar quantification were performed. All-cause and cardiovascular mortality were tracked for a minimum of two years after AVR. Results A total of 674 patients with severe AS (age 75 ± 14years; 63% male, aortic valve area 0.4 ± 0.1 cm2/m2) were included. Patients with low SVi by CMR &amp;lt;35ml/m2 were older and had a greater burden of comorbidities (atrial fibrillation [AF], diabetes, high BMI). Independent predictors of SVi were age, AF, increased left atrial volume, aortic valve regurgitant fraction and left ventricular mass (LV) mass index (by CMR). There was no difference in SVi with choice of intervention (TAVI vs SAVR) or presence of late gadolinium enhancement. In multivariate analysis (Table 1), SVi was associated with cardiovascular mortality in the whole cohort (HR 0.97, 95%CI 0.95-0.99, p = 0.02), and all-cause mortality after TAVI (HR 0.97, 95%CI 0.95-0.99, p = 0.006) but not SAVR (p = 0.6). Adjusted mortality hazard increases below 50ml/m2 and plateaus between 35-40ml/m2 (Figure 1A), adjusted for LGE, STS score (Society of Thoracic Surgery score) and wall thickness. Conclusion SVi by CMR is an independent predictor of cardiovascular mortality. Mortality hazard increases progressively below a SVi of 50mL/m2. Abstract Figure 1

Effect of Transaortic Valve Intervention for Aortic Stenosis on Myocardial Mechanics

Chronic afterload excess in aortic stenosis results in compensatory concentric hypertrophy which mitigates the increased systolic load. Surgical aortic valve replacement has been shown to decrease afterload and improve left ventricular (LV) ejection fraction (EF). The extent to which these changes take place in patients undergoing TAVI (transcatheter aortic valve intervention) may be different than what has been observed in the surgical aortic valve replacement patients who were generally younger with few co-morbidities. Accordingly, we analyzed indices of LV structure and ventricular mechanics pre- and 1-year after TAVI in 397 patients (mean age 81±9, 46% women) with severe symptomatic aortic stenosis, complete echocardiographic data was available in 156 patients and these patients compromised our study population. Our principal findings are: (1) LV remodeling occurs after TAVI; (2) afterload decreases significantly; (3) LV chamber and myocardial function, assessed by left ventricular ejection fraction and midwall fractional shortening, and stroke volume, respectively, remain unchanged or decrease. In conclusion, TAVI effects LV remodeling despite significant co-morbidities. Thus, TAVI reduces afterload and leads to LV remodeling. Surprisingly, however, systolic function does not improve. These data run counter to the paradigm that afterload reduction improves systolic function and suggest that the response to afterload reduction is complex in the TAVI population.

Surgery after transcatheter aortic valve interventions

Associate Editor's Introduction—Aortic valve replacement, whether performed open or percutaneously, inherently trades the native valve disease for a new disease by virtue of the prosthetic valve. Both approaches have pitfalls and complications early, from the procedure itself (eg, heart block, perivalvular leak, ventricular injury, coronary artery ostial impingement), and later (eg, prosthetic valve endocarditis, structural valve deterioration [SVD]). With transcatheter aortic valve replacement (TAVR), even after successful deployment, the biological nature of the valve implies that SVD will eventually occur, and the risks of thrombosis and prosthetic valve endocarditis remain.

Myocardial contractility recovery following acute pressure unloading after transcatheter aortic valve intervention (TAVI)\xa0in patients with severe aortic stenosis and different left ventricular geometry:\xa0a multilayer longitudinal strain echocardiographicanalysis

Aim of the present study was to describe the left ventricular longitudinal strain (LS) in all myocardial layers in patients with severe aortic stenosis (AS), preserved left ventricular ejection fraction (LVEF) in different LV geometry and to compare LS analysis before and early after acute LV unloading provided by transcatheter aortic valve implantation (TAVI). 68 patients were enrolled. LS was measured from the endocardial layer (Endo-LS), epicardial layer (Epi-LS) and full thickness of myocardium (Transmural-LS) before and after TAVI. Patients were divided in two groups accordingly with relative wall thickness (RWT): concentric LV hypertrophy (cLVH) vs eccentric LV hypertrophy (eLVH). Less impaired values of LS at baseline were observed, in all layers, in patients with cLVHas compared to patients with eLVH (Endo-LS was − 13.2 ± 2 vs − 11.1±3 %, p = 0.041; Epi-LS was − 11.8 ± 1.8 vs − 9.9 ± 3 %, p = 0.043; Transmural-LS was − 12.3 ± 1.8 vs − 10.49 ± 3.3 %, p = 0.02, respectively). A significant improvement in endocardial LS (Endo-LS) after TAVI was detected only in cLVH(− 13 ± 2 vs − 14 ± 2, p = 0.011). Our findings documented that concentric LVH had better basal strain function and showed a better myocardial recovery after TAVI compared to eLVH.