Transcatheter Aortic Valve Replacement Candidates Research Articles

TCT-770 Annual Number of Candidates for Transcatheter Aortic Valve Replacement Per Country

The number of transcatheter aortic valve replacement (TAVR) procedures is rapidly increasing. This has a major impact on healthcare resource planning. However, the annual numbers of TAVR candidates per country are unknown. The objective of this study is to provide an up-to-date estimate of the

CT angiography to evaluate coronary artery disease and revascularization requirement before trans-catheter aortic valve replacement

BackgroundCoronary artery disease (CAD) and aortic stenosis share pathophysiological mechanisms and risk factors. We evaluated the clinical utility of coronary computed tomography angiography (CTA) to identify CAD and revascularization requirement in patients with severe aortic stenosis considered for transcatheter aortic valve replacement (TAVR). MethodsConsecutive patients without known CAD underwent calcium scoring, CTA and invasive coronary angiography (ICA). A second-generation dual-source CT scanner was used. ICA-quantitative coronary angiography (QCA) served as reference standard. CAD was reported using a lenient threshold of ≥50% and a stricter threshold of ≥70% diameter reduction. Findings of ≥70% diameter reduction and of high-risk CAD were used to predict revascularization. ResultsThe study included 140 patients [68 males; 82.3 (7.7) years]. CAD defined by the 50% threshold on ICA was found in 58/140 (41%) patients. CAD by the 70% threshold was found in 23/140 (16%) patients. High-risk CAD was found in 16/140 (11%) patients. CTA and ICA had similar odd-ratios of 3.22 (1.26–8.23) and 4.62 (1.64–13.05), respectively, in predicting revascularization. Forty-two/140 (30%) patients had <400 Agatston calcium score, 98/140 (70%) patients had ≥400 calcium score. The diagnostic performance of CTA in the low calcium score group was better than the high calcium score group (AUC 0.81 vs. 0.63). ConclusionCTA remained questionable to rule-out CAD as gatekeeper to ICA in TAVR candidates who had severe coronary calcifications. In patients with less severe coronary calcifications, accounting for 30% of participants in this study, CTA may play a clinical role.

Predicting Early and Late Mortality After Transcatheter Aortic Valve Replacement

BackgroundFew studies have examined the impact of novel indices of comorbidity, frailty, and disability on outcomes after transcatheter aortic valve replacement (TAVR). ObjectivesThis study analyzed patients from the Medtronic CoreValve U.S. Pivotal Trial program to develop a simple scoring system that incorporates standard and novel predictor variables. MethodsA multidisciplinary heart team used objective criteria, such as The Society of Thoracic Surgeons Predicted Risk of Mortality (STS PROM), and subjective criteria to assess patients’ eligibility for TAVR. The analysis included 3,687 patients randomly divided (2:1) into a derivation cohort (n = 2,482) and a validation cohort (n = 1,205). The study evaluated predictors of all-cause death, which were used to calculate a risk score for each patient. ResultsThe overall mortality rate was 5.8% at 30 days and 22.8% at 1 year. Home oxygen use, assisted living, albumin levels <3.3 g/dl, and age >85 years predicted death at 30 days. Home oxygen use, albumin levels <3.3 g/dl, falls in the past 6 months, STS PROM score >7%, and severe (≥5) Charlson comorbidity score predicted death at 1 year. A simple scoring system created on the basis of these multivariable predictors effectively stratified risk at 30 days and 1 year into low-risk, moderate-risk, and high-risk subsets. This score showed a 3-fold difference in mortality rates for the low-risk and high-risk subsets at 30 days (3.6% and 10.9%, respectively) and 1 year (12.3% and 36.6%, respectively). The 1-year mortality model was more stable than the 30-day model (C-statistics: 0.79 vs. 0.75). ConclusionsA simple score dominated by novel predictors of outcome effectively stratified early and late mortality rates in extreme-risk and high-risk patients and may assist in selecting appropriate candidates for TAVR. (Safety and Efficacy Study of the Medtronic CoreValve System in the Treatment of Symptomatic Severe Aortic Stenosis in High Risk and Very High Risk Subjects Who Need Aortic Valve Replacement; NCT01240902)

Comprehensive non-contrast MR assessment of the iliofemoral arteries with visualization of vascular calcifications in TAVR candidates - initial experience

Background Transcatheter aortic valve replacement (TAVR) has emerged as an accepted therapeutic option for moderate and high-risk patients with severe aortic stenosis. In addition to vessel caliber, the presence and configuration of vascular calcifications by the iliofemoral access site is part of routine pre-interventional assessment with CTA and catheter angiography. Non-contrast MR angiography has been proven useful for evaluation of lower extremity peripheral vascular disease, however it cannot identify vascular calcifications using currently available sequences. Neutral contrast 3D and 3D point-wise encoding time reduction (PETRA) are novel MR techniques that can detect vascular calcifications and enable projection-like displays for review, similar to CT. We hypothesized that these techniques, associated with noncontrast Quiescent Interval Slice-Selective (QISS) MRA may be useful alternatives for pre-surgical planning in patients considered for TAVR.

Intracardiac Doppler Echocardiography for Monitoring of Pulmonary Artery Pressures in High-Risk Patients Undergoing Transcatheter Aortic Valve Replacement

Uncontrolled pulmonary hypertension may cause worse outcomes after transcatheter aortic valve replacement (TAVR), while hemodynamic monitoring is desirable for risk control. Pulmonary artery pressure (PAP) readings obtained by intracardiac Doppler echocardiography were evaluated. In 114 patients with symptomatic aortic stenosis and median Society of Thoracic Surgeons scores of 10.5% (interquartile range, 7.7%-15.0%), transfemoral and transapical TAVR was guided by intracardiac Doppler echocardiography. The continuous-wave Doppler beam interrogated the jet of tricuspid regurgitation from the "home view" position. Systolic PAP (PAPs) was estimated as the sum of the pressure gradient derived from the maximum transtricuspid regurgitation jet velocity and the central venous pressure. Mean PAP (PAPm) was calculated by the mean gradient method (1) and the Chemla formula (2). Measurements were obtained immediately before and after TAVR. Pre- and postinterventional readings showed marginal pressure underestimation in comparison with measurements derived from right-heart catheterization: PAPs, -2.7 (95% CI, -3.3 to 2.1) and -1.4 (95% CI, -1.9 to -0.9); PAPm by the mean gradient method, -1.9 (95% CI, -2.2 to -1.6) and -0.1 (95% CI, -0.4 to 0.2). Agreement (95% limits) for PAPs was -8.6 to 3.2 and -6.8 to 4.0; agreement for PAPm by the mean gradient method was -5.4 to 1.6 and -3.4 to 3.2. The repeatability coefficient (95% limits of agreement) for PAPs was excellent: 3.4 (-4.2 to 2.5) and 5.5 (-5.3 to 5.8); repeatability for PAPm was higher by the mean gradient method than by the Chemla method. In ≥ 85% of patients with pulmonary hypertension, PAPm improved after valve deployment. Intracardiac Doppler echocardiography-derived monitoring of PAP by the mean gradient method is accurate and well applicable to high-risk TAVR candidates for intraprocedural risk control.

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Limited amount of data suggest that patients with aortic stenosis and pulmonary hypertension (PH) who undergo transcatheter aortic valve replacement (TAVR) experience decrease in PH postprocedure. Inconsistent use of systolic pulmonary artery pressure cut-off values in previous studies limits our ability to draw meaningful conclusions regarding the prognostic role of PH in assessment of TAVR candidates. A total of 415 consecutive patients who underwent TAVR were included in the present study. Two groups were compared based on receiver-operating characteristics curve analysis for the best SPAP value to predict outcome, yielding 2 study groups of no/mild PH (≤50 mm Hg; n = 172, 41%) versus moderate/severe PH (>50 mm Hg; n = 243, 59%). Demographics and co-morbidities were comparable between the 2 groups; however, right-sided cardiac failure (35% vs 19.8%, p = 0.02) and mitral regurgitation (18.4% vs 8.6%, p = 0.007) were more frequent in patients with moderate/severe PH. Procedural characteristics and complications were comparable between the groups. Although there was an early overall decrease in SPAP postprocedure, only 26% of moderate/severe patients with PH experienced a significant decrease in SPAP (>10 mm Hg). The 30-day (14.5% vs 7.4%, p = 0.02) and 1-year mortality (30.8% vs 21%, p = 0.02) was higher in moderate/severe patients with PH. In multivariate analysis, systolic pulmonary artery pressure and chronic lung disease were identified as independent predictors for mortality at 1 year. PH is a frequent co-morbidity in patients with severe aortic stenosis who underwent TAVR. Significantly elevated pulmonary artery pressures at baseline may serve as a poor prognostic factor when performing preprocedural assessment of the patients.

Transcatheter Aortic Valve Replacement: A Physician-Patient's Story.

Until several months ago, I had severe aortic stenosis. Then something remarkable happened. I received a new aortic valve without having my chest opened. And more good things were to come. I would go home the next day, be back in my office 72 hours later, and resume full activities (including daily runs on my treadmill) less than 2 weeks after undergoing a transcatheter aortic valve replacement (TAVR). Immensely gratified by this sequence of events, I thought that the specifics of my case might prove interesting and be of value to candidates for a TAVR and to their doctors as well. Hence, this report.

Low-Volume Contrast Medium Protocol for Comprehensive Cardiac and Aortoiliac CT Assessment in the Context of Transcatheter Aortic Valve Replacement

To investigate the diagnostic performance of a comprehensive computed tomography (CT) protocol for both cardiac and aortoiliac evaluation of patients considered for transcatheter aortic valve replacement (TAVR) using a single, low-volume contrast medium (CM) injection. Forty-four TAVR candidates were retrospectively analyzed. All underwent retrospectively electrocardiogram-gated cardiac CT followed by high-pitch CT angiography of the aortoiliac vasculature using one of two single injection protocols of 320 mgI/mL iodine CM: group A (n = 22), iodine delivery rate-based (1.28 gI/s), 60-mL CM volume, 4.0 mL/s flow rate; group B (n = 22), clinical routine protocol, 100-mL CM volume, 4.0 mL/s flow rate. Mean arterial attenuation, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR) were calculated. Subjective image quality was assessed. Aortic root and iliofemoral dimensions could be analyzed in all cases. Patient characteristics showed no significant differences. Mean attenuation at the levels of the aortic root (285.8 ± 83.0 HU vs 327.5 ± 70.8 HU, P = .080) and the iliofemoral access route (256.8 ± 88.5 HU vs 307.5 ± 93.2 HU, P = .071), as well as SNR and CNR were nonsignificantly lower in group A compared to group B. Subjective image quality was equivalent. In multimorbid TAVR patients, the performance of a combined CT protocol using a single low-volume CM bolus is feasible with maintained image quality compared to a standard protocol.

Invited Commentary

Imagination is more important than knowledge. For knowledge is limited, whereas imagination embraces the entire world.–Albert Einstein, 1929 While Einstein wanted to describe imagination as the driving force behind the search for knowledge, the widespread use of a transcatheter aortic valve replacement (TAVR) is an example for the replacement of knowledge by imagination. It is quite astonishing that a novel technique like TAVR with at first a non-inferiority status [1Smith C.R. Leon M.B. Mack M.J. et al.Transcatheter versus Surgical Aortic-Valve Replacement in High-Risk Patients.N Engl J Med. 2011; 364: 2187-2198Crossref PubMed Scopus (4768) Google Scholar] over the established methods, shown in only 1 prospective randomized trial (by the way, sponsored by the same company selling the novel devices) with a very limited number of participants, could gain such relevance in patient treatment as well as in the scientific discussion. The superiority [2Adams D.H. Popma J.J. Reardon M.J. et al.Transcatheter aortic-valve replacement with a self-expanding prosthesis.N Engl J Med. 2014; 370: 1790-1798Crossref PubMed Scopus (2023) Google Scholar] of TAVR over conventional AVR could only later be shown in an, again, company-sponsored trial. The paper of Ribeiro and colleagues [3Ribeiro H. Dahou A. Urena M. et al.Myocardial injury after transaortic versus transapical transcatheter aortic valve replacement.Ann Thorac Surg. 2015; 99: 2001-2009Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar] deals with 2 different TAVR techniques (transaortic versus transapical approach) regarding myocardial injury and ventricular function after the procedure. A clear message can be read between the lines, although very cautiously phrased: transaortic (TAO) TAVR is superior to transapical (TA) TAVR because TAO TAVR leads to less myocardial injury and to a better left ventricular recovery. Interestingly, this does not lead to better clinical outcomes after 30 days or 12 months in the TAO TAVR group, as one would expect knowing the influence of high cardiac biomarkers on long-term outcomes after valve surgery [4Paparella D. Guida P. Caparrotti S. et al.Myocardial damage influences short- and mid-term survival after valve surgery: a prospective multicenter study.J Thorac Cardiovasc Surg. 2014; 148: 2373-2379Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar]. One important detail to be found in Supplemental Table 3 is not mentioned by the authors. Moderate or severe aortic valve regurgitation occurs nearly 4 times more often (nearly significantly more often) in the TAO TAVR group. Although there are data available on how high-degree aortic regurgitation worsens long-term survival [5Abdel-Wahab M. Zahn R. Horack M. et al.Aortic regurgitation after transcatheter aortic valve implantation: incidence and early outcome. Results from the German transcatheter aortic valve interventions registry.Heart. 2011; 97: 899-906Crossref PubMed Scopus (440) Google Scholar], the clinical outcomes of the 2 patient groups in this study are similar. Is it possible that higher biomarkers in the TA TAVR group and more aortic regurgitation in the TAO TAVR group balance each other? Clearly, the hypotheses of Ribeiro and colleagues [3Ribeiro H. Dahou A. Urena M. et al.Myocardial injury after transaortic versus transapical transcatheter aortic valve replacement.Ann Thorac Surg. 2015; 99: 2001-2009Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar] have to be proven “by future studies with larger sample size … to determine whether or not differences in myocardial injury … translate into significant differences in mortality…”, as the authors state themselves. Ribeiro and colleagues are to be congratulated on an excellent study inspired by their imagination, but they still have to contribute to the “limited knowledge.” Einstein again: “It’s important to go on asking questions.” Myocardial Injury After Transaortic Versus Transapical Transcatheter Aortic Valve ReplacementThe Annals of Thoracic SurgeryVol. 99Issue 6PreviewThe release of cardiac biomarkers of myocardial injury after transcatheter aortic valve replacement (TAVR) is common, but no data exist on patients undergoing TAVR through a transaortic approach. We aimed to evaluate the incidence and prognostic significance of the increase in cardiac biomarkers in nontransfemoral TAVR candidates, comparing transaortic and transapical approaches. Full-Text PDF

Myocardial Injury After Transaortic Versus Transapical Transcatheter Aortic Valve Replacement

The release of cardiac biomarkers of myocardial injury after transcatheter aortic valve replacement (TAVR) is common, but no data exist on patients undergoing TAVR through a transaortic approach. We aimed to evaluate the incidence and prognostic significance of the increase in cardiac biomarkers in nontransfemoral TAVR candidates, comparing transaortic and transapical approaches. After excluding patients deemed suitable for transfemoral TAVR, 251 consecutive patients (transaortic, 45; transapical, 206) were prospectively evaluated. Creatine kinase-myocardial band and cardiac troponin T levels were measured at baseline and at 6, 12, 24, 48, and 72 hours after TAVR. Baseline and 6- to 12-month echocardiographic and clinical follow-up were performed. After TAVR, cardiac troponin T increased above the upper normal values in all patients (peak value 0.64 μg/L [IQR, 0.39 to 1.03 μg/L]), whereas creatine kinase-myocardial band levels increased in 88% of patients (transaortic 51%, transapical 96%, p < 0.001; peak value 20.1μg/L [interquartile range, 14.3 to 31.6 μg/L]). Compared with the transaortic approach, the transapical approach was associated with a greater rise in both cardiac biomarkers (p < 0.001 for both), and a lesser improvement in left ventricular ejection fraction (p= 0.058) and global longitudinal strain (p= 0.039) at 6- to 12-month follow-up. Greater increases of cardiac troponin T levels were independently associated with 30-day and 1-year overall and cardiovascular mortality (p < 0.001 for all). A 15-fold rise in cardiac troponin T levels was the optimal threshold for determining poorer outcomes (p < 0.001). Periprocedural TAVR-related myocardial injury in nontransfemoral candidates was demonstrated in all patients, but the transapical approach was associated with significantly greater myocardial injury compared with the transaortic approach. A higher degree of myocardial injury translated into reduced left ventricular function improvement and lower early and midterm survival rates.

Prevalence and Impact of Pulmonary Hypertension on Patients With Aortic Stenosis Who Underwent Transcatheter Aortic Valve Replacement

Limited amount of data suggest that patients with aortic stenosis and pulmonary hypertension (PH) who undergo transcatheter aortic valve replacement (TAVR) experience decrease in PH postprocedure. Inconsistent use of systolic pulmonary artery pressure cut-off values in previous studies limits our ability to draw meaningful conclusions regarding the prognostic role of PH in assessment of TAVR candidates. A total of 415 consecutive patients who underwent TAVR were included in the present study. Two groups were compared based on receiver-operating characteristics curve analysis for the best SPAP value to predict outcome, yielding 2 study groups of no/mild PH (≤50 mm Hg; n = 172, 41%) versus moderate/severe PH (>50 mm Hg; n = 243, 59%). Demographics and co-morbidities were comparable between the 2 groups; however, right-sided cardiac failure (35% vs 19.8%, p = 0.02) and mitral regurgitation (18.4% vs 8.6%, p = 0.007) were more frequent in patients with moderate/severe PH. Procedural characteristics and complications were comparable between the groups. Although there was an early overall decrease in SPAP postprocedure, only 26% of moderate/severe patients with PH experienced a significant decrease in SPAP (>10 mm Hg). The 30-day (14.5% vs 7.4%, p = 0.02) and 1-year mortality (30.8% vs 21%, p = 0.02) was higher in moderate/severe patients with PH. In multivariate analysis, systolic pulmonary artery pressure and chronic lung disease were identified as independent predictors for mortality at 1 year. PH is a frequent co-morbidity in patients with severe aortic stenosis who underwent TAVR. Significantly elevated pulmonary artery pressures at baseline may serve as a poor prognostic factor when performing preprocedural assessment of the patients.

Arrhythmia burden in elderly patients with severe aortic stenosis as determined by continuous electrocardiographic recording: toward a better understanding of arrhythmic events after transcatheter aortic valve replacement.

This study sought to evaluate the prevalence of previously undiagnosed arrhythmias in candidates for transcatheter aortic valve replacement (TAVR) and to determine the impact on therapy changes and arrhythmic events after the procedure. A total of 435 candidates for TAVR underwent 24-hour continuous ECG monitoring the day before the procedure. Newly diagnosed arrhythmias were observed in 70 patients (16.1%) before TAVR: paroxysmal atrial fibrillation (AF)/atrial tachycardia (AT) in 28, advanced atrioventricular block or severe bradycardia in 24, nonsustained ventricular tachycardia in 26, and intermittent left bundle-branch block in 3 patients. All arrhythmic events but one were asymptomatic and led to a therapy change in 43% of patients. In patients without known AF/AT, the occurrence of AF/AT during 24-hour ECG recording was associated with a higher rate of 30-day cerebrovascular events (7.1% versus 0.4%; P=0.030). Among the 53 patients with new-onset AF/AT after TAVR, 30.2% had newly diagnosed paroxysmal AF/AT before the procedure. In patients who needed permanent pacemaker implantation after the procedure (n=35), 31.4% had newly diagnosed advanced atrioventricular block or severe bradycardia before TAVR. New-onset persistent left bundle-branch block after TAVR occurred in 37 patients, 8.1% of whom had intermittent left bundle-branch block before the procedure. Newly diagnosed arrhythmias were observed in approximately a fifth of TAVR candidates, led to a higher rate of cerebrovascular events, and accounted for a third of arrhythmic events after the procedure. This high arrhythmia burden highlights the importance of an early diagnosis of arrhythmic events in such patients to implement the appropriate therapeutic measures earlier.

Echo Doppler Estimation of Pulmonary Capillary Wedge Pressure in Patients with Severe Aortic Stenosis.

Transcatheter aortic valve replacement (TAVR) has become a treatment option for patients with severe aortic stenosis (AS) and high surgical risk. Assessment of symptoms in these patients is challenging because of advanced age, comorbidities, and limited physical activity. Noninvasive quantification of pulmonary capillary wedge pressure (PCWP) in candidates for TAVR may be helpful for risk stratification. The objective of the study was to create a model for estimation of PCWP by echo Doppler in patients with severe AS. Data from 80 patients with severe AS referred for TAVR were used to develop an echo Doppler model for predicting PCWP. Its performance was evaluated in the test cohort of 33 patients who had invasive and noninvasive evaluation. No single echo Doppler parameter estimated PCWP accurately. In the retrospective analysis, the multilinear regression provided an accurate estimate of PCWP (r(2) = 0.74). The model included, in order of importance (all P < 0.05), the ratio of early transmitral velocity (E) to annular velocity (E'), the left ventricular ejection fraction, and the velocity time integral of tricuspid regurgitation signal. In the prospective cohort of patients with severe AS, the model demonstrated good predictive ability of PCWP (r = 0.77, P < 0.01). In patients with severe AS, noninvasive estimation of PCWP is possible by integration of two-dimensional, spectral, and tissue Doppler variables.

High-Risk Patients With Inoperative Aortic Stenosis: Use of Transapical, Transaortic, and Transcarotid Techniques

Patient characteristics and procedural outcomes from nontransfemoral (non-TF) transcatheter aortic valve replacement (TAVR) in high-risk or inoperable patients with aortic stenosis have been incompletely reported. The purpose of this study was to compare outcomes with non-TF TAVR access techniques including transapical (TA), transaortic (TAo), and transcarotid (TC) TAVR with a balloon-expandable valve. A retrospective review was performed of all patients undergoing TA, TAo, and TC TAVR from 2007 to 2013 at Emory University. Preoperative risk factors and postoperative outcomes were evaluated using Valve Academic Research Consortium-2 definitions. Of 469 patients undergoing TAVR during that period at our institution, 139 underwent TA TAVR, 35 had Tao TAVR, and 11 had TC TAVR. Patients undergoing TC TAVR were younger than those undergoing TA TAVR and TAo TAVR (mean ages: TC, 68.9 ± 23.6 years; TA, 81.3 ± 7.7 years; Tao, 83.8 ± 8.3 years; p= 0.017). Most patients undergoing TAo TAVR were women (82.9%), whereas patients undergoing TA TAVR were more likely to be men (62.6%). Slightly more than half of patients undergoing TA TAVR (54.7%) and TC (54.6%) TAVR hadundergone previous coronary artery bypass grafting (CABG), whereas no patients underwent TAo TAVR (0%). There was no preoperative difference in ejection fraction, New York Heart Association classification, significant chronic obstructive pulmonary disease, and The Society of Thoracic Surgeons predicted risk of mortality between TA TAVR, Tao TAVR, and TC TAVR, respectively. Average postoperative length of stay was 9 to 11 days and was similar among groups (p= 0.22). There were 13 (9.4%) TA TAVR operative deaths and 4 (11.4%) operative deaths in the TAo TAVR group. There were no deaths in the TC TAVR group. In high-risk and inoperable patients who are not candidates for TF TAVR, careful selection of alternative access options can lead to excellent and comparable postoperative outcomes.

Effect on Outcomes and Exercise Performance of Anemia in Patients With Aortic Stenosis Who Underwent Transcatheter Aortic Valve Replacement

The objectives of this study were to determine the causes and impact of anemia and hemoglobin level on functional status, physical performance, and quality of life in the preprocedural evaluation and follow-up of transcatheter aortic valve replacement (TAVR) candidates. A total of 438 patients who underwent TAVR were included. Anemia was defined as a hemoglobin level <12g/dl in women and <13g/dl in men. Before TAVR, anemia was encountered in 282 patients (64.4%). A potential treatable cause of anemia was detected in 90.4% of patients and was attributed to iron deficiency in 53% of them. The occurrence of anemia was an independent predictor of poorer performance in the 6-minute walk test (6MWT), a lower Duke Activity Status Index score, and Kansas City Cardiomyopathy Questionnaires overall, clinical, and social limitation scores (p <0.05 for all). A lower hemoglobin level was associated with a higher prevalence of New York Heart Association class III to IV (p <0.001) and correlated negatively with the results of all functional tests (p <0.02 for all). At follow-up, anemia was found in 62% of patients and was associated with poorer performance in the 6MWT (p= 0.023). A lower hemoglobin level after TAVR was a predictor of poorer New York Heart Association class (p= 0.020) and correlated negatively with the distance walked in the 6MWT (r=-0.191, p= 0.004) and Duke Activity Status Index score (r=-0.158, p= 0.011) at 6-month follow-up. In conclusion, anemia was very common in TAVR candidates and was attributed to iron deficiency in more than half of them. The presence of anemia and lower hemoglobin levels determined poorer functional status before and after the TAVR procedure. These results highlight the importance of implementing appropriate measures for the diagnosis and treatment of this frequent co-morbidity to improve both the accuracy of preprocedural evaluation and outcomes of TAVR candidates.

Transcatheter aortic valve replacement: from the femoral artery to the left ventricular apex--the spectrum to access.

The role of transcatheter aortic valve replacement (TAVR) continues to evolve and expand at a rapid pace. The advanced age and frailty of many TAVR candidates often presents complex vascular access challenges when contemplating the exact route of valve delivery. As the indications and approved routes of delivery have evolved, so have the direct open vascular and percutaneous techniques paramount to success. We review the spectrum of access options that may be available for consideration during TAVR procedures and highlight the "pearls and pitfalls" of each technique. We additionally highlight reasons a technique may be preferred for a specific patient subset, as well as the concerns addressed by the anesthesiologist in approaching TAVR.

Dual-source CT imaging to plan transcatheter aortic valve replacement: accuracy for diagnosis of obstructive coronary artery disease.

To assess the accuracy of computed tomographic (CT) examinations performed for the purpose of transcatheter aortic valve replacement (TAVR) planning to diagnose obstructive coronary artery disease (CAD). With institutional review board approval, waivers of informed consent, and in compliance with HIPAA, 100 consecutive TAVR candidates (61 men, mean age 79.6 years ± 9.9) who underwent both TAVR planning CT (with a dual-source CT system) and coronary catheter (CC) angiographic imaging were retrospectively analyzed. At both modalities, the presence of stenosis in the native coronary arteries was assessed. Additionally, all coronary bypass grafts were rated as patent or occluded. With CC angiographic imaging as the reference standard, the accuracy of CT for lesion detection on a per-vessel and per-patient basis was calculated. The accuracy of CT for the assessment of graft patency was also analyzed. For per-vessel and per-patient analysis for the detection of stenosis that was 50% or more in the native coronary arteries, CT imaging had, respectively, 94.4% and 98.6% sensitivity, 68.4% and 55.6% specificity, 94.7% and 93.8% negative predictive value (NPV), and 67.0% and 85.7% positive predictive value. Per-patient sensitivity of stenosis 50% or greater with CT for greater than 70% stenosis at CC angiographic imaging was 100%. All 12 vessels in which percutaneous coronary intervention was performed were correctly identified as demonstrating stenosis 50% or greater with CT. There was agreement between CT and CC angiographic imaging regarding graft patency in 114 of 115 grafts identified with CC angiographic imaging. TAVR planning CT has high sensitivity and NPV in excluding obstructive CAD. An additional preprocedural CC angiographic examination may not be required in TAVR candidates with a CT examination that does not show obstructive CAD.

The safety of deep hypothermic circulatory arrest in aortic valve replacement with unclampable aorta in non-octogenarians.

Aortic valve replacement (AVR) in patients with severely atherosclerotic aortas (porcelain aorta) presents a significant technical challenge. Two strategies are deep hypothermic circulatory arrest (DHCA) during conventional surgery and transcatheter aortic valve replacement (TAVR). The aim of this study was to examine the outcomes in patients who underwent DHCA for AVR with a porcelain aorta to identify whether older patients are more suitable for TAVR. Between October 2004 and December 2012, 122 patients underwent AVR using DHCA for atherosclerotic aorta. Patients with concomitant valve surgery were excluded. Overall, 63.9% (78/122) were of age <80 (non-octogenarian group, NOG) and 36.1% (44/122) were >80 (octogenarian group, OG). Of the total cohort, 62.3% (76/122) had concomitant coronary artery bypass graft surgery. The mean age for the whole cohort was 75.7 ± 8.5 years; 70.2 ± 8.1 years for the NOG and 83.4 ± 2.6 years for the OG (P = 0.001). The OG had a higher rate of preoperative renal failure (20.5%, 9/44 vs 7.7%, 6/78, P = 0.048) and trends towards a greater history of cerebrovascular disease (9.1%, 4/44 vs 1.3%, 1/78, P = 0.056), but fewer reoperations (6.8%, 3/44 vs 19.2%, 15/78, P = 0.069). Cardiopulmonary bypass time, aortic cross-clamp time and circulatory arrest time were similar between the two groups. Postoperative complication rates were similar except for permanent stroke (OG 18.2%, 8/44 vs NOG 6.4%, 5/78, P = 0.065). The overall operative mortality rate was 8.2% (10/122); however, the OG had significantly higher operative mortality compared with the NOG (15.9%, 7/44 vs 3.8%, 3/78, P = 0.035). One- and 5-year survival rates were 88.9 and 79.3% for the NOG versus 75.0 and 65.9% for the OG (P = 0.027), respectively. Postoperative neurological events and operative mortality were, respectively, 3- and 4-fold higher in octogenarians undergoing AVR using DHCA. Such patients may represent suitable candidates for TAVR if favourable outcomes are demonstrated in patients with atherosclerotic aortas. Surgical AVR remains the standard treatment option with excellent outcomes for patients <80 years old with unclampable aortas.

Abstract 313: Risk Factors for Mortality in Patients with Severe Aortic Stenosis Referred for Transcatheter Aortic Valve Implantation Who Remain Untreated

Background: The availability of transcatheter aortic valve replacement (TAVR) has expanded the proportion of patients with severe aortic stenosis (AS) who are candidates for valve replacement. Nevertheless, many patients decline or are not candidates for TAVR or surgical replacement, and their prognosis and risk factors for mortality are incompletely understood. Methods: We examined 148 patients with severe AS referred for TAVR, but not treated with an aortic valve procedure, and with complete echocardiography and at least 3 months of follow-up. We determined all-cause mortality using the social security death index, and compared patient characteristics and echocardiography findings between survivors and non-survivors. Results: Mean age was 78.9±10.4 years, and 53.4% were male. Mean follow-up was 10.3±8.7 months, and death occurred in 63 (42.6%) of patients. Mean follow-up for survivors was 14.4±8.6 months, and mean time to death was 4.7±5.2 months. Cumulative survival was 55.7% and 47.2% at 1 and 2 years, respectively. Table 1 provides unadjusted and adjusted variables associated with all-cause mortality. Conclusions: Patients with severe AS referred for TAVR but remaining untreated experience a mortality rate of nearly 50% at one year. While comorbidities were not associated with mortality, presenting clinical variables and echocardiography findings can identify patients at increased risk of death.

Role of Advanced Cardiac Imaging in Transcatheter Aortic Valve Replacement Planning

The fast development of transcatheter aortic valvereplacement (TAVR) would not have possible withoutthe invaluable collaboration of multimodal cardiac imaging,particularly transesophageal echocardiography(TEE) and computerized axial tomography (CT scan).Given the elevated morbimortality associated with severeaortic stenosis (AS) presenting high surgical risk,an adequate selection of TAVR candidates is of vitalimportance for the program´s success. (1) This reviewdescribes the role of these techniques for the appropriateselection of candidates, vascular access routeevaluation and procedure planning in patients withsevere AS considered at high surgical risk.