Case Of Transcatheter Aortic Valve Replacement Research Articles

Abstract 4136013: Pre-operative Frailty Status and Short-term Complications Among Adults Undergoing Transcatheter Aortic Valve Replacement

Introduction: The use of Transcatheter Aortic Valve Replacement(TAVR) has provided a safer alternative to open surgical approaches. The introduction of frailty scoring systems has proven effective in improving healthcare approaches and outcomes in various aspects of medicine. As there is a paucity of data on the impact of frailty among TAVR patients, we aim to conduct a retrospective study to investigate further. Methods: Our study analyzed adult cases with a primary procedural code for TAVR among hospitalizations between 2016 and 2021 through the National Inpatient Sample(NIS). Frailty status was explored through the criteria of Gilbert’s frailty index. Multivariable regression models helped evaluate differences in short-term outcomes and complications between them. Results: Our study involved 374200 cases of TAVR that were divided into LFR(285425 cases, 76.3%), IFR(86005 cases, 23.0%), and HFR(2770 cases, 0.7%). Compared to patients with LFR, patients with MFR and HFR showed higher odds of several complications, including cardiogenic shock(MFR: aOR 6.933, p<0.001, HFR: aOR 13.303, p<0.001), acute kidney injury(MFR: aOR 9.737, p<0.001, HFR: aOR 26.685, p<0.001 ), use of invasive mechanical ventilation(MFR: aOR 10.763, p<0.001,HFR: aOR 39.432, p<0.001), events of acute myocardial infarction(MFR: aOR 3.32, p<0.001, HFR: aOR 6.021, p<0.001), need for transfusion of blood products(MFR: aOR 3.027, p< 0.001, HFR: aOR 5.938,p<0.001), post-procedural bleeding(MFR: aOR 2.475, p<0.001, HFR: aOR 3.277, p<0.001), IABP use(MFR: aOR 4.942, p<0.001, HFR: aOR 9.703, p<0.001), and need for pericardiocentesis(MFR: aOR 3.804, p<0.001, HFR: aOR 4.217, p<0.001). Moreover, patients with MFR and HFR reported higher mortality risks than those with LFR(MFR: aOR 6.375, p<0.001, HFR: aOR 16.035, p<0.001 )(Table 1). Conclusion: Our study confirms the higher odds of various complications with increasing frailty status, including all-cause in-hospital death. A careful assessment of pre-operative frailty status along with close monitoring of pre-, peri-, and post-operative status will help improve the outcomes and provide care in a timely fashion.

TAVR with self- expandable valves: what challenges in bicuspid aortic valve disease?

Background: The bicuspid aortic valve (BAV) represents a complex anatomic entity for transcatheter aortic valve replacement (TAVR) because of its unique technical challenges. All the randomized clinical trials comparing outcomes of TAVI with surgery till date, have excluded patients with bicuspid aortic valve. The only data in literature come from empirical observations, with large variability in implantation techniques across different centers and operators. Objective: These case reports describe the results of transcatheter aortic valve replacement (TAVR) in bicuspid aortic valve stenosis (BAV) using self-expandable valves with their clinical, imaging, procedural, and follow-up settings. Case reports: We report 3 cases of TAVR with BAV. The patients were at high risk of surgery. Baseline cardiac computed tomography (CT) was analyzed by interventional cardiologists. We used self-expandable valves in all the procedures. There were no cases of valve embolization or need for a second valve, no post-dilatation, no cases of moderate or severe aortic regurgitation, and none of the cases required a permanent pacemaker implantation. Conclusion: With the available observational data, it seems that TAVI is indeed technically feasible in selected BAV patients with acceptable results. Self-expandable valves can be safe and effective devices for these procedures. Most of the current data studies highlight the importance of preprocedural imaging determining the outcome of TAVI in BAV patients. Advancements device iterations and procedural refinements will continue to improve the outcomes of these patients treated by TAVR.

Sex differences in transcatheter aortic valve replacement outcomes among patients with bicuspid aortic stenosis

BackgroundDespite comprising almost half of all patients undergoing valvular repair, data on transcatheter aortic valve replacement (TAVR) in patients with bicuspid aortic stenosis (BAS) are limited. ObjectiveWe aimed to evaluate whether there are any sex differences in trends and outcomes of TAVR in this population. MethodsWe utilized the National Inpatient Sample from 2012 to 2020 to identify admissions with BAS who underwent TAVR and analyzed trends and outcomes. Our primary outcome was in-hospital mortality and secondary outcomes were in-hospital complications. We used two models to adjust for demographics (A) and interventions (B). ResultsBetween 2012 to 2020, there were 76,540 hospitalizations for BAS patients who underwent AVR, among which 6,010 (7.9 %) underwent TAVR. There was an overall increasing trend in number of TAVR cases with a decreasing trend in mortality (2013: 8.7 %, 2020: 1.3 %). TAVR was performed more in males (61.1% vs 38.9 %). Despite the worse baseline characteristics in males, in-hospital mortality (2.4% vs. 1.5 %; OR: 1.584; 95 % CI: 0.621–4.038; p = 0.335) and secondary outcomes were similar across both sexes, even after adjusting for demographics and interventions. ConclusionTAVR in BAS has grown rapidly in the last decade. Males comprised the majority and had more comorbidities, but mortality and complications were similar in both sexes. Despite the increasing number of cases, a decreasing trend in mortality was observed for both sexes ultimately approaching that of SAVR, suggesting that TAVR may be a safe alternative among eligible males and females with bicuspid AS.

E-48 | Urgency Unmasked: The Association Between Elective and Urgent Transcatheter Aortic Valve Replacement Cases and Patient Outcomes

E-48 | Urgency Unmasked: The Association Between Elective and Urgent Transcatheter Aortic Valve Replacement Cases and Patient Outcomes

The impact of concomitant chronic total occlusion on clinical outcomes in patients undergoing transcatheter aortic valve replacement: a large single-center analysis.

Coronary artery disease (CAD) is a common finding in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement (TAVR). However, the impact on prognosis of chronic total occlusions (CTOs), a drastic expression of CAD, remains unclear. We retrospectively reviewed 1,487 consecutive TAVR cases performed at a single tertiary care medical center. Pre-TAVR angiograms were analyzed for the presence of a CTO. At the time of TAVR, 11.2% (n = 167) patients had a CTO. There was no significant association between the presence of a CTO and in-hospital or 30-day mortality. There was also no difference in long-term survival. LV ejection fraction and mean aortic gradients were lower in the CTO group. Our analysis suggests that concomitant CTO lesions in patients undergoing TAVR differ in their risk profile and clinical findings to patients without CTO. CTO lesion per se were not associated with increased mortality, nevertheless CTOs which supply non-viable myocardium in TAVR population were associated with increased risk of death. Additional research is needed to evaluate the prognostic significance of CTO lesions in TAVR patients.

Impact of the COVID-19 Pandemic on Global TAVR Activity: The COVID-TAVI Study

BackgroundThe COVID-19 pandemic adversely affected health care systems. Patients in need of transcatheter aortic valve replacement (TAVR) are especially susceptible to treatment delays. ObjectivesThis study sought to evaluate the impact of the COVID-19 pandemic on global TAVR activity. MethodsThis international registry reported monthly TAVR case volume in participating institutions prior to and during the COVID-19 pandemic (January 2018 to December 2021). Hospital-level information on public vs private, urban vs rural, and TAVR volume was collected, as was country-level information on socioeconomic status, COVID-19 incidence, and governmental public health responses. ResultsWe included 130 centers from 61 countries, including 65,980 TAVR procedures. The first and second pandemic waves were associated with a significant reduction of 15% (P < 0.001) and 7% (P < 0.001) in monthly TAVR case volume, respectively, compared with the prepandemic period. The third pandemic wave was not associated with reduced TAVR activity. A greater reduction in TAVR activity was observed in Africa (−52%; P = 0.001), Central-South America (−33%; P < 0.001), and Asia (−29%; P < 0.001). Private hospitals (P = 0.005), urban areas (P = 0.011), low-volume centers (P = 0.002), countries with lower development (P < 0.001) and economic status (P < 0.001), higher COVID-19 incidence (P < 0.001), and more stringent public health restrictions (P < 0.001) experienced a greater reduction in TAVR activity. ConclusionsTAVR procedural volume declined substantially during the first and second waves of the COVID-19 pandemic, especially in Africa, Central-South America, and Asia. National socioeconomic status, COVID-19 incidence, and public health responses were associated with treatment delays. This information should inform public health policy in case of future global health crises.

Abstract 13661: In-Hospital Outcomes, Rates of Development of Complete Heart Block and Rates of Pacemaker Placement in TAVR and SAVR Cases: A 5-year Nationwide Inpatient Sample Analysis

Introduction: Complete Heart Block (CHB) is a commonly observed post-procedural complication associated with Transcatheter aortic valve replacement (TAVR) and Surgical aortic valve replacement (SAVR). Since 2016, limited data exists on In-hospital outcomes of TAVR and SAVR cases and rates of development of CHB. Methods: National Inpatient Sample 2016-2020 was used to identify and group TAVR and SAVR cases using appropriate ICD codes. Logistic regression was used to compare baseline characteristics and in-hospital outcomes. Results: 590,615 patients underwent aortic valve replacement (AVR) from 2016-2020, of which 49.6% were TAVR and 50.4% were SAVR. The most common diagnosis for AVR in both groups was nonrheumatic trileaflet aortic stenosis (AS) (86.6% in TAVR group and 53.5% in SAVR group, p&lt;0.001). In TAVR cases, development of CHB was more common (8.9%-vs-7.2%, p=0.235) along with increased need for transvenous pacing (16.6%-vs-8.7%, p=0.010) and permanent pacemaker placement (9.4%-vs-6.4%, p&lt;0.001). An upward trend in CHB occurrence and pacemaker placement (PPM) was noted in the TAVR group as shown in Image 1. TAVR group was observed to have higher rates of acute myocardial infarction (MI) (14.5%-vs-12.8%, p=0.074). SAVR group had higher rates of cardiogenic shock (8.10%-vs-2.20, p&lt;0.001) and in-hospital mortality (3.6%-vs-1.30%, p=0.02). Conclusions: Over the past few years, CHB has been more commonly observed with TAVR as compared to SAVR, necessitating increasing use for PPM placement. Despite these trends, in-hospital mortality and complications are lower with TAVR procedure.

Clinical outcomes of MANTA closure device in percutaneous endovascular aortic aneurysm repair

ObjectiveThe MANTA device is a plug-based vascular closure device (VCD) designed for large bore femoral arterial access site closure. It showed promising results in transcatheter aortic valve replacement cases. In this study, we report our results and evaluate the MANTA VCD in percutaneous endovascular aortic aneurysm repair (pEVAR). MethodsAll data of consecutive patients who underwent an elective pEVAR between October 2018 and December 2022 were retrospectively reviewed. In all patients at least one common femoral artery was intended to close with the MANTA VCD. Depending on the sheath size, the 14Fr or 18Fr MANTA VCD was used. On the preoperative computed tomography scan, the diameter of the common femoral artery (CFA) was measured and the amount of calcification based on the Peripheral Arterial Calcium Scoring System (PACSS) was scored. Primary outcome was procedural technical success. Procedural technical success was defined as placement of the MANTA closure device resulting in vascular closure with patent CFA, without requiring immediate open or endovascular surgery. The secondary outcomes were access site complications requiring reintervention and all-cause mortality at 30-day follow-up. ResultsIn total, 152 consecutive patients underwent pEVAR with 291 common femoral artery closure procedures with the Manta VCD. Mean age was 74.1 ± 6.4 years, with a mean body mass index of 27.7 ± 4.4 kg/m2. The mean diameter of the CFA was 10.5 ± 1.9 mm. In 52.6% of the cases, there were no calcification on the preoperative computed tomography scan. The 18Fr and 14Fr Manta VCD were used 169 and 122 times, respectively. The technical success rate was 96.6%. Major vascular complications were reported in 4.5% of the cases, without any death-related events. ConclusionsThis single-center retrospective cohort study analyzed the procedural technical success, major vascular complications and all-cause mortality at 30-day follow-up of the MANTA vascular closure device in 152 pEVAR patients with 291 common femoral artery closure procedures. The technical success rate was 96,6%. Major vascular complications were reported in 4.5% of the cases, without any death related events. We concluded that the MANTA device is a safe and feasible option with a high rate of technical success in patients undergoing pEVAR.

Transcatheter Aortic Valve Replacement in Patients With or Without Active Cancer.

Background Data on clinical outcomes after transcatheter aortic valve replacement (TAVR) in specific cancer types or the presence of metastatic disease remain sparse. This study aimed to investigate the impact of active cancer on short-term mortality, complications, and readmission rates after TAVR across different cancer types. Methods and Results The authors assessed the Nationwide Readmissions Database for TAVR cases from 2012 to 2019. Patients were stratified by specific cancer types. Primary outcome was in-hospital mortality. Secondary outcomes included bleeding requiring blood transfusion and readmissions at 30, 90, and 180 days after TAVR. Overall, 122 573 patients undergoing TAVR were included in the analysis, of whom 8013 (6.5%) had active cancer. After adjusting for potential confounders, the presence of active cancer was not associated with increased in-hospital mortality (adjusted odds ratio [aOR], 1.06 [95% CI, 0.89-1.27]; P=0.523). However, active cancer was associated with an increased risk of readmission at 30, 90, and 180 days after TAVR and increased risk of bleeding requiring transfusion at 30 days. Active colon and any type of metastatic cancer were individually associated with readmissions at 30, 90, and 180 days after TAVR. At 30 days after TAVR, colon (aOR, 2.51 [95% CI, 1.68-3.76]; P<0.001), prostate (aOR, 1.40 [95% CI, 1.05-1.86]; P=0.021), and any type of metastatic cancer (aOR, 1.65 [95% CI, 1.23-2.22]; P=0.001) were individually associated with an increased risk of bleeding requiring transfusion. Conclusions Patients with active cancer had similar in-hospital mortality after TAVR but higher risk of readmission and bleeding requiring transfusion, the latter depending on certain types of cancer.

Comprehensive Shielding System Enhances Radiation Protection for Structural Heart Procedures

BackgroundThis study of radiation exposure (RE) to physicians performing structural heart procedures evaluated the efficacy of a novel comprehensive radiation shield compared to those of traditional shielding methods. A novel comprehensive shielding system (Protego, Image Diagnostics Inc) has been documented to provide superior RE protection during coronary procedures compared to that provided by a standard “drop down” shield. The purpose of this study was to assess the efficacy of this shield in transcatheter aortic valve replacement (TAVR) procedures, which are associated with disproportionate RE to operators. MethodsThis single-center, 2-group cohort, observational analysis compared RE to the primary physician operator performing TAVR using the Protego shield (n = 25) with that using a standard drop-down shield with personal leaded apparel (n = 25). RE was measured at both thyroid and waist levels with a real-time dosimetry system (RaySafe i3, RaySafe) and was calculated on a mean per case basis. Data were collected on additional procedural parameters, including access site(s) for device implantation, per case fluoroscopy time, air kerma, and patient factors, including body mass index. Between-group comparisons were conducted to evaluate RE by group and measurement sites. ResultsThe Protego system reduced operator RE by 99% compared to that using standard protection. RE was significantly lower at both the thyroid level (0.08 ± 0.27 vs 79.2 ± 62.4 μSv; P < .001) and the waist level (0.70 ± 1.50 vs 162.0 ± 91.0 μSv, P < .001). “Zero” total RE was documented by RaySafe in 60% (n = 15) of TAVR cases using Protego. In contrast, standard protection did not achieve zero exposure in a single case. ConclusionsThe Protego shield system provides superior operator RE protection during TAVR procedures. This shield allows operators to work without the need for personal lead aprons and has potential to reduce catheterization laboratory occupational health hazards.

Development and Validation of a Machine Learning Risk-Prediction Model for 30-Day Readmission for Heart Failure Following Transcatheter Aortic Valve Replacement (TAVR-HF Score)

Transcatheter aortic valve replacement (TAVR) is the treatment of choice for patients with severe aortic stenosis across the spectrum of surgical risk. About one-third of 30-day readmissions following TAVR are related to heart failure (HF). Hence, we aim to develop an easy-to-use clinical predictive model to identify patients at risk for HF readmission. We used data from the National Readmission Database (2015-2018) utilizing ICD-10 codes to identify TAVR procedures. Readmission was defined as the first unplanned HF readmission within 30-day of discharge. A machine learning framework was used to develop a 30-day TAVR-HF readmission score. The receiver operator characteristic curve was used to evaluate the predictive power of the model. A total of 92,363 cases of TAVR were included in the analysis. Of the included patients, 3299 (3.6%) were readmitted within 30 days of discharge with HF. Individuals who got readmitted, vs those without readmission, had more emergent admissions during index procedure (33.4% vs 19.8%), electrolyte abnormalities (38% vs 16.7%), chronic kidney disease (34.8% vs 21.2%), and atrial fibrillation (60.1% vs 40.7%). Candidate variables were ranked by importance using a parsimony plot. A total of 7 variables were selected based on predictive ability as well as clinical relevance: HF with reduced ejection fraction (25 points), HF preserved EF (20 points), electrolyte abnormalities (17 points), atrial fibrillation (12 points), Charlson comorbidity index (<6 = 0, 6-8 = 9, 9-10 = 13, >10 = 14 points), chronic kidney disease (7 points), and emergent index admission (5 points). On performance evaluation using the testing dataset, an area under the curve of 0.761 (95% CI 0.744-0.778) was achieved. Thirty-day TAVR-HF readmission score is an easy-to-use risk prediction tool. The score can be incorporated into electronic health record systems to identify at-risk individuals for readmissions with HF following TAVR. However, further external validation studies are needed.

Procedural Volume and Outcomes of Transfemoral Transcatheter Aortic Valve Replacement: From a Japanese Nationwide Registry

The impact of procedural volume on transcatheter aortic valve replacement (TAVR) outcomes in Japan remains uncertain. Japan has carefully introduced TAVR after the establishment of techniques in Western countries and therefore may not exhibit volume-outcome relations after TAVR. Data on transfemoral TAVR was collected from the Japan Transcatheter Valve Therapy (J-TVT) registry between 2018 and 2020. Hospitals were categorized into quartiles (lowest, lower, high, and highest) based on annual TAVR volume. The primary analysis compared 30-day mortality among different TAVR volume hospitals. A multivariable adjustment analysis was performed to calculate the adjusted odds ratio (aOR) and 95% confidence intervals (CIs) of 30-day all-cause mortality with highest-volume hospital as the reference. A total of 2,741 transfemoral TAVR cases from 172 hospitals were included in the analysis. Median hospital TAVR volume was 38 (interquartile range 27 to 60) per year. Unadjusted 30-day mortality was 0.46%, 0.69%, 1.17%, and 1.18% from the lowest to the highest quartile of hospitals, respectively. There was no significant difference in 30-day mortality rates for lowest-volume hospitals (aOR 0.51, 95% CI 0.24 to 1.05, p=0.07), low-volume hospitals (aOR 0.76, 95% CI 0.46 to 1.26, p=0.29), or high-volume hospitals (aOR 1.11, 95% CI 0.74 to 1.67, p=0.60). An analysis from the contemporary national registry in Japan did not find an obvious inverse relation between annual hospital volume and 30-day mortality. Our results suggest that TAVR has now reached a level of procedural maturity, with standardized outcomes observed across hospitals regardless of their annual procedural volume.

A retrospective comparative study of anesthesia with remimazolam and remifentanil versus dexmedetomidine and remifentanil for transcatheter aortic valve replacement

Remimazolam, an ultrashort-acting benzodiazepine, allows for rapid and reliable arousal. Rapid awakening using remimazolam may be beneficial in transcatheter aortic valve replacement (TAVR), as it allows rapid detection of neurologic deficits. The purpose of this study was to compare arousal time and outcomes between monitored anesthesia care (MAC) with remimazolam and remifentanil and conventional MAC with dexmedetomidine, propofol, and remifentanil. This study was a single center retrospective study. All TAVR cases performed under MAC (MAC-TAVR) at our institution between 2019 and 2021 were included. Patients were classified by anesthesia method into remimazolam and dexmedetomidine groups. Among 258 MAC-TAVR patients, 253 were enrolled. After propensity score matching, 76 patients were assigned to each group. The time from end of drug-administration to arousal [20.0 (16.0, 24.0) min vs. 38.5 (30.0, 56.3) min, p < 0.0001] and the time from attempted-arousal to arousal [1.0 (1.0, 1.0) min vs. 12.5 (3.0, 26.8) min, p < 0.0001] were significantly shorter in the remimazolam group. There was no significant difference in the length of ICU stay [2.0 (2.0, 2.0) days vs. 2.0 (2.0, 2.0) days, p = 0.157] and postoperative hospital stay [6.0 (4.0, 9.0) days vs. 5.0 (4.0, 8.0) days, p = 0.262].Trial registration: Clinical trial number: R03-123, Registry URL: https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000051635Registration number: UMIN000045195, Principal investigator's name: Atsuhiro Kitaura,Date of registration: 20 August 2021.

Regional differences in the utilization and outcomes of cerebral embolic protection during transcatheter aortic valve replacement: an analysis of the National Inpatient Sample from 2017 through 2019.

Aim: To evaluate the utilization and outcomes of cerebral embolic protection (CEP) during transcatheter aortic valve replacement (TAVR) by USA region, using discharge data from the National Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality. Patients & methods: All TAVR discharge encounters from June 2017-2019 were included in the analysis. Discharge encounters with bicuspid anatomy were excluded. Regional CEP utilization rates were reported. For TAVR cases performed with the Sentinel CEP device (Boston Scientific, MA, USA), multivariable logistic regression was performed to model regional differences in TAVR outcomes including: stroke, transient ischemic attack (TIA), stroke/TIA combined, and in-hospital all-cause mortality. Generalized linear regression models were used to assess regional differences in length of stay (LOS) and hospital charges. Results: The Northeast had the greatest overall CEP utilization rate (11.3%), followed by the Midwest (11.1%), West (8.7%), then South (3.1%). Compared with the Northeast, the South was associated with a lower risk of stroke (OR: 0.267, 95% CI: 0.106-0.673; p= 0.005), and the West a higher risk of stroke (OR: 1.583, 95% CI: 1.044-2.401; p= 0.031). Compared with the Northeast, the West was associated with a higher risk of stroke/TIA combined (OR: 1.618, 95% CI: 1.107-2.364; p= 0.013). Compared with the Northeast, the Midwest (OR: 4.501, 95% CI: 2.229-9.089; p< 0.001) and West (OR: 5.316, 95% CI: 2.611-10.824; p< 0.001) were associated with a higher risk of in-hospital all-cause mortality. Adjusted charges and LOS were highest in the West. Conclusion: Within the USA, there are regional differences in the utilization and outcomes of CEP use during TAVR. To prevent regional disparities and ensure consistent quality of care in the USA, further research is needed to determine what variable(s) may be responsible for regional differences in TAVR outcomes, with or without CEP.

Referral for Cardiac Amyloidosis in Patients Who Underwent Transcatheter Aortic Valve Replacement: Results of the Quality Outcome Project.

Background Transthyretin cardiac amyloidosis (ATTR) is an important comorbidity present in severe aortic stenosis (AS). The purpose of this study was to raise awareness of ATTR in patients who underwent transcatheter aortic valve replacement (TAVR) for severe AS among healthcare providers and patients. Methodology We reviewed 197 consecutive TAVR cases performed from 2019 to 2020. Adapting predefined high-risk features for ATTR based on prior literature, we contacted the patients to discuss our clinical suspicion of ATTR and offered a referral to a cardiac amyloid specialist. Results We identified 125 (69.4%) patients who had high-risk features of ATTR. Of the 105 patients contacted, 44 patients agreed to referral, 46 patients were not able to be contacted after several attempts, and 15 patients declined referral. Of the 44 patients who agreed to the referral, 20 patients completed the evaluation for cardiac amyloidosis, all of whom were negative for transthyretin and light-chain cardiac amyloidosis. Conclusions Our attempt to detect ATTR in prior TAVR patients was unsuccessful two to three years post-TAVR. We believe that early detection of cardiac amyloidosis close to the timing of TAVR is important and the most effective means.

Ventricular pacing dependency after transcatheter aortic valve replacement: a prospective cohort.

Atrioventricular conduction disturbance occurs in a significant number of patients undergoing transcatheter aortic valve replacement (TAVR). However, not all cases are ventricular pacing-dependent. Thus, we aimed to study the incidence, predictors, and outcomes of new ventricular pacing dependency (VpDep) after TAVR. We prospectively analyzed 130 consecutive transfemoral TAVR cases performed in Ramathibodi Hospital between 2015 and 2020. Three patients with prior ventricular pacing-dependent on cardiac implantable electronic devices (CIEDs) were excluded. The endpoints were VpDep at 1 month and all-cause mortality at the follow-up period end in 2021. The effects of variables on VpDep and all-cause mortality were evaluated using multivariate binary logistic regression and Cox regression analyses, respectively. First-degree atrioventricular block (AVB) was considered severe when the PR interval was >300 ms. Of the 127 patients [mean age, 81.8 years; 62.2% females; 67.7% balloon-expandable (BE) device], 7 patients (5.5%) had CIEDs implanted before TAVR that were not ventricular pacing-dependent. TAVR was successfully performed in 126 (99.2%) patients. Periprocedural stroke, cardiac tamponade, and major bleeding occurred in 2 (1.6%), 4 (3.1%), and 4 (3.1%) patients, respectively. The VpDep incidence at 1 month was 7.9% (n=10) among all patients and 34.5% among those with CIEDs (n=29). VpDep was more likely to occur in patients with pre-existing right bundle branch block (RBBB) [odds ratio (OR), 21.38; 95% confidence interval (CI): 3.28-139.33; P=0.001] and severe 1st degree or Mobitz I AVB (OR, 14.79; 95% CI: 1.65-132.74; P=0.016). After a mean follow-up of 25.8 months [standard deviation (SD), 21.2 months], death from any cause occurred in 18 patients (14.2%). However, VpDep was not associated with an increased mortality. In this real-world cohort, pre-existing conduction abnormalities were significantly associated with a higher risk of VpDep. Mortality was similar between patients with and without VpDep.

Effectiveness and safety of transcatheter aortic valve replacement in elderly people with severe aortic stenosis with different types of heart failure

BackgroundImpaired left ventricular function is an independent predictor of adverse clinical outcomes in patients with aortic stenosis. The aim of this study is to evaluate the short-term changes of echocardiographic parameters, New York Heart Association (NYHA) class and B-type natriuretic peptide (BNP) level and adverse events amongst patients with heart failure (HF) after transcatheter aortic valve replacement (TAVR) procedure.MethodsThis was a retrospective cohort study conducted at affiliated Yantai Yuhuangding Hospital of Qingdao University between September 2017 and September 2022. TAVR cases were stratified into three groups [heart failure with reduced ejection fraction (HFrEF), heart failure with mildly reduced ejection fraction (HFmrEF), heart failure with preserved ejection fraction (HFpEF)] by left ventricular ejection fraction (LVEF). Baseline characteristics, changes in echocardiographic parameters (1 week and 1 month), BNP (1 month), and NYHA class (6 months) post-TAVR were compared across the three groups. Meanwhile, we observed the adverse events of the patients after TAVR.ResultsA total of 96 patients were included, of whom 15 (15.6%) had HFrEF, 15 (15.6%) had HFmrEF, and 66 (68.8%) had HFpEF. Compared to the HFpEF subgroup, patients in the HFrEF subgroup were younger (p < 0.05), and with a higher BNP (p < 0.05). The left ventricular end-diastolic dimension (LVEDD) in HFrEF group decreased significantly after TAVR. HFmrEF and HFrEF patients showed significant improvements in LVEF after TAVR. The pulmonary artery systolic pressure (PASP), aortic valve peak gradient (AVPG) and aortic valve peak gradient (Vmax) decreased significantly 1 month after TAVR in all three groups compared to the baseline (all p < 0.05). BNP significantly reduced in HFrEF group compared to HFpEF patients after TAVR (p < 0.05). The majority of patients experienced an improvement at least one NYHA class in all three groups 6 months post-TAVR. There is no significant increase in the risk of adverse events in the HFrEF group.ConclusionsPatients who underwent TAVR achieved significant improvements in BNP, NYHA class, LVEDD, LVEF, and PASP across the three HF classes, with a more rapid and pronounced improvement in the HFrEF and HFmrEF groups. Complication rates were low in the different HF groups. There is no significant increase in the risk of periprocedural complications in the HFrEF and HFmrEF groups.

Immediate change following valve deployment in left ventricular systolic and diastolic functions in transcatheter aortic valve replacement: a retrospective cohort study.

Transcatheter aortic valve replacement (TAVR) is an effective treatment for aortic valve disorder. Several studies have reported improvements in systolic and diastolic function following TAVR. However, few studies have addressed immediate post-deployment changes. Therefore, this study examines left ventricular (LV) systolic and diastolic function changes immediately after valve deployment in TAVR patients, distinguishing between those with normal and impaired LV ejection fraction (LVEF). In this single-center retrospective cohort study, intraoperative changes in LV systolic and diastolic function were analyzed in patients undergoing TAVR from January 2012 to September 2014. Participants were categorized into two groups based on preprocedural LVEF: the low ejection fraction (EF) group (LVEF <50%) and the normal EF group (LVEF ≥50%). LVEF, as an indicator of LV systolic function, along with lateral e' and the E/e' ratio as indicators of LV diastolic function before and immediately after valve deployment were compared in the overall cohort and within each group. Forty-eight TAVR cases were included, comprising 15 in the low EF group and 33 in the normal EF group. Overall, there was a significant improvement in LVEF {51.7% [standard deviation (SD)] 15.0 vs. 58.0% (SD 11.6), P=0.007}, with no significant changes in e' or E/e'. In the low EF group, a significant increase was observed in LVEF [31.8% (SD 8.0) vs. 45.5% (SD 9.9), P=0.006], e' [5.0 cm/s (SD 1.4) vs. 6.2 cm/s (SD 1.0), P=0.004], and a significant decrease was observed in E/e' [22.3 (SD 7.6) vs. 16.1 (SD 3.4), P=0.01]. The normal EF group showed a significant decrease in e' [6.2 cm/s (SD 1.8) vs. 5.9 cm/s (SD 1.6), P=0.04] without significant changes in LVEF and E/e'. This study revealed significant intraoperative improvements in systolic and diastolic functions immediately after valve deployment in TAVR patients with low preprocedural LVEF. These immediate improvements were not observed in patients with normal LVEF.

Transcarotid Transcatheter Aortic Valve Replacement for Severe Aortic Valve Stenosis with Narrow Aortic Root and Shaggy Aorta: A Case Report

Objective: Transcarotid access for transcatheter aortic valve replacement (TAVR) is a minimally invasive alternative approach if femoral access becomes unfavorable; however, it remains off-label use in Japan.Case Presentation: An 85-year-old female patient with severe aortic valve stenosis presented to our hospital and was diagnosed with acute heart failure. The Society of Thoracic Surgery score and the European System for Cardiac Operative Risk Evaluation 2 were 9.5% and 11.2%, respectively. Computed tomography revealed a small aortic annulus (annulus axis diameter: 18.5 mm × 22.8 mm, perimeter: 67.5 mm, area: 359 mm2), small aortic roots (Valsalva: noncoronary cusp, 22.7 mm; right coronary cusp, 22.8 mm; left coronary cusp, 24.3 mm; sinotubular junction: 18.5 mm × 22.8 mm), and a shaggy aorta with bilateral subclavian artery stenoses. Optimal medical therapy did not work well; therefore, we performed balloon aortic valvuloplasty (BAV). However, BAV did not improve aortic stenosis and worsened aortic regurgitation. The heart team decided to perform transcarotid TAVR owing to the presence of almost no plaque in the left common carotid artery (CCA), and brain magnetic resonance angiography revealed good communications between the anterior and posterior communicating arteries. On the 10th hospital day, transcarotid TAVR was performed, and Sapien 3 20-mm valve was directly implanted during the 30-min clamp time of the left CCA. The procedure was successful, and the clinical course following TAVR was good. Finally, she was discharged to her home on the 24th hospital day.Conclusion: We experienced a successful transcarotid TAVR case. Transcarotid access is a feasible approach in a case requiring an alternative approach.

Vascular management during transcatheter aortic valve replacement.

Transcatheter aortic valve replacement (TAVR), as an alternative to open heart surgery, has been established as the standard therapy for patients with severe aortic valve stenosis. Vascular access management, the first step in a TAVR procedure, should be managed properly. Moreover, the transfemoral and alternatives such as the transaxillary/subclavian, transcarotid, transapical, and transcaval approaches are considered access routes during TAVR. More than 90% of cases can be treated via the transfemoral approach in the current TAVR era, whereas other approaches should be considered in patients in whom the transfemoral approach is not suitable. Vascular complications regardless of access route differences are a specific issue of TAVR caused by the use of large sheaths. With the increased number of TAVR cases, we must manage vascular complications and decrease the morbidity and mortality rates associated with TAVR procedures. Thus, this study aimed to review the vascular complications during TAVR and summarize their prognosis, prevention, and adequate management.