Transcatheter Aortic Valve Replacement For Severe Aortic Stenosis Research Articles

Prognostic significance of preoperative ECG Strain after Transcatheter Aortic Valve Replacement for severe Aortic Stenosis

Electrocardiographic (ECG) Strain, a marker of severity in aortic stenosis and myocardial fibrosis is associated with major cardiovascular events in aortic stenosis (AS) and after surgical aortic valve replacement. We aimed at investigating the clinical significance of preoperative ECG Strain after Transcatheter Aortic Valve Replacement (TAVR). Between April 2008 and December 2015, we prospectively included consecutive patients referred to our Heart Valve Clinic for a first TAVR for severe AS. ECG Strain was defined as a ≥ 1 mm concave downslopping ST-segment depression with T inversion in V5–V6 on preoperatory ECG. Patients were followed for major events (ME), i.e. cardiovascular death, cardiac hospitalization for acute heart failure and stroke. 228 patients were included with a median follow up period of 2.9 years. The middle age was 80.3 years, 40.4% were men and for the most part with hypertension (72.4%). 73 patients had ECG Strain (32%). The ECG strain was independently associated with a more important dyspnea, according to the NYHA classification (1.68 [1.02–2.76] P = 0.04) and a significantly higher left ventricular mass in echocardiography (0.01 ± 0.006 P = 0.04). Finally, ECG Strain was significantly associated with increased occurrence of ME (46.6% vs 36.13% P = 0.05) but not with cardiovascular or all-cause deaths (respectively P = 0.90 and P = 0.32) ( Fig. 1 ). Preoperative ECG Strain was associated with higher risk of ME onset after TAVR for severe AS.

TCT-453 Appropriateness of Transcatheter Aortic Valve Replacement: Insight from the OCEAN-TAVI Registry

Transcatheter aortic valve replacement (TAVR) is widely used; however, the appropriateness of these procedures is unknown. Our aim was to investigate the appropriateness of TAVR in daily clinical practice. We assigned an appropriateness rating to patients undergoing TAVR for severe aortic stenosis

Clinical Arterial Peripheral Vascular Pathology Does Not Impact Short- or Long-Term Survival after Transcatheter Aortic Valve Replacement.

Introduction The dramatic changes in vascular hemodynamics after transcatheter aortic valve replacement (TAVR) are well noted. However, little postprocedural data exists on the outcomes in patients with clinical arterial peripheral vascular pathology [abdominal aortic aneurysm (AAA), carotid artery stenosis (CAS), and peripheral artery disease (PAD)] undergoing TAVR for severe aortic stenosis. Setting A single center healthcare system. Methodology A retrospective chart review case-control study of 342 consecutive patients who underwent a TAVR for severe aortic stenosis at Sanford Health in Fargo; ND was performed to determine if preprocedural comorbid AAA, CAS, or PAD was associated with worse outcomes after TAVR. Results Patients with preprocedural comorbid AAA, CAS, or PAD had no significant difference overall survival at 1 month (94% versus 95% p =.812), 6 months (88% versus 89% p = .847), 1 year (74% versus 83%, p =.130), or 2 years (58% versus 63%, p =.611) after TAVR. Patients with clinical arterial peripheral vascular pathology also had no significant difference in preprocedural outcomes. Conclusion This study gives evidence to suggest that patients with a comorbid clinical peripheral arterial pathology at the time of TAVR do not have a statistically significant increase in mortality out to 2 years after TAVR and no increase in procedural complications. These results affirm the safety and feasibility of TAVR in patients with AAA, CAS, and/or PAD.

Early mortality and safety after transcatheter aortic valve replacement using the SAPIEN 3 in nonagenarians.

BackgroundTranscatheter aortic valve replacement (TAVR) has been performed for many elderly patients with severe aortic stenosis (AS). The SAPIEN 3 is one of the latest balloon-expandable prosthesis. This study aimed to investigate the early clinical outcomes after TAVR using the SAPIEN 3 in nonagenarians.MethodsA total of 97 consecutive patients underwent TAVR for severe AS between December 2015 and December 2016. Of these, 85 consecutive patients who underwent TAVR using the SAPIEN 3 were included. According to the age, patients were classified into age ≥ 90 years group (17 patients) or age < 90 years group (68 patients). The clinical outcomes including all-cause mortality and composite endpoint of early safety at 30 days were evaluated.ResultsThe Society of Thoracic Surgeons score in age ≥ 90 years group was higher than age < 90 years group (12.3 ± 6.1% vs. 8.5 ± 5.1%, P < 0.01). There was no significant difference in 30-day mortality between the two groups. However, the life-threatening bleeding and major vascular complications in age ≥ 90 years group were greater than age < 90 years group (11.8% vs. 1.5%, P = 0.04 and 11.8% vs. 1.5%, P = 0.04, respectively). The composite endpoint of early safety at 30 days was similar between the two groups. Multivariate logistic regression analysis showed that prior myocardial infarction was an independent predictor of the composite endpoint of early safety (odds ratio: 4.76, 95% confidence interval: 1.02–22.21, P = 0.047).ConclusionsThe early mortality and safety after TAVR using the SAPIEN 3 in nonagenarians were similar and acceptable despite of higher operative risk.

Suitability for Watchman Implantation in TAVR Patients with Atrial Fibrillation

ABSTRACTBackground: We assessed the suitability for Watchman in transcatheter aortic valve replacement (TAVR) patients with atrial fibrillation (AF). Patients who undergo TAVR and have AF are at high-risk of stroke, major bleeding, and death. The Watchman device is now available as an alternative to anticoagulation (OAC) for stroke prevention in selected patients.Methods: We reviewed medical records of 113 patients who underwent TAVR for severe aortic stenosis (AS) with high- or extreme-surgical risk. We estimated the CHA2DS2VASC and HAS-BLED scores and investigated the presence of approved indications for the Watchman device in patients with AF.Results: Of the 113 patients, 48 (43%) had AF. CHA2DS2VASC score ≥3 was seen in 46 (96%) patients. A total of 31 (65%) AF patients had a high bleeding risk, comprised of HAS-BLED score ≥4 in 29 (60%), prior bleeding in 18 (38%) and both in 16 (33%). Warfarin was used for stroke prevention in 38 (80%) patients. At least one approved indication for Watchman was found in 44 (92%) patients: prior bleeding in 18 (38%); labile international normalized ratios (INR) in 24 (50%); non-adherence to oral anticoagulation (OAC) 6 (13%); prior falls in 30 (63%) and fall risk in 37 (77%) patients.Conclusions: Chronic OAC remains the mainstay of treatment in TAVR patients with AF. More than 90% of such patients have an appropriate indication for Watchman implant, stemming from their high stroke and bleeding risk. Our findings suggest an unmet need for Watchman in this population.

Mean Aortic pressure gradient and global longitudinal strain recovery after transcatheter aortic valve replacement – A retrospective analysis

BackgroundGlobal longitudinal strain (GLS) has incremental value in assessing left ventricular (LV) function in severe aortic stenosis and is related to clinical outcome after transcatheter aortic valve replacement (TAVR). We sought to identify relevant echocardiographic predictors of GLS improvement and myocardial function recovery after TAVR. MethodsWe analyzed baseline and 12-month follow-up echocardiograms for LV strain analysis from 123 patients who underwent at Emory University Hospital with the Edwards SAPIEN valve between 7/2007 and 7/2013. ResultsAt baseline, 61 had reduced LV ejection fraction (LVEF) ≤50% (rEF), and 80 had preserved LVEF >50% (pEF). Higher baseline mean pressure gradient (MPG) and aortic peak velocity (AV Vmax) predicted myocardial function recovery defined as ≥20% improvement in global longitudinal strain (r = 0.29, p < .001; r = 0.26, p = .002). When analyzing subjects with discordant changes in GLS and LVEF at follow-up, subjects with improved GLS, although reduced LVEF after TAVR, experienced a greater reduction in MPG and AV Vmax (−40 vs. −30, p = 0.015; −2.3 vs. −1.9, p = .021) after the procedure. ConclusionsIn high-risk patients undergoing TAVR for severe aortic stenosis, GLS is impaired and more impaired in patients with reduced EF. Higher baseline MPG predicts myocardial function recovery. GLS improvement after TAVR is related to relief of pressure overload.

Outcomes following transcatheter aortic valve replacement for aortic stenosis in patients of extreme age: Analysis from a rural population

Introduction: Previous single- and multi-center studies done in predominantly metropolitan areas have shown transcatheter aortic valve replacement (TAVR) to be a safe and effective treatment modality for patients of advanced age with severe aortic stenosis. However, it is unknown whether similar patient cohorts from rural areas have similar outcomes or if these initial studies are not representative of the experience in more rural areas. Setting: This is a single-center health-care system in a predominantly rural area. Methods: A retrospective chart review case–control study of 339 consecutive patients who underwent a TAVR for severe aortic stenosis at Sanford Health in Fargo, ND, was performed to determine if advanced age (>80 years of age) at the time of TAVR affects short- and long-term outcomes. Results: Despite higher predicted baseline surgical risk,s predominantly rural patients of advanced age had no significant difference in overall survival at 1-month (93% vs. 97%, P = 0.228), 6-month (88% vs. 90%, P = 0.695), 1-year (79% vs. 82%, P = 0.611), or 2-year (63% vs. 60%, P = 0.731) post-TAVR versus younger patients from the same geographical area. Patients of advanced age also had no significant difference in periprocedural or echocardiographic outcomes out to 1-year post-TAVR. Conclusion: This study from a predominantly rural area gives evidence to suggest that there is no association between extreme age (>80 years of age) and decreased overall survival. In addition, high baseline Society of Thoracic Surgeons and European System for Cardiac Operative Risk Evaluation predicted risk was not suggestive of worse outcomes in patients of advanced age. This study gives reassurance of the safety of TAVR in patients of advanced age in rural areas.

Beta blocker use is associated with an improvement in intermediate overall survival after Transcatheter Aortic Valve Replacement (TAVR)

BACKGROUND: Despite initially concerns about their use, beta-adrenergic blockers (BB) have been associated with improved outcomes in patients with uncorrected aortic stenosis. However, the effect of beta blockers on outcomes after transcatheter aortic valve replacement (TAVR) is unknown. PURPOSE: To elucidate the effect of beta blockers on patient-specific outcomes after TAVR. METHODS: A retrospective cohort study of 339 consecutive patients who underwent a TAVR for severe aortic stenosis was performed to determine the effect of beta blockers on outcomes after TAVR. RESULTS: Despite a greater prevalence of several significant comorbidities and a higher predicted surgical risk, beta-adrenergic blockers are associated with an improve in overall survival at 1 year (83% vs. 67%, p =0.0398). The use of beta blocker was also associated with a reduction of major adverse cardiovascular and cerebrovascular events in the short-term (30 days- 6 months) time period (23% vs. 39%, p =0.0208) CONCLUSION: This study gives evidence to suggest that beta blockers are associated with an improvement of overall survival in the intermediate time period. This finding suggests that TAVR may be a compelling indication for use of a beta blocker.

Long-term outcomes and prosthesis performance after transcatheter aortic valve replacement: results of self-expandable and balloon-expandable transcatheter heart valves.

Data on transcatheter aortic valve replacement (TAVR) long-term clinical outcomes and hemodynamic performance of the self-expandable CoreValve (CV) and the balloon-expandable Edwards SAPIEN XT (ES) (Edwards Lifesciences, Irvine, California, USA) transcatheter heart valves (THV) are limited. Therefore, this study aimed to compare long-term clinical outcome data and hemodynamic performance of TAVR with either CV or ES. We reviewed prospectively collected data of 171 patients treated with TAVR for severe aortic stenosis (AS) at our center between June 2007 and December 2010, with last follow-up contact in 2016. Out of 171 patients treated with TAVR at our Institution, 87 received a CV and 84 an ES THV. Mean age was 81 [78-85] years, and mean Society of Thoracic Surgeons (STS) score was 7.5% (4.5-13.9%). Hemodynamic success by Valve Academic Research Consortium (VARC) definition was 97.1%. Mean trans-prosthetic gradient remained low and stable during follow-up in both groups (at 5-year 9.2±6.4 versus 12.7±5.1 mmHg, P=0.10). Late prosthesis failure occurred in 4 cases (2.4%). Thirty-day mortality was 4.7%, and estimated survival rates by Kaplan-Meyer after 1, 5 and 8 years were 87.6%, 44.9%, and 24.5%, respectively, without difference between THV groups. Rates of cardiovascular death, stroke, myocardial infarction (MI) and congestive heart failure (CHF) were also similar with CV and ES at long-term follow-up. History of CHF, pre-existent severe mitral regurgitation, paravalvular leak grade ≥2+, and chronic obstructive pulmonary disease were independent predictors of late mortality at multivariable analysis. Clinical and hemodynamic outcomes of patients treated by self-expandable CV or balloon-expandable ES THV were favorable and similar throughout long-term follow-up, with a rate of prosthesis failure of less than 3%.

Prognostic Impact of Low-Flow Severe Aortic Stenosis in Small-Body Patients Undergoing TAVR: The OCEAN-TAVI Registry

ObjectivesThis study aimed to analyze the prognostic impact of low-flow (LF) severe aortic stenosis in small-body patients undergoing transcatheter aortic valve replacement (TAVR). BackgroundWestern literature demonstrates a poor prognosis with paradoxical LF and low-flow low-gradient (LF-LG) severe aortic stenosis (AS), as defined by stroke volume index (SVi) <35 ml/m2 and mean pressure gradient <40 mm Hg with preserved left ventricular ejection fraction (LVEF). However, this poor prognosis is contested in Japan owing to the smaller body size of Japanese patients relative to that of Western patients. Additionally, there are no reports of the prognostic implication of paradoxical LF or LF-LG severe AS in small-body patients undergoing TAVR. MethodsThis was a retrospective analysis of 723 consecutive Japanese patients (median age 85 years; 32.6% male; median body surface area 1.4 m2) who underwent TAVR for severe AS at 9 sites in Japan. The primary and secondary endpoints were cumulative all-cause and cardiovascular mortality after TAVR, respectively. ResultsNinety-seven (13.4%) patients had paradoxical LF severe AS whereas 38 (5.3%) had paradoxical LF-LG with severe AS. PLF was associated with a significant increase in all-cause (hazard ratio [HR]: 3.00; 95% confidence interval [CI]: 1.34 to 6.72; p < 0.001) and cardiovascular mortality (HR: 5.58; 95% CI: 1.19 to 26.2; p < 0.01), as compared with patients’ normal flow and preserved LVEF. PLF-LG was associated with a significant increase in all-cause mortality (HR: 3.76; 95% CI: 1.09 to 13.73; p < 0.01), as compared with normal flow high gradient with preserved LVEF. SVi was an independent predictor of cardiovascular mortality on multivariate analysis after adjustments for age, sex, clinically relevant variables, and other echocardiographic parameters (HR: 1.96; 95% CI: 1.19 to 3.23; p < 0.01). ConclusionsAmong Japanese small-body patients with severe AS, both paradoxical LF and LF-LG severe AS were associated with poor outcomes following TAVR. SVi was an independent predictor of cardiovascular mortality after TAVR. (Optimised Transcatheter Valvular Intervention registry [OCEAN-TAVI]; UMIN000020423)

The impact of trans-catheter aortic valve replacement induced left-bundle branch block on cardiac reverse remodeling

BackgroundLeft bundle branch block (LBBB) is common following trans-catheter aortic valve replacement (TAVR) and has been linked to increased mortality, although whether this is related to less favourable cardiac reverse remodeling is unclear. The aim of the study was to investigate the impact of TAVR induced LBBB on cardiac reverse remodeling.Methods48 patients undergoing TAVR for severe aortic stenosis were evaluated. 24 patients with new LBBB (LBBB-T) following TAVR were matched with 24 patients with a narrow post-procedure QRS (nQRS). Patients underwent cardiovascular magnetic resonance (CMR) prior to and 6 m post-TAVR. Measured cardiac reverse remodeling parameters included left ventricular (LV) size, ejection fraction (LVEF) and global longitudinal strain (GLS). Inter- and intra-ventricular dyssynchrony were determined using time to peak radial strain derived from CMR Feature Tracking.ResultsIn the LBBB-T group there was an increase in QRS duration from 96 ± 14 to 151 ± 12 ms (P < 0.001) leading to inter- and intra-ventricular dyssynchrony (inter: LBBB-T 130 ± 73 vs nQRS 23 ± 86 ms, p < 0.001; intra: LBBB-T 118 ± 103 vs. nQRS 13 ± 106 ms, p = 0.001). Change in indexed LV end-systolic volume (LVESVi), LVEF and GLS was significantly different between the two groups (LVESVi: nQRS -7.9 ± 14.0 vs. LBBB-T -0.6 ± 10.2 ml/m2, p = 0.02, LVEF: nQRS +4.6 ± 7.8 vs LBBB-T -2.1 ± 6.9%, p = 0.002; GLS: nQRS -2.1 ± 3.6 vs. LBBB-T +0.2 ± 3.2%, p = 0.024). There was a significant correlation between change in QRS and change in LVEF (r = -0.434, p = 0.002) and between change in QRS and change in GLS (r = 0.462, p = 0.001). Post-procedure QRS duration was an independent predictor of change in LVEF and GLS at 6 months.ConclusionTAVR-induced LBBB is associated with less favourable cardiac reverse remodeling at medium term follow up. In view of this, every effort should be made to prevent TAVR-induced LBBB, especially as TAVR is now being extended to a younger, lower risk population.