Transcatheter Aortic Valve Replacement Procedures Research Articles

Comparable efficacy and safety for bicuspid aortic valve stenosis patients undergoing transcatheter aortic valve replacement with balloon-expandable or self-expanding valves using Wei's sizing method.

The present study aimed to investigate whether proper sizing can improve the procedural and clinical outcomes of transcatheter aortic valve replacement (TAVR) with new-generation self-expanding valves (SEVs) and balloon-expandable valves (BEVs) for treating bicuspid aortic stenosis (BAS). We retrospectively evaluated consecutive patients who underwent TAVR with Sapien 3 valves (Edwards Lifesciences, Irvine, CA) or Evolut R/PRO valves (Medtronic, Minneapolis, MN) for severe BAS from 2017 to 2022. The primary endpoints were device success rate and major adverse cardiac and cerebral events (MACCEs), including mortality, non-fatal myocardial infarction or disabling stroke, transcatheter heart valve failure, or clinically relevant valve thrombosis during follow-up. Our team employed a complementary approach of supra-annular sizing in addition to the conventional annular sizing method (Wei's method) to guide the TAVR procedures. We recruited a total of 75 consecutive patients, of whom 43 (57%) were treated with BEVs from October 2017 to June 2021, and 32 (43%) were treated with SEVs from July 2021 to December 2022. Device success was similar between the BEV and SEV groups (93% vs. 94%; p > 0.99), and no cases of annular rupture occurred in either group. Similar rates of moderate-to-severe paravalvular leak were observed in the BEV and SEV groups (5% vs. 6%, p > 0.99). At a median follow-up of 464 days, the MACCE rates were comparable between the two groups. In multivariate analysis, the presence of previous percutaneous coronary interventions (hazard ratio: 5.43; p = 0.039) and New York Heart Association functional class III/IV heart failure at 30 days of follow-up after TAVR (hazard ratio: 9.90; p = 0.037) were independently associated with long-term MACCEs. Our results demonstrated comparable efficacy and safety for BAS patients undergoing TAVR using either BEVs or SEVs when using Wei's sizing method.

Early vs. late transcatheter aortic valve replacement in acute heart failure hospitalizations: A comparative nationwide analysis

BackgroundSevere aortic stenosis (AS) is the most common valvular disease in the USA. Patients undergoing urgent or emergent transcatheter aortic valve replacement (TAVR) have worse clinical outcomes than those undergoing non-urgent procedures. No studies have examined the impact of procedural TAVR timing on outcomes in AS complicated by acute heart failure (AHF). AimsWe aimed to evaluate differences in in-hospital mortality and clinical outcomes between early (<48 h) vs. late (≥48 h) TAVR in patients hospitalized with AHF using a real-world US database. MethodsWe queried the National Inpatient Sample database to identify hospitalizations with a diagnosis of AHF, aortic valve disease, and a TAVR procedure (2015–2020). The associations between TAVR timing and clinical outcomes were examined using logistic regression model. ResultsA total of 25,290 weighted AHF hospitalizations were identified, of which 6855 patients (27.1 %) underwent early TAVR, and 18,435 (72.9 %) late TAVR. Late TAVR patients had higher in-hospital mortality rate (2.2 % vs. 2.8 %, p < 0.01) on unadjusted analysis but no significant difference following adjustment for demographic, clinical, and hospital characteristics [aOR 1.00 (0.82–1.23)]. Late TAVR was associated with higher odds of cardiac arrest (aOR 1.50, 95 % CI: 1.18–1.90) and use of mechanical circulatory support (aOR 2.05, 95 % CI: 1.68–2.51). Late TAVR was associated with longer hospital stay (11 days vs. 4 days, p < 0.01) and higher costs ($72,851 vs. $53,209, p < 0.01). ConclusionEarly TAVR was conducted in approximately 25 % of the AS patients admitted with AHF, showing improved in-hospital outcomes before adjustment, with no significant differences observed after adjustment.

Rates, predictors, and causes of readmission after transcatheter aortic valve replacement in patients with chronic kidney disease.

Transcatheter aortic valve replacement (TAVR) is a revolutionary procedure for severe aortic stenosis. The coexistence of chronic kidney disease (CKD) and TAVR introduces a challenge that significantly impacts patient outcomes. To define readmission rates, predictors, and causes after TAVR procedure in CKD stage 1-4 patients. We used the national readmission database 2018 and 2020 to look into readmission rates, causes and predictors after TAVR procedure in patients with CKD stage 1-4. Out of 24758 who underwent TAVR and had CKD, 7892 (32.4%) patients were readmitted within 90 days, and had higher adjusted odds of being females (adjusted odds ratio: 1.17, 95%CI: 1.02-1.31, P = 0.02) with longer length of hospital stay > 6 days, and more comorbidities including but not limited to diabetes mellitus, anemia, and congestive heart failure (CHF). Most common causes of readmission included CHF (18.0%), sepsis, and complete atrioventricular block. Controlling readmission predictors with very close follow-up is warranted to prevent such high rate of readmission.

A Comprehensive Geriatric Workup and Frailty Assessment in Older Patients with Severe Aortic Stenosis.

Aortic stenosis (AS) represents a notable paradigm for cardiovascular (CV) and geriatric disorders owing to comorbidity. Transcatheter aortic valve replacement (TAVR) was initially considered a therapeutic strategy in elderly individuals deemed unsuitable for or at high risk of surgical valve replacement. The progressive improvement in TAVR technology has led to the need to refine older patients' stratification, progressively incorporating the concept of frailty and other geriatric vulnerabilities. Recognizing the intricate nature of the aging process, reliance exclusively on chronological age for stratification resulted in an initial but inadequate tool to assess both CV and non-CV risks effectively. A comprehensive geriatric evaluation should be performed before TAVR procedures, taking into account both physical and cognitive capabilities and post-procedural outcomes through a multidisciplinary framework. This review adopts a multidisciplinary perspective to delve into the diagnosis and holistic management of AS in elderly populations in order to facilitate decision-making, thereby optimizing outcomes centered around patient well-being.

Effect Of Transcatheter Heart Valve Size And Deployment Height On Coronary Flow Obstruction

Coronary artery disease (CAD) is commonly found in patients with aortic stenosis; therefore, its prevalence is high in patients that are candidate for transcatheter aortic valve replacement (TAVR). As the TAVR procedure is expanding into younger and lower-risk population, the importance of early CAD monitoring and detection, as well as determination of potential impact of implant design or deployment strategy on CAD progression is of great importance. In this study, we investigate the effect of transcatheter heart valve (THV) size and deployment height on coronary flow obstruction during normotensive hemodynamic flow conditions. We employ unsteady, pulsatile flow, generated by a left heart model, and utilize clinically relevant geometry, pressure, and flow waveforms. Of particular interest is to understand the interaction between THV and anatomy regarding coronary flow obstruction. For a wide range of parameters, we examine two distinct THV deployment scenarios: nominal deployment – high coronary blockage (ND-HCB), and high deployment – low coronary blockage (HD-LCB). Additionally, we investigated the impact of the locations of coronary ostia and THV commissure alignment onto the risk of coronary flow obstruction. With the aid of 2D-2C particle image velocimetry (PIV), the distinctive flow patterns within the aortic sinus space are identified from the response of the flow to the presence of THV. Comparison between two THV deployment scenarios revealed that ND-HCB configurations lead to formation of stagnant flow zones, while the HD-LCB configuration provided an adequate washout of the entire coronary sinus. The optimal washout of the aortic root sinus is achieved when the distance between native leaflets and coronary ostia is maximized. Furthermore, results showed that up to 4% improvement in the coronary flow rate can be achieved if commissure alignment procedure is performed. As the coronary artery obstruction phenomenon is additive in its nature, a pre-existing stenotic condition in association with suboptimal THV deployment may lead to increased risk of full coronary blockage and immediate need for coronary intervention. In conclusion, this study using an experimental coronary assessment tool may provide potential insights to inform pre-procedural TAVR strategies in challenging patients’ anatomies, thereby maximizing the associated benefit.

Comparing outcomes of balloon-expandable vs. self-expandable valves in transcatheter aortic valve replacement: a systematic review and meta-analysis.

Aortic stenosis (AS) is a common heart condition categorized into congenital and acquired forms. Transcatheter aortic valve replacement (TAVR) is an innovative method for AS management, and two valve types, self-expanding valves (SEV) and balloon-expandable valves (BEV), are used in TAVR. The objective of this study is to compare the clinical outcomes associated with balloon-expandable and self-expandable valves in transcatheter aortic valve replacement. The researchers conducted a comprehensive meta-analysis following PRISMA guidelines and AMSTAR-2 tool. The methodology involved a systematic literature search, strict eligibility criteria, unbiased study selection, meticulous data extraction, quality assessment, and rigorous statistical analysis. Our analysis included twenty-six papers and 26553 patients. BEV exhibited significant advantages over SEV in overall mortality across 21 studies, particularly in perioperative and 30-day assessments. However, no substantial disparities emerged between the two valve types in stroke incidence. BEV demonstrated notable benefits in reducing hospitalization rates across 6 studies and significantly fewer instances of permanent pacemaker implantations across 19 studies, particularly evident in the perioperative setting. Other secondary outcomes like bleeding, acute kidney injury, and myocardial infarction showcased non-significant differences between BEV and SEV. The analysis indicates that BEV may offer benefits in specific aspects of TAVR outcomes, but further research is needed to fully understand the factors influencing patient outcomes and mortality in TAVR procedures.

Transcatheter aortic valve replacement outcomes in patients with high gradient versus low ejection fraction low gradient severe aortic stenosis: A meta-analysis of randomized controlled trials

BackgroundThe outcome of Low Flow-Low Gradient (LF-LG) severe aortic stenosis (AS) patients who underwent Transcatheter Aortic Valve Replacement (TAVR) procedure is not well defined. We conducted a systematic review of the literature to compare the outcomes of TAVR in LF-LG AS patients to the more traditional high gradient (HG) aortic stenosis. MethodsWe comprehensively searched for controlled randomized and non-randomized studies from 4 online databases. We are presenting the data using risk ratios (95 % confidence intervals) and measuring heterogeneity using Higgins' I2 index. ResultsOur analysis included 4380 patients with 3425 HG patients and 955 LF-LG patients from 6 cohort (5 retrospective and 1 prospective) studies. When compared to LFLG; TAVR was associated with significantly lower 30 days mortality in HG patients (5.1 % vs 7.4 %; relative risk [RR]: 0.55; 95 % confidence interval [CI]: 0.35 to 0.86; p < 0.01). Similar findings were also observed in 12-month cardiovascular (CV) mortality (5.5 % vs. 10.4 %; RR: 0.47; 95 % CI: 0.38 to 0.60; p < 0.01 and 12-month all-cause mortality (15.9 % vs 20.9 %; RR: 0.70; 95 % CI: 0.49 to 1.00; p < 0.05). There was no significant difference in myocardial infarction (MI) after TAVR between HG and LF-LG at 30 days (0.16 % vs. 0.95 %; p < 0.09) or 12 months (0.43 % vs. 0.95 %; p = 0.20). Similarly, there was no difference in stroke rates at 30 days (2.9 % vs. 2.86 %) or at 12 months (3.6 % vs. 3.06 %). Conclusions and relevancePatients with LF-LG severe AS who underwent TAVR had worse 1-year all-cause mortality, 30-day all-cause, and 1-year CV mortality when compared to TAVR in HG severe AS. There was no difference in MI or stroke rates. Therefore, with heart team discussion and informed patient decision regarding the risk and benefit, TAVR would still offer better outcomes in LFLG AS compared to conservative medical management.

Self-Expanding Versus Balloon-Expanding Valves 5-Years After Transcatheter Aortic Valve Replacement: Systematic Review and Meta-analysis

Background: With transcatheter aortic valve replacement (TAVR) gaining dominance in the treatment for aortic stenosis, it is crucial to determine which type of valve is most superior long-term. Previous studies have compared shorter term outcomes of the two valves; however, long-term outcomes are yet to be determined. Objectives: This systematic review and meta-analysis evaluate the five-year outcomes of self-expanding valves (SEV), in comparison to balloon-expanding valves (BEV) in an intermediate to high-risk population. Methods: The systematic review and meta-analysis followed the 2020 PRISMA guidelines. Seven online databases (PubMed, Embase, Web Of Science, Scopus, Google Scholar, Cochrane, Rowan-Virtua SOM Library) were screened. 15 studies met the inclusion criteria (10,416 TAVR procedures). Mortality, cardiovascular-related mortality, new pacemaker implantation rates, mean aortic gradient, and aortic regurgitation rates were assessed at five years. Results: A lower mean aortic gradient (p &lt; 0.0006, Cohen’s d = 2.86) throughout SEV procedures, and a lower number of new pacemaker implantation rates (p &lt; 0.0001, Cohen’s d = 0.29) from BEV procedures were analyzed. All other outcomes did not yield significant results. Conclusion: TAVR using either SEV or BEV portrayed similar outcomes, with exception to new pacemaker implantation rates and mean aortic gradient. Using BEV to treat aortic stenosis in an intermediate to high-risk population may lower chances of new pacemaker implantation within 5 years, reducing the need for future procedures and their associated risks. Further studies utilizing RCTs would be beneficial in controlling confounding variables, such as surgeon experience, and patient compliance to postoperative instructions.

Left versus right ventricular pacing during TAVR and balloon aortic valvuloplasty: A systematic review and meta‐analysis

AbstractIntroductionWhile right ventricular pacing (RVP) is the conventional temporary pacing modality used for transcatheter aortic valve replacement (TAVR), this approach possesses inherent risks and procedural challenges. We aim to assess and compare the safety and efficacy of left ventricular pacing (LVP) and RVP during TAVR and balloon aortic valvuloplasty (BAV).MethodsFollowing PRISMA guidelines, a comprehensive literature search was conducted in four databases from inception to December 15th, 2023. We included observational studies and clinical trials comparing LVP with RVP during TAVR and BAV procedures. Primary outcomes included short‐term mortality, mortality due to cardiac tamponade, and procedural complications including bleeding, vascular complications, and cardiac tamponade. Secondary outcomes comprised procedure duration and length of hospital stay.ResultsFive studies involving 830 patients with RVP and 1577 with LVP were included. Short‐term mortality was significantly higher in the RVP group (RR 2.32, 95% CI: [1.37–3.93], P = .002), as was the incidence of cardiac tamponade (RR 2.19, 95% CI: [1.11–4.32], P = .02). LVP demonstrated shorter hospital stays (MD = 1.34 d, 95% CI: [0.90, 1.78], P &lt; .001) and reduced procedure duration (MD = 7.75 min, 95% CI: [5.08, 10.41], P &lt; .00001) compared to RVP. New pacemaker implantation was higher in the RVP group (RR 2.23, 95% CI: [1.14, 4.39], P = .02).ConclusionLVP during TAVR and BAV emerges a safer alternative to RVP, offering reduced mortality, hospital stays, and procedure durations.

Feasibility of standby ECMO with preset femoral vascular sheaths for high-risk transcatheter aortic valve replacement

Objective Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can provide temporary circulatory and respiratory support allowing hemodynamic stabilization during high-risk transcatheter aortic valve replacement (TAVR). However, the optimal timing of VA-ECMO use in high-risk TAVR remains controversial. We aimed to report our experience using a novel standby ECMO strategy during high-risk TAVR. Methods We retrospectively evaluated consecutive patients who received high-risk TAVR with standby ECMO between March 1,2023 and March 1,2024 at the Beijing Anzhen Hospital. Small, 5F or 6F sheaths were placed in ipsilateral femoral vein and artery before TAVR procedures. The primary outcome of this study was survival to hospital discharge with good neurological recovery defined as cerebral performance category (CPC) 1-2. Results A total of 24 patients undergoing high-risk TAVR with standby ECMO were included. Six (25.0%) of the 24 patients with standby ECMO suffered from cardiogenic shock or cardiac arrest and required emergency VA-ECMO institution. The median (IQR) cannulation time was 8 (6–11) minutes, and the median (IQR) ECMO duration was 35 (24–48) hours. All of the 24 patients underwent successful TAVR procedures and survival to hospital discharge with CPC1-2. Conclusions Standby ECMO with preset femoral vascular sheaths was feasible and effective for refractory cardiogenic shock and cardiac arrest during high-risk TAVR.

Balloon‐expandable versus self‐expanding valves for transcatheter aortic valve replacement using new generation devices: An analysis of the Brazilian RIBAC‐NT registry

AbstractBackgroundConflicting data yet exists regarding the clinical outcomes of transcatheter aortic valve replacement (TAVR) using balloon‐expandable (BEV) and self‐expanding valves (SEV).AimTo compare the in‐hospital outcomes of TAVR performed with new‐generation BEV vs. SEV in a real‐world population.MethodsRetrospective study using data from the Brazilian TAVR registry. All consecutive native tricuspid TAVR procedures using new‐generation valves were included. Transapical procedures were excluded. Patients were analyzed according to the type of prosthesis implanted (BEV vs. SEV). Unadjusted and propensity‐score matching comparisons were made. Primary outcome was in‐hospital mortality. Secondary outcomes included major vascular complication, major or life‐threatening bleeding, any stroke, and new pacemaker implantation.ResultsA total of 1706 patients from 25 centers were included in the analysis, 887 in the BEV and 819 in the SEV groups. Mean age was 80.7 ± 7.2 years and 48.9% were women. The SEV group had a higher proportion of female patients (53.5% vs. 44.6%, p ≤ 0.001) and more comorbidities, yielding a higher EuroSCORE‐2 (3.4 [2–6.4] vs. 4.5 [2.5–8.2], p &lt; 0.001). The Sapien 3/Ultra (Edwards Lifescience, Irvine, CA, USA) and the Evolut R/PRO (Medtronic, Minneapolis, MN, USA) accounted for 97.8% and 72.6% of BEV and SEV cases, respectively. Pre‐ and postdilatation was more common for SEV (both p &lt; 0.001). Valve embolization, the need for a second valve, and coronary occlusion were rare but more frequent for SEV. There was no difference in the unadjusted in‐hospital mortality (BEV = 3.6% vs. SEV = 4.8%, p = 0.27) and after propensity‐score matching (3.5% vs. 5.0%, p = 0.16). There were also no significant differences between groups in vascular complications, bleeding, stroke, and the need for a new pacemaker. Logistic regression adjusted for sex, EuroSCORE‐2, and vascular access also indicated similar mortality between both valves (OR 1.22, p = 0.4). Sensitivity analysis, including only Sapien 3 and Evolut cases, showed consistent results with the primary analysis.ConclusionIn real‐world all‐comers TAVR patients, from Brazil procedures performed with newer generation BEV and SEV devices had comparable in‐hospital outcomes.

Association of neighborhood socioeconomic status with echocardiographic parameters and re-admission following transcatheter aortic valve replacement.

Data on predictors of poor hemodynamic presentation and rehospitalizations following transcatheter aortic valve replacement (TAVR) are limited. We evaluate the association between neighborhood socioeconomic status (NSES) on echocardiographic presentation and post-TAVR readmission at a high-volume institution. All patients undergoing TAVR at a single institution between 2012 and 2022 were included. Patient addresses, baseline variables including Society of Thoracic Surgeons (STS) preoperative risk of mortality and frailty, and post-procedural outcomes were extracted from electronic health records. Using a validated US Census Bureau Index, the NSES of each patient (1-100) was tabulated, with lower values correlating to increased social deprivation. Patients were separated into four ranked groups based on NSES (rank 1: 1-25, rank 4: 76-100). Multivariable regression was performed to determine variables associated with number of days hospitalized in one-year following index TAVR procedure. A total of 2031 patients were included. The median NSES was 68 (IQR: 53-80). There was a total of 232 (11.4%) readmissions. The median number of days hospitalized in one year following TAVR was 4 (interquartile range [IQR]: 2-7) After adjusting for baseline variables including STS risk score and patient frailty, compared to patients in the lowest ranked socioeconomic group, patients of higher NSES were associated with lower aortic valve gradients at baselines (Exp[β]=0.997, 95% CI: 0.993-0.999, P=0.049). Additionally, compared to patients in the lowest ranked socioeconomic group, patients of NSES were associated with shorter duration of readmission after risk-factor adjustments (Exp[β]=0.996, 95% CI: 0.992-0.999, P=0.032). Patients of lower socioeconomic status are associated with higher aortic valve gradient at baseline and more days hospitalized in the first year after their index TAVR procedure after adjusting for other risk factors. As TAVR volume continues to expand, physicians and health systems must consider this independent factor when determining patient prognosis and readmission policies.

High-Degree Heart Block During Noncardiac Surgery Soon After Transcatheter Aortic Valve Replacement: A Case Report.

Patients undergoing transcatheter aortic valve replacement (TAVR) as a bridge to noncardiac surgery have improved outcomes. Older clinical trials concluded no increased risk of performing noncardiac surgery within 30 days of the TAVR procedure. Emerging evidence suggests patients with preexisting conduction abnormalities may require additional intervention to proceed safely with noncardiac surgery. More data are needed to clarify this clinical situation, especially for the anesthesiologist whose job is to mitigate risk for these patients. We present a patient who received a TAVR and suffered associated complications during subsequent surgery. We further discuss preventative measures and perioperative considerations for this patient population.

Echocardiographic and clinical features of patients developing prosthesis‐patient mismatch after transcatheter aortic valve replacement: Insights from the Recovery-TAVR registry

The impact of prosthesis-patient mismatch (PPM) on major endpoints after transcatheter aortic valve replacement (TAVR) is controversial and the effects on progression of heart damage are poorly investigated. Therefore, our study aims to evaluate the prevalence and predictors of PPM in a "real world" cohort of patients at intermediate and low surgical risk, its impact on mortality and the clinical-echocardiographic progression of heart damage. 963 patients who underwent TAVR procedure between 2017 and 2021, from the RECOVERY-TAVR international multicenter observational registry, were included in this analysis. Multiparametric echocardiographic data of these patients were analyzed at 1-year follow-up (FU). Clinical and echocardiographic features were stratified by presence of PPM and PPM severity, as per the most current international recommendations, using VARC-3 criteria. 18% of patients developed post-TAVR. PPM, and 7.7% of the whole cohort had severe PPM. At baseline, 50.3% of patients with PPM were male (vs 46.2% in the cohort without PPM, P = .33), aged 82 (IQR 79-85y) years vs 82 (IQR 78-86 P = .46), and 55.6% had Balloon-Expandable valves implanted (vs 46.8% of patients without PPM, P = .04); they had smaller left ventricular outflow tract (LVOT) diameter (20 mm, IQR 19-21 vs 20 mm, IQR 20-22, P = .02), reduced SVi (34.2 vs 38 mL/m2, P < .01) and transaortic flow rate (190.6 vs 211 mL/s, P < .01). At predischarge FU patients with PPM had more paravalvular aortic regurgitation (moderate-severe AR 15.8% vs 9.2%, P < .01). At 1-year FU, maladaptive alterations of left ventricular parameters were found in patients with PPM, with a significant increase in end-systolic diameter (33 mm vs 28 mm, P = .03) and a significant increase in left ventricle end systolic indexed volume in those with moderate and severe PPM (52 IQR 42-64 and 52, IQR 41-64 vs 44 IQR 35-59 in those without, P = .02)). No evidence of a significant impact of PPM on overall (P = .71) and CV (P = .70) mortality was observed. Patients with moderate/severe PPM had worse NYHA functional class at 1 year (NYHA III-IV 13% vs 7.8%, P = .03). Prosthesis size≤23 mm (OR 11.6, 1.68-80.1) was an independent predictor of PPM, while SVi (OR 0.87, 0.83-0.91, P < .001) and LVOT diameter (OR 0.79, 0.65-0.95, P = .01) had protective effect. PPM was observed in 18% of patients undergoing TAVR. Echocardiographic evaluations demonstrated a PPM-related pattern of early ventricular maladaptive alterations, possibly precursor to a reduction in cardiac function, associated with a significant deterioration in NYHA class at 1 year. These findings emphasize the importance of prevention of PPM of any grade in patients undergoing TAVR procedure, especially in populations at risk.

Cardiology department versus intensive care unit admission after successful uncomplicated transcatheter aortic valve replacement (TAVR)

BackgroundMost patients after transcatheter aortic valve replacement (TAVR) are admitted directly to the cardiac intensive care unit (CICU) despite low complication rates. Reducing unnecessary CICU hospitalization reduces healthcare costs. This study aimed to compare the outcomes between patients admitted directly to the cardiology department (CD) and those admitted to CICU based on prespecified protocols. MethodsHistorical cohort study of all patients who underwent TAVR and were admitted directly to the CD according to a prespecified protocol (uncomplicated procedure, hemodynamically stable, without new conduction abnormalities) in 2017–2018, and the same number of patients meeting the same criteria who were admitted to the CICU in 2015–2016 before direct CD admission was initiated. Pacemaker implantation during the procedure was not considered a new conduction abnormality. In-hospital outcomes and 30-day post-discharge outcomes were compared. ResultsOverall, 260 patients (130 CICU + 130 CD) were included in the study. There was no in-hospital mortality in either group, and the post-procedure length of stay was shorter for patients admitted to CD (median and IQR: 2, 2–4 vs. 4, 3–5 days, p <0.001). There was no significant difference in 30-day emergency department visits between groups (CICU:13.9% vs. CD:16.2%, p = 0.602), rehospitalization rate (9.3%) was the same in both groups, and one patient from the CICU group died. Similar results were observed in multivariable analysis and after matching. ConclusionDirect admission to the CD after TAVR, according to the proposed criteria, may be considered as a safe and less expensive alternative for stable patients after an uncomplicated TAVR procedure.

Prediction of hypoattenuating leaflet thickening in patients undergoing transcatheter aortic valves replacement based on clinical factors and 4D-computed tomography morphological characteristics: A retrospective cross-sectional study

BackgroundThe rapid increase in the number of transcatheter aortic valve replacement (TAVR) procedures in China and worldwide has led to growing attention to hypoattenuating leaflet thickening (HALT) detected during follow-up by 4D-CT. It's reported that HALT may impact the durability of prosthetic valve. Early identification of these patients and timely deployment of anticoagulant therapy are therefore particularly important. MethodsWe retrospectively recruited 234 consecutive patients who underwent TAVR procedure in Fuwai Hospital. We collected clinical information and extracted morphological characteristics parameters of the transcatheter heart valve (THV) post TAVR procedure from 4D-CT. LASSO analysis was conducted to select important features. Three models were constructed, encapsulating clinical factors (Model 1), morphological characteristics parameters (Model 2), and all together (Model 3), to identify patients with HALT. Receiver operating characteristic (ROC) curves and decision curve analysis (DCA) were plotted to evaluate the discriminatory ability of models. A nomogram for HALT was developed and verified by bootstrap resampling. ResultsIn our study patients, Model 3 (AUC = 0.738) showed higher recognition effectiveness compared to Model 1 (AUC = 0.674, p = 0.032) and Model 2 (AUC = 0.675, p = 0.021). Internal bootstrap validation also showed that Model 3 had a statistical power similar to that of the initial stepwise model (AUC = 0.723 95%CI: 0.661–0.786). Overall, Model 3 was rated best for the identification of HALT in TAVR patients. ConclusionA comprehensive predictive model combining patient clinical factors with CT-based morphology parameters has superior efficacy in predicting the occurrence of HALT in TAVR patients.

Feasibility and effectiveness of left bundle branch area pacing after TAVR: the single center experience

Abstract Introduction Transcatheter aortic valve replacement (TAVR) is a safe alternative to open-heart surgery in patients with symptomatic severe aortic stenosis and high surgical risk due to multiple comorbidities, advanced age, and severe left ventricle dysfunction. Due to anatomical considerations of the atrioventricular node, conduction abnormalities requiring the implantation of a pacemaker are common findings after TAVR. High-grade atrioventricular block and new-onset left bundle branch block (LBBB) are the most commonly reported conduction abnormalities after TAVR. Purpose The aim of our study was to assess the feasibility, success rates, and effectiveness of LBBAP in patients requiring pacing after TAVR. Methods A total of 302 patients underwent the TAVR procedure in our institution in the period from January 2022 to November 2023. In this cohort, 38 patients required ventricular pacing in the postoperative period. 16 patients who underwent permanent pacing using LBBAP were included in this observational study. Patients undergoing traditional right ventricular pacing biventricular pacing or leadless pacemaker implantation were excluded from the study. Results LBBAP was successfully performed in 16 patients (89%). 2 patients underwent conventional CRT implantation (1 cardiac resynchronization therapy pacemaker and 1 cardiac resynchronization therapy defibrillator) in order to severe calcification and presence of fibrotic tissue in the target area. The mean age was 60.5±2.74 years, and 10 patients (62.5%) were women. According to the patient’s medical history, 14 patients (84%) had hypertension; coronary artery disease – 2 (12.5%), 2 (12.5%) patients had atrial fibrillation and atrial flutter, and 7 (43.5%) patients had diabetes mellitus. The mean left ventricle ejection fraction (LVEF) was 46.2±14.7%. Interventricular septal thickness 11.8 ± 1.9 mm. Type of conduction diseases: Infranodal AV block and LBBB were present in 9 (56.5%) patients. 5 (31,25%) patients had persistent complete AV block and 2 (12,25%) had Mobitz II AV block. In 2 patients we observed congestive heart failure combined with LBBB. Pre-TAVR QRS morphology was normal in 15 (93%), and RBBB morphology in 1 (7%). The mean QRS duration at baseline was 105±20 ms. Pre-implant QRS duration 135±52 ms. The single-chamber pacemaker was implanted in 1 patient, dual-chamber pacemaker - 13 patients, and cardiac resynchronization therapy defibrillators in 2 patients. Procedural duration and fluoroscopy times were 105. ± 31.9 min and 18 ± 11 min, respectively. Conclusion Complete AV block and new-onset LBBB after TAVR is still an important issue. LBBB correction using conduction system pacing technology is an effective strategy for this type of patient. LBBAP is one of the most exciting developments in pacing therapy over the last few years. Long-term clinical outcomes and safety of physiological pacing data are limited and require further investigations

Permanent pacemaker reduction using temporary-permanent pacemaker as a 1-month bridge after transcatheter aortic valve replacement: a prospective, multicentre, single-arm, observational study

The permanent pacemaker (PPM) implantation and pacemaker dependency rates after transcatheter aortic valve replacement (TAVR) are highly variable as some of the conduction disturbances are reversible. It remains poorly investigated how to optimise temporary pacing in these patients. This study aimed to explore the potential reduction in the PPM implantation rate using temporary-permanent pacemaker (TPPM) as a 1-month bridge. This is a prospective, multicentre, single-arm, observational study. Consecutive patients undergoing TAVR from March 1, 2022 to March 1, 2023 in 13 tertiary hospitals in China were screened. Patients who developed high-degree atrioventricular block, complete heart block, or first-degree atrioventricular block plus new onset left bundle branch block during the TAVR procedure or within 1 month after TAVR were included to receive TPPM. Patients with pre-existing PPM implantation or indications for PPM implantation before the TAVR procedure were excluded. Patients with TPPM were monitored to determine whether the conduction disturbances persisted or recovered. The primary endpoint was the rate of freedom from indications for PPM implantation 1 month after TAVR. This study is registered with ChiCTR, ChiCTR2200057931. Of 688 patients who have undergone TAVR, 71 developed conduction disturbance and met the inclusion criteria, 1 patient withdrew due to noncompliance, 70 patients received TPPM and completed follow-up. There were 41 (58.6%) men and 29 (41.4%) women in the study, with a mean age of 74.3±7.3 years. At 1 month follow-up, 75.7% (53/70) of the patients with TPPM did not require PPM implantation. For 688 patients who have undergone TAVR, the rate of PPM implantation at 1 month was 2.47% (17/688, 95% CI 1.55%-3.92%), representing a significant reduction in self-comparison with the rate at 48 h after TPPM (2.47% vs. 8.28% [95% CI 6.45%-10.58%], P<0.0001). Similar results were obtained in the subgroup analysis of patients with HAVB/CHB. Multivariate analysis revealed the baseline PR interval, difference between the membranous septum length and implantation depth, and timing of postprocedural conduction disturbance occurrence were independent predictors of freedom from indications for PPM implantation at 1 month after TAVR. Using TPPM as a 1-month bridge allows for a buffer period to distinguish whether conduction disturbances are reversible or persistent, resulting in a significant reduction in the PPM implantation rate after TAVR when compared with the current strategy. However, this is an observational study, the results need to be confirmed in a randomized trial. Beijing Science and Technology Plan 2022 from Beijing Municipal Science & Technology Commission.

Loss and recovery of percutaneous femoral access during transcatheter aortic valve replacement. A case report

Loss and recovery of percutaneous femoral access during transcatheter aortic valve replacement. A case report

Association of urgent transcatheter aortic valve replacement (TAVR) with acute kidney injury 30-days post-TAVR: a systematic review and meta-analysis

Abstract Funding Acknowledgements None. Introduction Recent studies have proven that TAVR is a viable treatment option for symptomatic aortic stenosis (AS), regardless of surgical risk, even though, there are certain significant hazards associated with it. Even with the improvements in technique and experience, peri- and post-procedural complications like acute kidney injury (AKI) continue to occur frequently and are recognized for their serious clinical implications in the setting of TAVR. The vast majority of TAVR procedures conducted across the US are elective procedures on patients who are hemodynamically stable. Nonetheless, published data, imply that urgent TAVR, despite higher mortality rates is a feasible option to treat decompensated severe aortic valve stenosis. Purpose The aim of this systematic review and meta-analysis is to assess AKI in patients 30-days after an urgent TAVR and compare them with the elective TAVR population. Methods This meta-analysis adhered to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A comprehensive database search was conducted using three major databases (Medline, Cochrane Central Register of Controlled Trials and Scopus) for studies comparing patients submitted to urgent versus elective TAVR. Primary endpoint of our systematic review and meta-analysis is the AKI 30-days after TAVR. Only studies provided data about our primary endpoint were considered in the analysis. Secondary endpoints included myocardial infarction (MI), permanent pacemaker implantation (PPM) and bleeding events during the first 30-days post-procedurally. Risk ratio (RR) was calculated with 95% confidence intervals (CIs) and a random-effects model (Mantel-Haenzel) was used to estimate the pooled RR. Results A total of 16 studies with 101,568 patients were added in our analysis. Among them, 16,349 patients underwent an urgent TAVR, while the rest 85,219 had an elective procedure. Our analysis showed that patients submitted to urgent TAVR have 258% higher risk for AKI during the first 30-days post-procedurally (RR: 2.58, 95%CI: 1.98, 3.37) (Figure). Data about the 30-days MI, PPM and bleeding events were available for 9, 15 and 11 studies, respectively. The risk for MI appeared to be significantly higher in patients undergone urgent TAVR (RR: 5.49, 95% CI: 1.76, 17.05), while the risk for bleeding events was slightly higher in the same group (RR: 1.39, 95% CI: 1.14, 1.70). No significant differences were observed in PPM incidence (RR: 1.05, 95%CI: 1.00, 1.11) during 30-days follow-up. Conclusion In this systematic review and meta-analysis, patients undergoing urgent TAVR procedures compared to elective procedures have increased risk for AKI during the first 30-days post-TAVR. Thus, when urgent TAVR is performed risk factors for AKI should be evaluated and proper renal protection measures, such as adequate hydration and minimal contrast agent administration, should be implemented. Further research in this area is warranted.