Transcatheter Aortic Valve Implantation Research Articles

Abstract 4138782: A Meta-Analysis Comparing Same-Day Discharge to Later-Day Discharge in Transcatheter Aortic Valve Replacement

Background: One of the benefits of transcatheter aortic valve replacement (TAVR) over surgical aortic valve replacement (SAVR) is the possibility of same-day discharge, allowing for early mobilization and reduced total hospital stay. However, there is limited evidence comparing same-day discharge to later-day post-TAVR discharge. This meta-analysis aimed to compare the outcomes of same-day and later-day discharge post-TAVR in patients with aortic stenosis. Methods: A systematic bibliographic search was conducted using electronic databases, including PubMed, Embase, and the Cochrane Library, from inception to May 23, 2024. We pooled the risk ratios (RR) with 95% confidence intervals (CI) using the inverse-variance random-effects model. Statistical significance was set at p <0.05. Results: Six studies were included with 71,550 patients undergoing TAVR (2215: same-day discharge; 69335: later-day discharge). The mean age for the same-day and later-day discharge groups was 77.3 ± 8.3 and 78.3 ± 8.5, respectively. Same-day discharge for patients post-TAVR was associated with a higher risk of 30-day stroke [RR: 1.93; 95% CI: 1.14, 3.27] and 30-day major vascular complications [RR: 1.82; 95% CI: 1.02, 3.24] as compared to later-day discharge post-TAVR. However, no significant differences in the risks of 30-day mortality [RR: 0.30; 95% CI: 0.06, 1.57], 30-day readmission [RR: 0.93; 95% CI: 0.66, 1.32], 30-day major bleeding [RR: 0.86; 95% CI: 0.52, 1.42], 30-day new permanent pacemaker [RR: 1.00; 95% CI: 0.81, 1.22], 30-day acute kidney injury [RR: 1.04; 95% CI: 0.73, 1.49], and 30-day valve reintervention [RR: 5.77; 95% CI: 0.60, 55.39] were noted between the two groups. Conclusion: This meta-analysis concluded that same-day discharge post-TAVR is associated with a higher risk of 30-day stroke and 30-day major vascular complications than later-day discharge after TAVR. Same-day discharge was comparable to later-day discharge post-TAVR in terms of 30-day mortality, 30-day readmission, 30-day major bleeding, 30-day new permanent pacemaker, 30-day acute kidney injury, and 30-day valve reintervention. This study underscores the possibility of same-day discharge after uncomplicated TAVR in select patients. Further randomized studies are required to evaluate the safety and feasibility of the same-day discharge protocols.

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.

Abstract 4119146: Pulmonary Artery Enlargement Predicts Mortality in Patients with Severe Aortic Stenosis after Transcatheter Aortic Valve Replacement.

Background: Pulmonary hypertension is associated with extensive remodeling of the pulmonary tree, with key finding the enlargement of the pulmonary artery (PA). Although the independent predictive value of the pulmonary hypertension in patients undergoing transcatheter aortic valve replacement for severe aortic stenosis has been clearly demonstrated, data about the potential predictive value of the pre-interventional PA enlargement on mortality are scarce. Research questions: The aim of the present study was to assess the prognostic significance of the pre-interventional PA enlargement, assessed by cardiac CT scan, in patients undergoing transcatheter aortic valve replacement for severe aortic stenosis. Methods: We conducted a retrospective study and recruited 337 patients with aortic stenosis, who underwent a right heart catheterization and a cardiac CT scan before the transcatheter aortic valve replacement. The cohort was divided in two groups according to the presence of an enlarged PA (PA e ), (main PA axial diameter ≥ 29 mm for males and ≥ 27 mm for females, n=192, mean age 83±6 years, 41% males) or not (PA n ), ( n=145, mean age 84±6 years, 46% males). The primary endpoint was all-cause mortality at 1 year. Results: Globally, a strong correlation between invasive mean PA pressure and main PA axial diameter was noted (Pearson r=0.393, p<0 .001). Compared to the PA n group, patients with enlarged PA exhibited higher 1 year mortality rates (hazard ratio 2.51, 95% CI: 1.1-6.04, p=0.027). The prognostic significance was even stronger after indexing the PA to the ascending aorta diameter (hazard ratio 3.82, 95% CI: 1.86-7.87, p<0.001, figure 1). Conclusions: Pre interventional PA enlargement, is strongly associated with 1-year all-cause mortality in patients undergoing transcatheter aortic valve. This may pave the way for a more precise non-invasive risk stratification in patients with severe aortic stenosis.

Abstract 4136989: Association of alternating PR intervals with paroxysmal atrioventricular block in patients with right bundle branch block following cardiac surgery

Background: We previously observed a positive correlation between QRS duration and the preceding RP interval in sinus rhythm in certain patients experiencing new onset left bundle branch block (LBBB) after transcatheter aortic valve replacement (TAVR). This unique phenomenon, termed inverse decremental conduction ( IDC ) or Yan conduction, prompted us to investigate whether IDC in the left bundle could manifest as AV conduction in an IDC pattern in patients with preexisting right bundle branch block (RBBB) and its association with atrioventricular block (AVB). Methods: 12 lead ECGs, available in-patient telemetry and mobile cardiac outpatient telemetry were reviewed in patients with sinus rhythm and preexisting RBBB who developed paroxysmal AVB requiring temporary or permanent pacemaker within 7 days following any types of cardiac surgery from 2014 to 2023 in Lankenau Medical Center. Results: A total of 9 patients (5 males) with a mean age of 71±15 years were identified to exhibit PR interval changes consistent with IDC prior to paroxysmal AVB. Among these patients, 6 had undergone TAVR, while the remaining 3 had undergone surgical aortic valve replacement, mitral valve repair, and ventricular septal defect repair, respectively. Specifically, PR interval alternation in the setting of RBBB occurred during sinus rhythm in a pattern that the longer RP interval is followed by a longer PR interval (Figure 1). This pattern exhibits the following features: 1) 8 of 9 patients had RBBB plus left anterior fascicular block (LAFB); 2) PR alternation occurred at sinus rates from 68 to 91 bpm within 5 days following surgical procedures; 3) proximal AVB occurred within 1 to 12 hours after PR interval alternation began. A positive correlation was established between PR and preceding RP interval in 2 of 9 patients whose telemetry data were available for analysis ( Figure 2A ). In a patient with RBBB who developed paroxysmal AVB without IDC changes in the PR interval post TAVR, intracardiac recording showed a decrease in AH interval but an increase in HV interval with slowing heart rates ( Figure 2B ), indicating that decremental conduction in AV node can mask IDC in Purkinje system. Conclusion: 1) PR alternation with longer PR following longer preceding RP interval in presence of RBBB, likely due to IDC in left bundle, heralds paroxysmal AVB; 2) PR interval changes resulting from IDC in left bundle in the setting of RBBB may be masked by decremental conduction in AV node.

Abstract 4139177: Five-Year Clinical Outcomes of Balloon-Expandable versus Self-Expanding Transcatheter Aortic Valve Replacement in Patients with Small Aortic Annulus

Introduction: Self-expanding transcatheter aortic valves (SEV) have reportedly better hemodynamic outcomes, and similar clinical outcomes compared to balloon-expanding valves (BEV) at 1 year in patients with a small aortic annulus based on results from the SMART trial. Head-to-head comparison of long-term clinical outcomes, however, is lacking. Objectives: To compare the long-term (5 years) echocardiographic and cardiovascular outcomes in BEV versus SEV in patients with small aortic annulus undergoing transcatheter aortic valve replacement (TAVR). Methodology: The RESOLVE registry included consecutive patients who underwent TAVR and survived up to 30 days at Cedars-Sinai Medical Center with either BEV or SEV from 2015 to 2020, with clinical variables obtained from the STS/TVT registry. CT core lab analysis identified patients with a small aortic annulus (<430 mm 2 ), who were systematically followed up with clinical exams and echocardiography until December 2023. The primary outcome was a composite of all-cause mortality, stroke or transient ischemic attack, or heart failure hospitalization at 5 years. Results: Out of 1392 patients, a total of 423 met criteria for small aortic annulus (345 BEV, 78 SEV), with a median follow-up of 5 years (4-6 years). There were no significant differences in baseline sociodemographic and clinical characteristics between the BEV and SEV groups. (Figure 1) The post-TAVR invasive aortic valve mean gradient were similar in both groups [Median (IQR): BEV:3(1-5.8), SEV: 3.4(0.4-6.6), p 0.58], while echocardiographic gradients were higher in BEV group [Median (IQR): BEV:12 (9-15), SEV:8(6-11), p<0.001)].There was no significant difference in primary outcome at 5 years in Cox multivariable regression analysis (HR:1.21, 95% CI 0.81-1.82, p 0.33) (Figure 2). There were no significant differences in other clinical endpoints at 5 years, although patients with SEV had lower echocardiographic gradients and higher indexed effective orifice area. (Figure 2-3) Conclusion: Post-TAVR invasive aortic valve gradients were similar between BEV and SEV, despite higher echocardiographic transaortic gradients in BEV patients. We found no significant difference in 5-year clinical outcomes between patients who received TAVR with BEV or SEV.

Abstract 4113301: A Rare Cause of Recurrent Heart Failure Exacerbations After Transcatheter Aortic Valve Replacement: Ventricular Septal Defect and Significant Paravalvular Leak

Introduction: Ventricular septal defects (VSD) have been reported in <1% of cases following transcatheter aortic valve replacement (TAVR). A retrospective record review of VSD cases occurring after all TAVRs performed between January 2012 and September 2020 at one urban US tertiary hospital showed 0.37% incidence of these complications, mostly with small and restrictive VSD. Case Description: An 80-year-old woman with history of hypertension, HFpEF, and TAVR 8 months prior for severe aortic stenosis (AS) at an outside hospital presented with worsening dyspnea and peripheral edema over the past month. Blood pressure was 148/53mmHg, heartrate 83bpm, oxygen saturation 98% and auscultation revealed a harsh holosystolic murmur 4/6 loudest at left sternal border and bibasilar rales. Chest X-ray showed pulmonary edema and bilateral pleural effusions. NT-proBNP was 17,000pg/ml and troponin-I was negative. Echocardiogram showed EF55-60%, a membranous VSD, severe pulmonary hypertension, and moderate paravalvular leak (PVL). Coronary angiogram showed non-obstructive disease. Right heart catheterization confirmed significant left to right shunting. Treatment/Outcomes: Cardiothoracic surgery was consulted for multidisciplinary evaluation, and joint recommendation was for surgical aortic valve replacement and VSD closure which was successfully performed. One month follow-up echocardiogram showed normal aortic valve gradient without PVL and normal right ventricular pressure. Discussion/Conclusion: Numerous potential risks such as severe and uneven calcification of the native valve, an elliptic aortic annulus, excessive valve sizing, or elevated valve placement can lead to VSD. A recurrent element in many of these instances involves direct trauma to the septum caused by the implanted valve, exacerbated by subsequent annulus dilation. The presence of PVL is common post-TAVR and is an established independent prognostic factor, while VSD post-TAVR is uncommon, but may be associated with low implantation position relative to the aortic annulus or post-implantation balloon dilatation. Rarely, worsening VSD may require operative management. In this case, the improvement of heart failure symptoms and echocardiogram parameters after transthoracic surgery confirmed successful repair.

Abstract 4120270: Risk Factors for Catastrophic Complications Requiring Emergent Extracorporeal Life Support in Patients Undergoing Transcatheter Aortic Valve Replacement

Background: Transcatheter Aortic Valve Replacement (TAVR) is often performed in the cardiology catheterization suite. Although rare, instances of annular rupture, cardiac arrest, and coronary occlusion may occur requiring institution of emergent extracorporeal life support (ECLS). This study aims to examine the risk factors for complications requiring ECLS during TAVR procedures to identify patients who may benefit from having procedures performed in hybrid operating rooms. Methods: Data from the Transcatheter Valve Therapy registry for our institution was obtained on patients (n=4908) who underwent TAVR between November 2012 and July 2023. Univariable logistic regression was performed to compare relevant covariates in those requiring intraoperative ECLS (n=23) to the rest of the patient cohort (n=4885). All-cause mortality during the follow-up period was compared to assess the impact of emergent intraoperative ECLS. Results: The patients requiring ECLS experienced significantly higher all-cause mortality (69.6% versus 28.8%, p<0.001) with median follow up of 2 years (Table 1) . Female sex (p=0.013) and smaller annulus size (p=0.007) were significant independent risk factors for complications requiring emergent intraoperative ECLS based on univariable logistic regression (Table 2). Patients requiring ECLS had significantly smaller annulus sizes (21.0-23.2 mm) compared to the uncomplicated cohort (22.0-25.8 mm). Of the patients requiring ECLS, 11 cases (47.8%) were due to annular/ventricular rupture while 4 cases (17.4%) resulted from valve embolization. Of note, valve type (self-expanding versus balloon expandable), annular calcification, and porcelain aorta were not found to be significant risk factors. Conclusions: In this large volume single-center retrospective cohort study, female sex and smaller aortic annular size significantly increased the risk of complications necessitating ECLS support during TAVR procedures. Our study represents the first to identify independent risk factors for catastrophic complications during TAVR procedures. Patients with these high-risk profiles should have their TAVR procedures performed in the hybrid operating room with cardiopulmonary bypass on immediate standby.

Abstract 4116340: The Effect of Periprocedural Statin Therapy on Mortality and Cardiovascular Outcomes in Patients Undergoing Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis

Background: Transcatheter aortic valve replacement (TAVR) stands as a notable alternative to surgery for severe aortic stenosis (AS). Despite the established benefits of statins in cardiovascular pathologies, their specific impact in patients with severe AS undergoing TAVR remains uncertain. Our study aims to assess whether perioperative statin use improves survival and outcomes post-TAVR. Methods: A search was conducted across various databases to retrieve studies comparing perioperative statin use versus no statin use in patients undergoing TAVR. The primary outcome of interest was all-cause mortality (ACM). Secondary outcomes included stroke, acute kidney injury (AKI), 30-day mortality, myocardial infarction (MI), cardiovascular complications, and in-hospital mortality. Comprehensive Meta-Analysis Software (v. 3) was used to pool odds ratio (OR) under a random-effects model, with statistical significance set at p < 0.05. Results: Our analysis encompassing 20663 patients from 15 observational studies found that perioperative statin use was associated with a significant reduction in ACM (OR= 0.71, 95% CI: 0.61-0.83, I 2 = 50.3%, p<0.001). Although not statistically significant, perioperative statin use demonstrated a trend towards a decreased risk of stroke (OR= 0.90, 95% CI: 0.68-1.19, I 2 = 0%, p= 0.455), AKI (OR= 0.99, 95% CI: 0.75-1.31, I 2 = 49%, p= 0.968), and 30-day mortality (OR= 0.71, 95% CI: 0.46-1.10, I 2 = 0%, p= 0.126), and no difference was seen in the risk of MI (OR= 1.72, 95% CI: 0.73-4.04, I 2 = 0%, p= 0.214), cardiovascular complications (OR= 1.12, 95% CI: 0.91-1.37, I 2 = 0%, p= 0.297), and in-hospital mortality (OR= 0.42, 95% CI: 0.13-1.38, I 2 = 65.8%, p= 0.151) (Figure 1 and 2). Conclusion: Perioperative statin therapy reduces all-cause mortality in TAVR patients but shows limited impact on other outcomes. Further large-scale prospective studies and trials are necessary to corroborate our findings.

Abstract 4138722: Large Language Model based multi-agent Transcatheter Aortic Valve Implantation team to augment multidisciplinary meetings - proof of concept.

Introduction: Multidisciplinary team (MDT) discussions are integral to Transcatheter Aortic Valve Implantation (TAVI) decision making. Large language model (LLM) ubiquity and low-code no-code platforms have enabled clinician lead solution development. Specialised chatbots or ‘agents’ have evolved into multi-agent systems that can personify human collaboration. We assess the performance of an artificial intelligence (AI) multi-agent TAVI MDT. Methods: Four de-identified TAVI cases from two metropolitan Australian hospitals were assessed by a mock human TAVI MDT (h-MDT) and an AI multi-agent TAVI MDT (ai-MDT). The ai-MDT was created with Agentflow within Flowise AITM and had a hierarchical multi-agent architecture suited to complex reasoning required for TAVI MDT simulation (figure). LLM limitations necessitated the ai-MDT rely on imaging reports rather than clinical images. The h-MDT and ai-MDT consisted of similar team members. Outputs from the h-MDT and ai-MDT was adjudicated by a panel of four blinded TAVI doctors that determined if output was human vs AI and assigned a SMIC score (4-12, 4=good, 12=poor) that assessed structure, missing information, incorrect information and clinical utility. Time durations for h-MDT and ai-MDT were recorded. Results: Adjudicators differentiated human vs. AI output 100% of the time and ai-MDT output had better SMIC scores than h-MDT (U-stat 213, p=0.0011). ai-MDT outperformed h-MDT in the domains of structure, missing information and clinical utility but was not statistically different in the incorrect information domain (U-stat 132, p=0.88). The average time for each case in h-MDT was 15 minutes and 45 seconds compared to 97 seconds for ai-MDT. Conclusion: This demonstrates the potential of using LLM based multi-agent systems as a clinical adjunct in highly specialized multidisciplinary clinical meetings. AI responses were superior for structure, clinical utility and missing information and non-inferior for incorrect information compared to humans, which highlights that hallucinations remain an issue with generative AI. Time was saved but image interpretation still requires human input, for now. Cognitive AI continues to require human supervision for implementation.

Abstract 4135061: Myocardial work in different patients with electrical dysynchrony due to left bundle branch block

Left bundle branch block (LBBB) in patients with dilated cardiomyopathy (DCM) is defined by huge wasted work and decreased myocardial constructive work. The aim of this study is to assess the myocardial work in patients in LBBB and other clinical situations. Materials and methods: The echocardiographic study was performed in 25 patients with LBBB and DCM (LBBB-DCM); 20 patients with DCM and narrow QRS complex (nonLBBB-DCM group); 15 patients with LBBB developed after transcatheter aortic valve implantation (TAVI group); 12 patients with idiopathic LBBB, normal systolic LV function and excluded cardiovascular pathology (LBBB group); 27 patients with right ventricular pacing due to atrioventricular block of high grade (RVP group) and 20 healthy volunteers (HV group). In all of them global longitudinal strain (GLS) and myocardial work parameters including global constructive work (GCW), global wasted work (GWW), global work index (GWI) and global work efficiency (GWE) were assessed. In all patients the segments with maximum and minimum GWI value were determined. Results: GLS, GWI and GCW values were comparable in LBBB and RVP groups, whereas in TAVI and in both DCM groups they was significantly lower than in HV (p = 0.049, 0.006, 0.025; p < 0,001 respectively, (Fig.1A,B,C)). Patients from LBBB, TAVI, RVP and LBBB-DCM groups were characterized by increased amount of GWW (261 [203.5; 291.5], 273 [184.8; 385,3] and 237 [149.5; 445.3] vs 108 [74.3; 137.3] mmHg%, p = 0.033, 0.006, < 0.001, < 0.001 respectively). GWW value in LBBB-DCM group was the highest (346.5 [255.5; 437.8] mmHg% (Fig.1D). There was moderate strength of relation between GWW and QRS duration (ρ=0.456, p<0.001). A huge amount of wasted work affected the GWE value and led to its considerable reduction in LBBB, TAVI, RVP and LBBB-DCM groups compared to HV (p = 0.033, 0.007, 0.023, < 0,001, respectively, Fig.1E). The zone of maximum GWI localized in posterolateral wall, the zone of minimum GWI was in interventricular septum in most LBBB patients (Fig.1F). At the same time, these zones turned out to be very variable in RVP group. Conclusion: Although all patients with LBBB pattern of electrical activation are characterized by significant amount of wasted work, its contribution to global myocardial work manifested only in DCM patients. Wasted work doesn’t lead to reduced constructive work in patients with idiopathic LBBB and RVP and normal systolic function probably due to compensatory mechanisms.

Abstract 4136643: Automated cardiac arrest detection using a photoplethysmography wristband: Evaluation of the time to detection of the circulatory arrest event

Introduction: Out-of-hospital cardiac arrest survival depends on immediate recognition and early cardiopulmonary resuscitation. For victims of unwitnessed cardiac arrest, accounting for 30-50% of cases worldwide, survival chances are dismal as help often comes too late. Automated cardiac arrest detection and alarming would offer a solution to shorten treatment delays. Within the DETECT project, a wristband with the functionality of automated cardiac arrest detection is developed. During the DETECT-1 study, we developed a photoplethysmography (PPG) algorithm to detect circulatory arrest in patients with induced circulatory arrest. Research question: In this sub analysis of the DETECT-1 study, we aim to study the delay between the actual circulatory arrest and the algorithms’ cardiac arrest alarm. Methods: Patients undergoing circulatory arrest induction during transcatheter aortic valve implantation (TAVI), subcutaneous ICD (S-ICD) implantation or ventricular tachycardia (VT) ablation wore a PPG wristband. Continuous ECG and arterial blood pressure data were collected as reference standard. PPG data were used to develop a circulatory arrest detection algorithm in three training iterations and one validation. Time to detection was defined as the difference between the algorithm’s cardiac arrest alarm and the circulatory arrest annotated based on the arterial blood pressure data. Results: The validation set consisted of 86 patients (77 TAVI, 3 S-ICD, 6 VT ablation) with 97 induced circulatory arrest events of which 95 were correctly identified by the algorithm (sensitivity 97% [95% CI 90-100%]). The median time to circulatory arrest detection was -1 second (IQR -2 – 0). In total, 50 (53%) events were detected before the annotated time (median; -1 sec), 33 (35%) events were detected at t=0, and 12 (13%) events were detected after the annotation (median; +2 sec). A total of 65 (68%) induced circulatory arrest events were detected within one second before and after the annotated start time of the circulatory arrest. Return of PPG pulsations were detected in all patients, with a median of 4 seconds (IQR 3 – 7) after pulsations returned (Figure 1 and 2). There were no differences in detection time between the three subgroups. Conclusion: The PPG algorithm detects the induced circulatory arrest events directly when blood pressure lowers. Further research is needed to validate the circulatory arrest detection algorithm and detection interval in spontaneous cardiac arrest.

Abstract 4132498: Hemodynamic and Clinical Outcomes with Balloon-Expandable Valves Versus Self-Expanding Valves in Patients with Small Aortic Annulus Undergoing Transcatheter Aortic Valve Implantation: A Meta-Analysis of Randomized Controlled Trials and Propensity Score Matched Studies

Background: Transcatheter aortic valve implantation (TAVI) is thought to be more effective than surgery for patients with small aortic annulus (SAA), however, the comparative efficacy of different transcatheter heart valves (THVs) remains uncertain. The objective of this meta-analysis was to compare the effects of balloon-expandable valves (BEVs) and self-expanding valves (SEVs) on hemodynamic parameters and clinical outcomes in patients with SAA who underwent TAVI. Methods: A thorough literature search was performed across PubMed/MEDLINE, Embase, and the Cochrane Library from their inception until May 2024 to identify eligible randomized controlled trials (RCTs) and propensity-score matched (PSM) studies. Clinical outcomes were evaluated using a random-effects model to pool risk ratios (RRs) with 95% confidence intervals (CIs). Results: The analysis included 8 studies; 2 RCTs and 6 PSM studies, with a total of 2,180 patients with SAA. BEVs were associated with a smaller indexed effective orifice area (MD: -0.18, 95% CI: -0.31 to -0.05) and a higher transvalvular mean pressure gradient (MD: 5.23, 95% CI 3.44 to 7.02) than SEVs. The risk for prosthesis-patient mismatch (PPM) (RR= 1.82, 95% CI: 1.27 to 2.60) and severe PPM (RR= 2.77, 95% CI: 1.93 to 3.98) was significantly higher for patients receiving BEVs than those receiving SEVs. However, no significant difference was observed between BEVs and SEVs regarding the risk of paravalvular leak (RR= 0.98, 95% CI: 0.57 to 1.69) and the permanent pacemaker implantation (RR= 0.78, 95% CI: 0.50 to 1.23). Although patients receiving BEVs showed a slightly lower risk of major bleeding events (RR= 0.69, 95% CI: 0.49 to 0.99), BEVs were associated with a significantly increased risk of 1-year cardiovascular mortality (RR= 1.61, 95% CI: 1.05 to 2.47) compared to those receiving SEVs. However, no significant differences were observed between BEVs and SEVs regarding 30-day all-cause mortality (RR= 1.19, 95% CI: 0.57 to 2.49), 1-year all-cause mortality (RR= 1.17, 95% CI: 0.89 to 1.53), stroke rates (RR= 0.83, 95% CI: 0.52 to 1.31) and any vascular complication (RR= 1.13, 95% CI: 0.72 to 1.75). Conclusion: In patients with SAA, SEVs showed reduced risks of PPM and severe PPM compared to BEVs, along with a larger indexed effective orifice area. Moreover, SEVs were associated with a lower risk of 1-year cardiovascular mortality.

Abstract 4118342: Acoustic Analysis For The Detection Of Leaflet Thrombosis After Transcatheter Aortic Valve Replacement

Introduction: Following trans-catheter aortic valve replacement (TAVR), patients may develop aortic valve leaflet thrombosis, a condition associated with an increased risk of embolic events. Currently, the diagnosis of post-TAVR leaflet thrombosis is based on echocardiography surveillance or cardiac tomography (CCT) scan, both require specialized team and equipment, and may also expose the patients to radiation and contrast. Acoustic analysis is a non-invasive reproducible method, which incorporates the recording of cardiac sounds and analyzing them via machine learning algorithms. Here, we investigated the diagnostic abilities of acoustic analysis in the detection of post-TAVR leaflet thrombosis. Methods: Using an electronic stethoscope, heart sounds were prospectively recorded at 2 time points: 24-hours and 6-months post-TAVR. CCT scan was performed 6-months following TAVR to detect leaflet thrombosis. Acoustic sounds were analyzed, using a Gaussian support vector machine (SVM) algorithm, to identify features associated with leaflet thrombosis. Results: Of 19 consecutive patients, 3 were found to have high-grade leaflet thrombosis based on CCT results. The SVM algorithm effectively classified heart sounds into "normal" and "thrombotic", with a sensitivity of 100% and specificity of 97.2%. Following anticoagulation therapy, all 3 patients showed no signs of leaflet thrombosis on follow-up CCT scans and were also classified as "normal" by the algorithm. Notably, at the time of leaflet thrombosis, Doppler echocardiographies showed normal pressure gradients across the affected valves. Conclusions: These initial results suggest that acoustic analysis, combined with machine learning algorithms, may identify post-TAVR leaflet thrombosis, providing a non-invasive, cost-effective, and radiation-free alternative to traditional diagnostic methods.

Response to "Comment on 'Effects of remimazolam versus dexmedetomidine on recovery after transcatheter aortic valve replacement under monitored anesthesia care: a propensity score-matched, non-inferiority study'".

Response to "Comment on 'Effects of remimazolam versus dexmedetomidine on recovery after transcatheter aortic valve replacement under monitored anesthesia care: a propensity score-matched, non-inferiority study'".

Abstract 4137823: Influence of Hospital and Cardiac Rehabilitation Facility Proximity on Enrollment Rates Among Medicare Beneficiaries

Background: Participation in cardiac rehabilitation (CR) is enhanced by proximity to CR facilities and communication between inpatient and outpatient settings but may become fragmented when patients are distant from their discharging hospital and nearest CR facility. Research Question: This study investigates how patient distance to both hospitals and CR facilities impacts the rates of CR participation. Methods: This study included 100% Medicare fee-for-service claims for beneficiaries with 12 months of continuous Part A/B coverage who had coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or surgical or transcatheter aortic valve replacements (SAVR or TAVR) between 07/2016-12/2018, excluding patients discharged to hospice or died within 30 days. Google Maps defined travel distances from the patient to hospital and CR facility locations using geographic centroids of ZIP codes, which were then categorized into quartiles. CR enrollment was defined as attending at least one session within one year of discharge. Logistic regression models estimated marginal CR enrollment rates across both hospital and CR facility distance categories adjusting for patient, hospital, and regional factors. Results: The study included a total sample of 501,049 beneficiaries undergoing PCI (62%), CABG (19%), SAVR (7%), and/or TAVR (15%). The median travel distance to the hospital was 18.6 miles (IQR 8.2-43.3 miles) and to the CR facility was 7.7 miles (IQR 2-15.3 miles). A total of 188,963 (37.7%) beneficiaries attended at least one CR session, which varied across categories of distance to hospital (Q1: 36.8% to Q4: 37.5%) and CR facility (Q1: 44.7% to Q4: 30.0%, p<0.01). Adjusted CR enrollment rates improved when beneficiaries lived farther from their admitting hospitals but closer to CR facilities (Figure 1), with the highest enrollment for those located farthest from their admitting hospital but closest to the CR facility (47.5%) and lowest enrollment among those closest to the hospital but farthest from the CR facility (20.6%). Conclusions: Greater distance to the admitting hospital was associated with higher CR enrollment, while greater distance to the CR facility was associated with lower enrollment among eligible Medicare beneficiaries. Addressing geographic barriers to CR participation may require tailored solutions based on patient proximity to hospitals and CR facilities.

Abstract 4122134: Relationships between aortic valve area planimetry on four-dimensional cardiac computed tomography and survival following transcatheter aortic valve replacement

Background: Aortic valve area planimetry (AVA CT ) is feasible on four-dimensional computed tomography (4D-CT) for grading aortic stenosis severity, with superior spatial but inferior temporal resolution to echocardiography, however its prognostic utility is not well-established. We evaluated the prognostic value of AVA CT in patients with significant aortic valve stenosis undergoing transcatheter aortic valve replacement (TAVR). Methods: We studied 1035 native aortic valve stenosis patients (age 79.0±9.0 years, 429 (41.5%) women) undergoing TAVR during 2019-2020. AVA CT and indexed to body surface area (AVAi CT ) were retrospectively measured on contrast-enhanced 4D-CT at peak systole, and standard statistical analyses performed to evaluate its associations with all-cause mortality during follow-up. Results: Mean AVA CT and AVAi CT were 1.02±0.21 cm 2 and 0.53±0.12 cm 2 /m 2 respectively, with 240 (23.2%) deaths during mean follow-up of 2.1±0.9 years. Areas under curves and optimal thresholds for identifying severe aortic stenosis (defined as AVA<1.0 cm 2 on echocardiography) were 0.78 and <1.10 cm 2 for AVA CT and 0.83 and <0.65 cm 2 /m 2 for AVAi CT . AVA CT and AVAi CT below these thresholds representing severe aortic stenosis were independently associated all-cause mortality during follow-up, with hazards ratios (95% confidence intervals) of 1.84 (1.34-2.53) and 2.38 (1.48-3.81) respectively in multivariable analyses. The Figure illustrates Kaplan-Meier survival curves for the cohort based on A) AVA CT and B) AVAi CT thresholds. Conclusion: Optimal thresholds of AVA CT (<1.10 cm 2 ) and AVAi CT (<0.65 cm 2 /m 2 ) were independently associated with worse survival in patients undergoing TAVR, indicating that AVA CT and AVAi CT as potentially useful additional imaging biomarkers in the diagnostic and prognostic evaluation of aortic stenosis patients.

Response to "Comment on effects of remimazolam versus dexmedetomidine on recovery after transcatheter aortic valve replacement under monitored anesthesia care: a propensity score-matched, non-inferiority study".

Response to "Comment on effects of remimazolam versus dexmedetomidine on recovery after transcatheter aortic valve replacement under monitored anesthesia care: a propensity score-matched, non-inferiority study".

Abstract 4138277: Protamine Administration and Bleeding Risk Following Transcatheter Aortic Valve Implantation: A Systematic Review and Meta-Analysis

Background: Bleeding risk is a major concern for patients receiving transcatheter aortic valve implantation (TAVI) due to heparin use. In recent studies, Heparin antagonists, such as protamine, have shown potential in mitigating this complication. We aim to evaluate its potential role in reducing the risk of bleeding in patients post-TAVI. Methods On March 18, 2024, related articles were searched in the following databases: PubMed, Embase, Scopus, Web of Science, Cochrane Library, Wiley Library, VHL, Google Scholar, and clinicaltrials.gov. The inclusion criteria consisted of studies that reported the use of protamine in patients who underwent TAVI, with the aim of reducing bleeding risk compared to administering a placebo or no treatment. Our primary outcomes included major bleeding, life-threatening bleeding, the need for blood transfusion, the 30-day mortality rate, and any events of stroke or transient ischemic attack (TIA). The effect size was calculated using the odds ratio with a 95% confidence interval. Meta-analysis was conducted based on random-effect model using Revman. Results Out of the 14,705 articles we obtained, only 5 papers were included. One was a randomized controlled trial; the remaining 4 were observational cohorts with control groups. These studies comprised a total of 3,502 patients. Protamine significantly reduced major bleeding (OR 0.44, 95% CI 0.29-0.69, p = 0.0003, I 2 = 37%), especially with full-dose administration (1 mg/100 U UFH) compared to partial-dose administration (0.5 mg/100 U UFH) (OR 0.38, 95% CI 0.25-0.58, p < 0.00001, I 2 = 0%). Similarly, protamine significantly reduced life-threatening bleeding (OR 0.37, 95% CI 0.20-0.67, p = 0.001, I 2 = 4%), particularly with full-dose usage compared to partial-dose (OR 0.37, 95% CI 0.18-0.73, p = 0.004, I 2 = 0%). However, no significant difference was observed in the need for blood transfusion (OR 0.75, 95% CI 0.46-1.24, p = 0.27, I 2 = 33%), stroke/TIA risk (OR 0.82, 95% CI 0.41-1.61, p = 0.56, I 2 = 49%), or 30-day mortality (OR 0.93, 95% CI 0.62-1.39, p = 0.73, I 2 = 0%). Conclusions The use of protamine appears to significantly reduce major and life-threatening bleeding. The need for blood transfusion, risk of stroke or TIA, and 30-day mortality did not show significant differences. These findings suggest that protamine may be an effective intervention for reducing bleeding complications post-TAVI. However, large randomized controlled trials are needed to validate these findings.

Weekly Journal Scan: Should we treat obstructive coronary artery disease in patients undergoing transcatheter aortic valve implantation?

Weekly Journal Scan: Should we treat obstructive coronary artery disease in patients undergoing transcatheter aortic valve implantation?

Abstract 4137145: Aortic Stenosis in Pregnancy: A Multidisciplinary Team Approach

Introduction: The hemodynamic adaptations that occur during pregnancy can have significant effects on patients with aortic stenosis (AS). These changes can lead to structural changes identified on echocardiogram even during uncomplicated pregnancies. While some cases can be managed with medical therapy and activity modification, others may require valve intervention in the gestational period. Case: A 29-year-old female with history of congenital bicuspid aortic valve, G1P0 presented at 42+2 weeks of pregnancy and was admitted to cardiac intensive care unit for continuous hemodynamic monitoring via use of arterial line. Her prior aortic valve disease was treated by valve repair with valvotomy, removal of tissue from pseudo raphe, removal of calcified scar tissue from both commissures, and a mitral valve repair for closure of an iatrogenic tear in her anterior leaflet. She followed closely with maternal fetal medicine and cardiology but became symptomatic at week 28 with lightheadedness, shortness of breath and decreased exercise tolerance (NYHA Class II). By week 33 she noticed lower extremity edema. Despite recommendations for planned delivery, she opted to wait until full term for delivery. Surveillance echoes revealed rising velocities yet stable valve area by planimetry. She ultimately underwent an uncomplicated Cesarean delivery of baby boy in week 42. At 6 months post partum she had successful transcatheter aortic valve replacement. Discussion: As the severity of valvular disease worsens there is a higher risk of complications during pregnancy. In our case, aortic valve velocities were elevated due to the expected hemodynamic changes of pregnancy. Thus, echocardiography monitoring should be used to assess the left ventricle’s ability to tolerate and compensate for these changes, while intervening based on symptoms and NYHA classification. We highlight the importance of multidisciplinary collaboration for safe and successful delivery in patients with AS.