Transcutaneous Aortic Valve Replacement Research Articles

7698 A case of Pheochromocytoma in a patient with severe aortic stenosis

Abstract Disclosure: C. Lane: None. L.E. Aguirre: None. J. Azocar-Villalobos: None. R.I. Dorin: None. Background: Pheochromocytomas are rare neuroendocrine tumors derived from chromaffin tissue of the adrenal medulla and can secrete catecholamines. Pre-operative management of pheochromocytoma involves initiation of a- followed by b-adrenergic receptor blockade. In critical aortic stenosis (AS), adrenergic blockade may be complicated by decreased cardiac output and hypotension owing to dependence of venous return on maintenance of high afterload (1). We report a case of critical AS and incidentally discovered pheochromocytoma and describe our management strategy, which involved prioritization of aortic valve repair prior to adrenal surgery and multidisciplinary approach to initiation and titration of a- and b-adrenergic blockade prior to cardiac catheterization and transcutaneous aortic valve replacement (TAVR) procedures. Clinical Case: A 75-year-old Caucasian male with past medical history of obstructive sleep apnea, tobacco use, and cocaine use disorder was admitted with progressive dyspnea, decreased exercise tolerance, and involuntary weight loss of 18 kg over 3 months, and community acquired pneumonia. On admission, he was found to have critical aortic stenosis (valve area of 0.59 cm2, mean gradient 83 mmHg) and new HFrEF (EF 40-45%). CT chest demonstrated incidental right adrenal mass (5.6 x 5.0 x 4.7 cm) with central necrosis, HU units >10, and evidence of internal hemorrhage. Subsequent laboratory and functional imaging studies confirmed diagnosis of pheochromocytoma. Pre-procedural a-adrenergic blockade with doxazosin followed by beta-blockade was managed by a multidisciplinary team with ICU admission for monitoring and uncomplicated completion of cardiac catheterization and TAVR. Conclusions: Pre-procedural diagnosis of pheochromocytoma, multidisciplinary management, and intensive care setting for monitoring hemodynamic response to initiation and titration of a and b-adrenergic blockade appeared to be key factors in achieving uncomplicated completion of cardiac interventions prior to surgical resection of pheochromocytoma and critical AS. Successful TAVR was associated with marked improvement in hemodynamic status. Maintenance of b-adrenergic blockade to reduce myocardial contractility was critical to preservation of the prosthetic aortic valve and in preparation for planned robotic resection of the pheochromocytoma.

Extrapolation of CT aortic annulus derived diameter/CT aortic annulus area from 2D echocardiography aortic annulus diameter in TAVR: not a reliable tool

Abstract Funding Acknowledgements Type of funding sources: None. Background Computed tomography (CT) aortic annulus area, CT area derived diameter and two-dimensional echocardiography (2D ECHO) diameters are used for valvular sizing in transcutaneous aortic valve replacement (TAVR). According to our previous study, 2D ECHO annulus diameter was smaller in comparison to CT derived diameter (22.6±2.9 vs 25.0±5.5mm, p = 0.013), but both CT aortic annulus area derived diameter/CT aortic annulus and 2D ECHO diameter predicted correct valve size selection with the same accuracy of 79–80%. However, CT requires radiation and iodine contrast administration, which might be the limitation in patients with chronic kidney disease or history of iodine allergy. Purpose To determine if 2D ECHO diameter can be used for reliable estimation of CT area derived diameter/CT aortic annulus area. Methods 139 consecutive patients with favourable outcome of Sapien XT/Sapien S3 TAVR (no more than mild aortic regurgitation, only one valve implanted) were included in the study. 2D ECHO diameter was measured from mid oesophageal three-chamber view (110–135°) just below the anatomical aortic valve annulus. CT aortic annulus was obtained as double oblique plane by manual multiplanar reconstruction of CT dataset, defined by three lowest attachment points of valvular leaflets. Aortic annulus area was measured by manual tracking of lumen contours, area derived diameter as 2*√(area/π). Linear regression analysis between pre-implant CT area derived diameter and 2D ECHO diameter was performed; extrapolated CT annulus area diameter and CT aortic annulus area [π*(d/2)2] were calculated from 2D ECHO diameter. Concordance of valve size selection based on extrapolated CT area derived diameter vs original CT area derived diameter and extrapolated CT aortic annulus area vs original CT aortic annulus area was determined on patients where CT aortic annulus area/annulus derived diameter were falling outside the overlap of the manufacturer recommended ranges for neighbouring valve sizes. Results Significant relationship between CT aera derived diameter and 2D ECHO diameter was found (r=0.720, p<0.001, Fig 1,2). Extrapolated CT area derived diameter would have led to inappropriate size selection in 33/100 more cases (undersizing in 16%, oversizing in 17%), similar to extrapolated aortic annulus area, where both undersizing and oversizing was observed in 18/106 (17%) more cases in comparison to original CT based parameters. Conclusion Extrapolation of CT aortic annulus area/area derived diameter from 2D ECHO diameter is not a reliable tool in valvular sizing for balloon expandable Sapien valve. In patients with chronic kidney disease or history of iodine allergy, three-dimensional (3D) ECHO aortic annulus assessment remains the only viable alternative tool.

870 COMBINING PERCUTANEOUS CORONARY INTERVENTION AND TRASCATHETER AORTIC VALVE REPLACEMENT PROCEDURES: THE IMPORTANCE OF INTRAVASCULAR LITHOTRIPSY

Abstract Background Calcified coronary artery disease and severe valvular aortic stenosis (AS) often coexist. For instance, severely calcified lesions may strongly influence the revascularization strategy in patients undergoing transcutaneous aortic valve replacement (TAVR). Shock wave intravascular lithotripsy (S-IVL) (Shockwave Medical Inc. Santa Clara, CA) is the only technology available that cracks both medial and intimal calcium while minimizing trauma to the vessel wall, thus allowing a safe plaque debulking. We report a case of percutaneous coronary intervention (PCI) and TAVR in the same procedure, where S-IVL has been used to treat a heavily calcified lesion and optimize stent under-expansion. Case Report A 79 years-old male patient with a history of diabetes mellitus type 2, hypertension, and peripheral artery disease, was admitted to our institution with symptomatic severe AS and severe calcified left anterior descending (LAD) artery lesion at CT scan. Deemed eligible for TAVR, Heart Team planned a percutaneous coronary intervention (PCI) of LAD and TAVR in the same procedure. Through the left radial artery, coronary angiography confirmed 90% stenosis of the LAD at the central segment. Accordingly, pre-dilatation of the stenosis was performed with a 2.5×12 mm non-compliant balloon (NCB) and, because of the severe calcification, S-IVL with a 3.0×12 mm balloon inflated at 4-6 Atmospheres (ATM), delivering 40 pulses. Following, a 3.5×18-mm drug-eluting stent was implanted at 18 ATM. After implantation, an inadequate expansion of the stents was observed, which persisted despite post-dilation with 3.75×8 mm NCB at high-pressure. Bail-out S-IVL was then performed with the 3.0×12 mm balloon inflated at 4-6 ATM, delivering 40 pulses in-stent, followed by a further stent post-dilated with a 3.75×8 mm NCB up to 20 ATM. The final angiogram showed a satisfactory stent expansion. Since the low contrast volume was used, we decided to go ahead with transfemoral TAVR. Therefore, through the left femoral artery access, a 34-mm self-expandable Evolut R valve was implanted. Transthoracic echocardiography showed optimal valve implantation with a trivial periprosthetic leak. No complications were observed after the procedures and the patient was discharged after 6 days with 6 months of mandated dual antiplatelet therapy (Aspirin and Clopidogrel). Discussion In this case, the bail-out use of S-IVL was essential for an optima stent implantation, allowing TAVR procedure and avoiding prolonged theoretical antithrombotic therapy underlying suboptimal stent implantation. Despite encouraging initial results, future large studies with long-term observation are required to evaluate the safety and efficacy of S-IVL in this scenario.

The use of warfarin as part of antithrombotic strategy after transcutaneous aortic valve replacement is not associated with better medium-term outcomes

Abstract Background Bioprosthetic valve thrombosis is currently a well-recognized cause of bioprosthetic valve dysfunction. It was found to be associated with accelerated degeneration of the bioprosthesis with higher rates of valve re-replacement, even after treatment with anticoagulation. We hypothesized that the use of warfarin for three months after transcatheter aortic valve replacement (TAVR) protects against accelerated valve degeneration and is therefore associated with better outcomes compared to dual antiplatelet therapy (DAPT). Methods Consecutive adult patients who underwent TAVR in our clinic between 2012 and 2019 were identified retrospectively. Patients with atrial fibrillation were excluded. Subsequently, patients who received DAPT were propensity matched to up to 2 patients who received three months of warfarin as part of their anti-thrombotic regimen. Matching was performed for variables that were significantly different at baseline between the two groups and included diabetes mellitus, prior myocardial infarctions, chronic lung disease, peripheral arterial disease, hemoglobin at time of TAVR, kidney function [creatinine>2], use of angiotensin-converting enzyme inhibitors / angiotensin II receptor blockers, beta blockers, the Society of Thoracic Surgeons (STS) score [STS ≥8, STS 4–8, STS<4], and valve size. The two groups were then compared for outcomes of ischemic stroke, death, valve re-replacement/intervention, the composite endpoint of the aforementioned three outcomes, as well as the three-month outcome of hemorrhagic strokes. Kaplan Meier was used for outcome analysis, and discharge date was considered time zero. Patients who had their anti-thrombotic therapy interrupted were censored at that time point. Results A total of 1,373 patients who underwent TAVR were identified. Of these, 576 patients with atrial fibrillation were excluded. Baseline characteristics were compared between 633 patients who received three months of warfarin and 164 patients who received DAPT after TAVR. After matching the two groups, 435 patients were included in the final analysis [warfarin in 281, DAPT in 154; median time to last follow up 2.61 years], Table 1. There was no difference in matched (Figure 1) or unmatched analysis (not shown) in outcomes of ischemic stroke, death, valve re-replacement/intervention, their composite endpoint, or hemorrhagic strokes (p>0.05 for all). Conclusion Antithrombotic regimen including three months of warfarin after TAVR was not associated with better outcomes of ischemic strokes, deaths, and valve re-replacement/intervention or with increased risk of hemorrhagic strokes compared to DAPT. Funding Acknowledgement Type of funding sources: None.

Correlation between aortic valve calcification and routine laboratory test results in patients with aortic valve sclerosis

Background and Aims : Aortic valve calcification (AVC) has been associated with increased risk for cardiovascular disease and vascular thrombosis and has also been proposed as a predictor of adverse outcomes in many interventional cardiology procedures,such as the transcutaneous aortic valve replacement (TAVR).The aim of this study was to investigate and correlate biochemical measurements in patients with aortic sclerosis

Increased rate of new-onset left bundle branch block in patients with bicuspid aortic stenosis undergoing TAVR; data from a national registry

Abstract Background There is a growing interest in transcutaneous aortic valve replacement (TAVR) therapy among patients with bicuspid severe aortic stenosis (BAV). Conduction disturbances remain a frequent complication of TAVR, and new-onset permanent LBBB (NOP-LBBB) post-TAVR may be a marker of worse outcomes. Purpose To evaluate primarily the rate of NOP-LBBB following TAVR among patients with BAV as compared to tricuspid severe aortic stenosis (TAV). Methods Patients enrolled in the multicenter (5 centers) Bicuspid AS TAVR Registry were reviewed and compared with patients with TAV. Patients with prior aortic valve replacement, other valve morphologies and those with preprocedural LBBB or pacemaker were excluded. NOP-LBBB was defined as LBBB first detected and persisting 30-days following TAVR. Results A total of 387 patients (66 with BAV, 321 with TAV), age 80.3±7.3, 47% females were analyzed. The device success rates were 95% in both groups without any conversions to surgery. The rate of NOP-LBBB was significantly higher among patients with BAV vs. TAV (29.2% vs. 16.9%, p=0.02). However, the rate of post procedural pacemaker implantation was similar (14.8% vs. 12.5%; respectively, p=0.62). In BAV and TAV groups, 1-year mortality (6.1% vs. 7.2%; respectively, p=0.75) and stroke rates (6.1% vs. 3.5%; respectively, p=0.3) were not significantly different. Multivariate analysis identified BAV as an independent predictor of NOP-LBBB (OR=2.7, 95% CI 1.3–5.4). Furthermore, BAV subtypes with raphe (type 1) were identified as independent predictors of NOP-LBBB (OR=3.2, 95% CI: 1.5–6.7). Conclusions Patients with BAV undergoing TAVR have greater risk for developing NOP-LBBB compared with patients with TAV and the presence of raphe was associated with increased risk of NOP-LBBB. The prognostic significance for this finding warrants further evaluation in future studies. Funding Acknowledgement Type of funding sources: None.

Simulating the time evolving geometry, mechanical properties, and fibrous structure of bioprosthetic heart valve leaflets under cyclic loading

Currently, the most common replacement heart valve design is the ‘bioprosthetic’ heart valve (BHV), which has important advantages in that it does not require permanent anti-coagulation therapy, operates noiselessly, and has blood flow characteristics similar to the native valve. BHVs are typically fabricated from glutaraldehyde-crosslinked pericardial xenograft tissue biomaterials (XTBs) attached to a rigid, semi-flexible, or fully collapsible stent in the case of the increasingly popular transcutaneous aortic valve replacement (TAVR). While current TAVR assessments are positive, clinical results to date are generally limited to <2 years. Since TAVR leaflets are constructed using thinner XTBs, their mechanical demands are substantially greater than surgical BHV due to the increased stresses during in vivo operation, potentially resulting in decreased durability. Given the functional complexity of heart valve operation, in-silico predictive simulations clearly have potential to greatly improve the TAVR development process. As such simulations must start with accurate material models, we have developed a novel time-evolving constitutive model for pericardial xenograft tissue biomaterials (XTB) utilized in BHV (doi: 10.1016/j.jmbbm.2017.07.013). This model was able to simulate the observed tissue plasticity effects that occur in approximately in the first two years of in vivo function (50 million cycles). In the present work, we implemented this model into a complete simulation pipeline to predict the BHV time evolving geometry to 50 million cycles. The pipeline was implemented within an isogeometric finite element formulation that directly integrated our established BHV NURBS-based geometry (doi: 10.1007/s00466-015-1166-x). Simulations of successive loading cycles indicated continual changes in leaflet shape, as indicated by spatially varying increases in leaflet curvature. While the simulation model assumed an initial uniform fiber orientation distribution, anisotropic regional changes in leaflet tissue plastic strain induced a complex changes in regional fiber orientation. We have previously noted in our time-evolving constitutive model that the increases in collagen fiber recruitment with cyclic loading placed an upper bound on plastic strain levels. This effect was manifested by restricting further changes in leaflet geometry past 50 million cycles. Such phenomena was accurately captured in the valve-level simulations due to the use of a tissue-level structural-based modeling approach. Changes in basic leaflet dimensions agreed well with extant experimental studies. As a whole, the results of the present study indicate the complexity of BHV responses to cyclic loading, including changes in leaflet shape and internal fibrous structure. It should be noted that the later effect also influences changes in local mechanical behavior (i.e. changes in leaflet anisotropic tissue stress-strain relationship) due to internal fibrous structure resulting from plastic strains. Such mechanism-based simulations can help pave the way towards the application of sophisticated simulation technologies in the development of replacement heart valve technology.

Comparative immunogenicity of decellularized wild type and alpha 1,3 galactosyltransferase knockout pig lungs

Decellularized pig lungs recellularized with human lung cells offer a novel approach for organ transplantation. However, the potential immunogenicity of decellularized pig lungs following exposure to human tissues has not been assessed. We found that exposure of native lungs from wildtype and transgenic pigs lacking alpha (1,3)-galactosyltransferase (α-gal KO) to sera from normal healthy human volunteers demonstrated similar robust IgM and IgG immunoreactivity, comparably decreased in decellularized lungs. Similar results were observed with sera from patients who had previously undergone transcutaneous porcine aortic valve replacement (TAVR) or from patients with increased circulating anti-α-gal IgE antibodies (α-gal syndrome). Depleting anti-α-gal antibodies from the sera demonstrated both specificity of α-gal immunoreactivity and also residual immunoreactivity similar between wildtype and α-gal KO pig lungs. Exposure of human monocytes and macrophages to native wildtype lungs demonstrated greater induction of M2 phenotype than native α-gal KO pig lungs, which was less marked with decellularized lungs of either type. Overall, these results demonstrate that native wildtype and α-gal KO pig lungs provoke similar immune responses that are comparably decreased following decellularization. This provides a further platform for potential use of decellularized pig lungs in tissue engineering approaches and subsequent transplantation schemes but no obvious overall immunologic advantage of utilizing lungs obtained from α-gal KO pigs.

Prevalence of Left Ventricular Hypertrophy Caused by Systemic Hypertension Preceding the Development of Severe Aortic Stenosis

It is generally assumed that left ventricular (LV) hypertrophy in aortic stenosis (AS) is a compensatory adaptation to chronic outflow obstruction. The advent of transcutaneous aortic valve replacement has stimulated more focus on AS in older patients, most of whom have antecedent hypertension. Accordingly, our aim was to investigate the interaction between hypertension and AS on LV remodeling in contemporary practice. We studied consecutive patients referred for echocardiograms with initial aortic valve (AV) peak velocity <3.0 m/s and a peak velocity of >3.5 m/s on a subsequent study performed at least 5 years later. LV size and geometry were measured echocardiographically. Midwall fractional shortening (FSmw) and peak systolic stress were calculated from 2-dimensional echocardiographic and Doppler data. Of 80 patients with progressive AS, 59% were women with mean age 82 ± 9 years. The average interval between the 2 echocardiograms was 5.9 ± 1.8 years. During the study period, peak velocity increased from 2.5 ± 0.4 to 4.2 ± 0.6 m/s (p < 0.01) and LV mass indexed to body surface area increased from 80 ± 28 to 122 ± 51 g/m2 (p < 0.01) with a corresponding shift from normal or concentric LV remodeling geometry to concentric hypertrophy. There was no correlation between change in LV mass index and AV mean gradient or valvulo-arterial impedance. However, change in LV mass index did correlate positively with initial peak velocity and inversely with initial LV mass. Plots of FSmw against circumferential stress at baseline and follow-up suggest that systolic function more than compensates for increasing load in many patients. In conclusion, most patients seen in our practice with severe AS have antecedent hypertension and LV remodeling at a time when outflow obstruction is mild. LV remodeling worsens in parallel with worsening severity of AS. Remodeling in these patients features increasing concentric remodeling of the LV, rather than LV dilation. Systolic function, as assessed by FSmw, remains compensated, or even improves relative to afterload, during progression of AS. Given these findings, we speculate that regression of LV hypertrophy to normal will not be affected by transcutaneous aortic valve replacement because LV hypertrophy preceded hemodynamically severe AS.

Performance of Prediction Models for Contrast-Induced Acute Kidney Injury after Transcutaneous Aortic Valve Replacement

Background: Acute kidney injury (AKI) has shown to adversely affect outcomes in patients undergoing transcutaneous aortic valve replacement (TAVR), and its correct risk estimation may interfere in procedural planning and strategies. The aim of the study was to test and compare 6 scores in predicting AKI after TAVR. Methods: We tested 6 scores (the contrast material limit score, volume-to-creatinine clearance ratio, ACEF, CR4EATME3AD3, Mehran model A, and Mehran model B) in a total of 559 consecutive patients included in the Brazilian TAVR registry. Results: All scores had a poor accuracy and calibration to predict the occurrence of AKI grade 1 or 2. All scores improved the accuracy of AKI risk prediction when stratified for AKI grade 2/3 and AKI grade 3 for all scores. The CR4EATME3AD3 was the best predictor of AKI stage 2/3 (AUC: 0.62; OR: 1.12; 95% CI 1.01–1.26; p = 0.04) and AKI stage 3 (AUC: 0.64; OR: 1.16; 95% CI 1.02–1.32; p = 0.02). Mehran models A and B were both good models for AKI stage 3 (AUC: 0.63; OR: 1.10; 95% CI 1.01–1.22; p = 0.05; and AUC: 0.62; OR: 1.10; 95% CI 1.00–1.21; p = 0.05, respectively). Conclusions: None of the current models demonstrated validity in detecting AKI when its lower grades were evaluated. CR4EATME3AD3 was the best score in predicting moderate to severe AKI after TAVR. These findings suggest that contrast-induced AKI may not be the only factor related to kidney injury after TAVR.

Unusual Cause of Left Ventricular Pseudoaneurysm

Closed mitral valvotomy (CMV) became an accepted surgical procedure to open a stenotic mitral valve (MV) about 50 years ago. CMV is performed through an incision in the left atrial appendage. Tubbs dilator is passed in to the left ventricle via the apex and then advanced retrogradely through the stenosed MV and is then opened within the orifice to split the commissures. The dilator is then removed and the orifice closed. Incisional left ventricular pseudo aneurysm has been described as a rare complication of this technique. Here we encountered a similar scenario. Percutaneous transmitral commissurotomy has virtually replaced CMV. But with the expanding use of the transapical approach to treat a variety of structural heart diseases, especially transcutaneous aortic valve replacement, one is likely to encounter similar complications in the modern era also.

Distribution and prognostic value of left ventricular global longitudinal strain in elderly patients with symptomatic severe aortic stenosis undergoing transcatheter aortic valve replacement

AimsThe aim of present study was to examine the preoperative prevalence and distribution of impaired left ventricular global longitudinal strain (LVGLS) in elderly patients with symptomatic aortic stenosis (AS) undergoing transcutaneous aortic valve replacement (TAVR) and to determine the predictive value of LVGLS on survival.MethodsWe included 411 patients with symptomatic severe AS treated with TAVR during a 5-year period, where a baseline echocardiography including LVGLS assessment was available.ResultsMean age was 80.1 ± 7.1 years and aortic valve area (AVA) index 0.4 ± 0.1 cm2. 78 patients died during a median follow-up of 762 days. Mean left ventricular ejection fraction (LVEF) was 50 ± 13% and mean LVGLS was − 14.0%. LVEF was preserved in 60% of patients, while impaired LVGLS > − 18% was seen in 75% of the patients. Previous myocardial infarction, LVEF < 50%, LVGLS > − 14%, low gradient AS (< 4.0 m/s), tricuspid regurgitant gradient > 30 mmHg were identified as significant univariate predictors of all-cause mortality. On multivariate analysis LVGLS > − 14% (HR 1.79 [1.02–3.14], p = 0.04) was identified as the only independent variable associated with all-cause mortality. Reduced survival was observed with an impaired LVGLS > − 14% in the total population (p < 0.002) but also in patients with high AS gradient with preserved LVEF. LVGLS provided incremental prognostic value with respect to clinical characteristics, AVA and LVEF (χ2 19.9, p = 0.006).ConclusionsIn patients with symptomatic AS undergoing TAVR, impaired LVGLS was highly prevalent despite preserved LVEF. LVGLS > − 14% was an independent predictor of all-cause mortality, and survival was reduced if LVGLS > − 14%.

Dextrocardia: When right is wrong!

Dextrocardia is a malposition of the heart in the thoracic cavity. Dextrocardia has been known to cause diagnostic dilemmas with atypical presentations in acute coronary syndrome, as well as technical challenges in patients who require interventions such as coronary catheterization, transcutaneous aortic valve replacement, ablation for arrhythmias, or pacemaker/defibrillator placement. Transcription factor Pitx2 has been shown to have a fundamental role during cardio-genesis, and its misexpression has been implicated in arrhythmogenesis and congenital heart diseases including visceral situs inversus. This association between congenital heart diseases and arrythmias is intriguing and need exploring. We aimed to quantify the likelihood of arrhythmias in patients with dextrocardia. A descriptive, retrospective study was conducted on the National Inpatient Sample (NIS) databases for the year 2016. Patients with dextrocardia and arrhythmias were selected based on appropriate diagnostic codes. We used propensity score-matching to assemble a matched cohort in which adults with dextrocardia and controls balanced on measured baseline characteristics. This was done to reduce the confounding effect of between-group imbalances on outcomes. Complex survey design, weights, and clustering were accounted for during analysis. Multivariate regression analysis was performed to determine the relationship of arrhythmias and length of hospitalization with dextrocardia. The prevalence of arrhythmias in patients with dextrocardia was significantly higher than the control group. Overall, the odds of arrhythmia were higher for patients in the dextrocardia group when compared to a propensity matched control group [adjusted Odds ratio OR 2.60, Confidence Interval (CI) (1.67-4.06), p<0.001]. When looking at only principal/primary diagnosis on admission, the odds of an admitting diagnosis of arrhythmia were significantly higher in the dextrocardia group when compared to the matched cohort [adjusted OR 3.70, CI (1.26-10.89), p 0.02]. The increased odds of arrhythmia in dextrocardia patients were mostly accounted for by the increased odds of atrial fibrillation/atrial flutter [OR 3.06, CI (1.02-9.18), p 0.046] in these patients. No significant difference was found in the odds of other arrhythmias or the length of stay between the two groups. In a large inpatient population, patients with dextrocardia were more likely to have arrhythmias especially atrial fibrillation/atrial flutter than patients without dextrocardia. Ours is the first study that investigates the clinical manifestations of molecular and embryologic associations between congenital heart disease and arrhythmias.

The impact of advances in percutaneous catheter interventions on redo cardiac surgery.

Toward the end of the twentieth century, redo cardiac surgery accounted for approximately 15-20% of total cardiac surgical volume. Major risk factors for redo cardiac surgery include young age at time of the first operation, progression of native coronary artery disease (CAD), vein graft atherosclerosis, bioprosthetic valve failure and endocarditis, and transplantation for end stage heart failure. Historically, redo coronary artery bypass grafting (CABG) alone carried a mortality risk of around 4%. Factors such as older age, female sex, comorbidities, combined procedures, hemodynamic instability, and emergency procedures contributed to even higher mortality and morbidity. These poor outcomes made it necessary to look for less invasive alternate methods of treatment. Advances in catheter-based interventions have made a major impact on redo cardiac surgeries, making it no longer the first option in a majority of cases. Percutaneous interventions for recurrence following CABG, transcutaneous aortic valve replacement (TAVR) for calcific aortic stenosis, valve in valve (VIV) implantations, device closure of paravalvular leaks (PVL), and thoracic endovascular aortic repair (TEVAR) for residual and recurrent aneurysms and mitral clip to correct mitral regurgitation (MR) in heart failure are rapidly developing or developed, obviating the need for redo cardiac surgery. Our intent is to review these advances and their impact on redo cardiac surgery.

The Role of Echocardiography in the Cancer Patient.

To review the uses of echocardiography in patients with cancer and how it has expanded beyond the typical monitoring of systolic function during potentially cardiotoxic cancer therapeutics. In addition to myocardial strain imaging being a predictor of subsequent left ventricular dysfunction, it can be used for pattern recognition to help identify patients with cardiac amyloidosis or Takotsubo cardiomyopathy. Echocardiography is essential for diagnosis and planning of intervention for aortic stenosis in radiation-induced valvular disease, for which transcutaneous aortic valve replacement that gives many cancer patients that are not surgical candidates an option for treatment. The safety of transesophageal echocardiography has recently been demonstrated in patients with cancer with thrombocytopenia and depleted white blood cell counts who are at increased risk of endocarditis. Echocardiography is an essential tool for evaluating common conditions in cancer patients such as pericardial disease, radiation-induced heart disease, and intracardiac tumors-with specific uses of specialized echocardiography techniques such as deformation imaging, transesophageal echocardiography, and point-of-care ultrasound.

Similar Procedural Success of Transcutaneous Aortic Valve Replacement with Prosthesis Valve Sizing by Either Three-Dimensional Transesophageal Echocardiography Modeling or Computed Tomography

Similar Procedural Success of Transcutaneous Aortic Valve Replacement with Prosthesis Valve Sizing by Either Three-Dimensional Transesophageal Echocardiography Modeling or Computed Tomography

CLINICAL CHARACTERISTICS AND OUTCOMES OF PATIENTS UNDERGOING TRANSCATHETER AORTIC VALVE REPLACEMENT WITH AND WITHOUT UNDERLYING MALIGNANCY

Transcutaneous aortic valve replacement (TAVR) is known to improve patient survival in inoperable aortic stenosis. However, data is limited about performing TAVR in patients with underlying malignancy. Hence, we hypothesized to study clinical outcomes of performing TAVR in these patients. We

Comparing Transcatheter Aortic Valve Replacement (AVR) With Surgical AVR in Lower Risk Patients: A Comprehensive Meta-Analysis and Systematic Review.

BackgroundTranscutaneous aortic valve replacement (TAVR) is a novel percutaneous procedure for severe aortic stenosis and has been recently approved by Food and Drug Administration in lower risk patients. We performed the first ever meta-analysis and literature review of clinical trials comparing both 30-day and 1-year outcomes in lower risk patients undergoing TAVR vs. surgical aortic valve replacement (SAVR, having Society of Thoracic Surgeons score < 4% or equivalent).MethodsUsing predefined selection criteria as above, 68 articles were identified. Seven eligible articles were selected after extensive review. Primary effect outcomes were 30-day and 1-year all-cause mortality using risk ratio (RR) with significant P value of < 0.05.ResultsA total of 4,859 subjects were included. Risk of 30-day all-cause mortality was 40.1% less in TAVR group, RR 0.59 (95% confidence interval (CI): 0.38 - 0.92, P = 0.02) with no significant heterogeneity. Six studies except Schymik et al also reported 1-year risk. This was, however, not statistically significant with a 21% decrease in the TAVR group, RR 0.79 (95% CI: 0.57 - 1.09, P = 0.15). Six studies reported 30-day risk of secondary outcomes. The risk of 30-day stroke was 36% less in TAVR group, although this was not statistically significant, RR 0.64 (95% CI: 0.38 - 1.9, P = 0.10). The risk of acute kidney injury (AKI) stage 2 and above was 56% less in post-TAVR patients, RR 0.43 (95% CI: 0.35 - 0.54, P < 0.001) with no heterogeneity. For vascular complications, RR was high in TAVR group 4.62 (95% CI: 1.42-15.18, P = 0.01). Significant heterogeneity was demonstrated though (I2 = 81). The risks for permanent pacemaker (PPM) were also higher in the TAVR group, RR 3.30 (95% CI: 2.04 - 5.33, P < 0.001) and significant heterogeneity was observed. After removing Thyregod et al and Partner 3 trial from the analysis, heterogeneity was removed, but the RR was still high 3.21 (95% CI: 2.54 - 4.068, P < 0.001). Post-operative incidence of endocarditis among TAVR patients was low but not statistically significant. The 30-day risk for infective endocarditis was RR 0.67 (95% CI: 0.13 - 3.48, P = 0.63). The 1-year risk was similarly low but not significant, RR 0.73 (95% CI: 0.28 - 1.92, P = 0.53).ConclusionsAmong low risk patients, TAVR was found to be superior in short-term all-cause mortality and 1-year stroke, a result that was statistically significant for TAVR and close to significance for stroke. TAVR patients were also less likely to have post-operative bleeding and AKI stage 2 and beyond. Post-operative incidence of endocarditis among TAVR patients was low but not statistically significant. However, the rates of PPM and vascular complications are higher in TAVR patients. The results of TAVR in low risk population are thus extremely encouraging. However, the issue of long-term valve durability in this group needs further studies. Also, caution needs to be exercised while extending the indications to extremely young patients due to lack of enough studies.

P782 Septal flash is a prevalent and early dyssynchrony marker in transcatheter aortic valve replacement-induced left bundle branch block

Abstract BACKGROUND New-onset left bundle branch block (LBBB) is a frequent complication after transcutaneous aortic valve replacement (TAVR). LBBB is associated with echocardiographic dyssynchrony in heart failure patients, but this has not been thoroughly investigated in acute LBBB following TAVR. PURPOSE This study aims to assess the timing and incidence of echocardiographic dyssynchrony in acute TAVR-induced LBBB patients. METHODS The study enrolled all TAVR-induced LBBB patients at our Hospital between January 2013 and May 2019. Presence of LBBB was scored within 72 hours following TAVR. Dyssynchrony was assessed by: 1/ presence of septal flash (SF), 2/ interventricular mechanical delay (IVMD, the difference between left and right ventricular pre-ejection interval using pulsed wave Doppler; cut-off ≥40 ms) and 3/ presence of ‘classical dyssynchronous strain pattern’ assessed with speckle tracking (Figure 1). As a control, these three LBBB-related dyssynchrony markers were assessed and compared to LBBB patients without TAVR (non-TAVR patients) in normal ànd reduced EF, but all having SF. RESULTS Out of 134 consecutive TAVR procedures, 30 (22%) were complicated by acute LBBB. SF was present in 72% of TAVR-induced LBBB patients, with a median time from TAVR to SF diagnosis of 24 hours. However, only 1 (5%) of these TAVR patients exhibited a classical dyssynchronous contraction strain pattern (Figure 1), despite presence of SF. Finally, the IVMD values in these TAVR-LBBB patients did not meet the ‘dyssynchrony’ cut-off. As a control, we compared these dyssynchrony parameters in patients with non-TAVR related LBBB with normal and reduced EF, all exhibiting SF. A classical strain pattern was present in 33% of non-TAVR LBBB patients with preserved left ventricular ejection fraction (LV EF) (p = 0.17), and in 80% of non-TAVR LBBB patients with reduced LV EF ≤30% (p &amp;lt; 0.001). The IVMD in non-TAVR LBBB patients with SF and preserved LV EF was 52 ms (p = 0.002) and 57 ms in non-TAVR LBBB patients with SF and LV EF ≤30% (p = 0.009). CONCLUSION SF as dyssynchrony marker develops early after TAVR-induced LBBB and is much more prevalent than the classical strain-based dyssynchrony pattern and IVMD. Our findings from the control population suggest that progressive LBBB-induced LV remodeling (septal thinning and relative lateral thickening) may be required for a ‘classical dyssynchrony strain pattern’ or significant IVMD to occur in TAVR-LBBB patients, but longitudinal follow-up studies in TAVR-LBBB patients are required as proof-of-concept. Abstract P782 Figure 1

Transcatheter Versus Surgical Aortic Valve Replacement in Renal Transplant Patients: A Meta-Analysis.

BackgroundThe outcome of transcutaneous aortic valve replacement (TAVR) in patients with kidney transplant is unknown, as majority of these patients were excluded from the major TAVR clinical trials. We sought to compare patients with severe aortic stenosis who underwent TAVR versus surgical aortic valve replacement (SAVR) with a history of kidney transplant.MethodsPubMed, Google Scholar and Cochrane databases were searched to identify relevant articles. The incidence of all-cause mortality and acute kidney injury (AKI) was calculated using relative risk on a random effect model.ResultsA total of 1,538 patients (TAVR 328, SAVR 1,210) were included in the study. TAVR was associated with lower mortality as compared with SAVR at 30 days from the index procedure (odds ratio (OR) 0.48, 95% confidence interval (CI): 0.25 - 0.93; P = 0.03). One-year mortality was studied in three studies and showed comparable mortality in patients undergoing TAVR and SAVR (OR: 0.76, 95% CI: 0.10 - 5.51; P = 0.78). Compared to SAVR, TAVR carries an identical risk of AKI (OR: 0.44, 95% CI: 0.10 - 1.90; P = 0.27). A sensitivity analysis performed by exclusion of Voudris et al study showed a non-significant difference in the mortality incidence of two groups at 30 days (OR: 0.72, 95% CI: 0.27 - 1.91; P = 0.51).ConclusionsIn patients with a history of kidney transplant, TAVR was associated with a comparable risk of mortality and AKI compared to SAVR.