Urgent Transcatheter Aortic Valve Replacement Research Articles

Mortality rates in patients undergoing urgent versus elective transcatheter aortic valve replacement: a systematic review and meta-analysis

Abstract Background Patients with severe aortic stenosis (AoS) often present with acute heart failure and compensation, leading frequently to cardiogenic shock. Transcatheter Aortic Valve Replacement (TAVR) has been recently performed as a bailout treatment in such patients. The aim of our meta-analysis is to compare urgent TAVR to elective procedures. Methods We systematically screened three databases searching for studies comparing urgent versus elective TAVR. Primary endpoint is the 30-days mortality. Secondary endpoints included in-hospital mortality, device success, periprocedural vascular complications, 30-day stroke, 30-day acute kidney injury (AKI), permanent pacemaker implantation (PPM), moderate or severe paravalvular leakage and 30-day bleedings. Results Seventeen studies were included, with a total of 84,495 patients. Urgent TAVR was associated with an increased risk for 30-days mortality (RR: 2.53, 95% CI: 1.81 – 3.54), in-hospital mortality (RR: 2.67, 95% CI: 1.94 – 3.68), periprocedural vascular complications (RR: 1.91, 95% CI: 1.28 – 2.85) and AKI (RR: 2.83, 95% CI: 1.93 – 4.14), compared to elective procedure. No differences were observed in the rest secondary endpoints. Conclusions Urgent TAVR was associated with higher in-hospital and 30-day mortality, possibly driven by the increased incidence of AKI and vascular complications in urgent TAVR. The results highlight the importance of early TAVR in stable AoS patients.

A Novel Protocol for Contrast-Free Transcatheter Aortic Valve Replacement Evaluation and Implantation

BackgroundWe aimed to develop a transcatheter aortic valve replacement (TAVR) sizing algorithm and implantation method to facilitate safe and effective TAVR without contrast use in patients with severe chronic kidney disease (CKD) who do not yet require renal replacement therapy. Patients with CKD are a challenging patient subset to treat using standard TAVR care pathways which most usually require the use of iodinated contrast media both during gated computed tomography (CT) angiography sizing, and valve deployment. Iodinated contrast exposure may worsen kidney function in a dose-dependent fashion, and may result in a need for renal replacement therapy. Therefore, a method to eliminate, or greatly lessen, contrast exposure during TAVR is highly desirable. MethodsOne hundred sixty patients who underwent standard CT angiography and TAVR implantation were used to develop (100 patients) and validate (60 patients) an algorithm to predict balloon-expandable valve size using measurements available from noncontrast CT. Model accuracy was measured using Pearson correlation between algorithm-predicted valve size and actual size used based on annular area. As proof of concept, we then report a case series of 35 consecutive patients who underwent TAVR evaluation and implantation with moderate sedation and no contrast between May 2021 and April 2024. ResultsThe valve sizing algorithm incorporates sinus and sinotubular junction diameters, both available from a reformatted noncontrast, cardiac-gated CT. The algorithm demonstrated a strong correlation with the actual valve size used (development cohort R = 0.81, validation cohort R = 0.76). Thirty-five patients underwent “no-contrast TAVR” with noncontrast CT for valve sizing. Forty-eight percent were urgent inpatient TAVR. Technical procedural success, as defined by the VARC3 criteria, was 100%, with no patient deaths during the index procedure. Three patients had a mild paravalvular leak. No valve embolization or need for a second valve occurred. Four patients required a pacemaker. ConclusionsWe present a novel algorithm for TAVR evaluation and implantation without the use of iodinated contrast media in a high-risk patient subset with CKD.

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.

Urgent transcatheter aortic valve replacement (TAVR) in patients with severe aortic stenosis is associated with increased 30-days mortality: a systematic review and meta-analysis

Abstract Funding Acknowledgements None. Introduction In patients with severe symptomatic aortic stenosis (AS), transcatheter aortic valve replacement (TAVR) has emerged as a safe and effective therapeutic option; yet, 20% of these patients' hospitalizations are related to acute decompensation. The vast majority of TAVR procedures conducted across the US are elective procedures on patients who are hemodynamically stable. Despite that, according to recent research, urgent TAVR may be a feasible option for AS patients experiencing acutely decompensated heart failure or cardiogenic shock. Additionally, there is also a gap in the guidelines concerning the interventions in this acute setting, with only a brief recommendation for aortic balloon valvuloplasty as a bridge to TAVR or surgery in decompensated AS. Purpose The aim of this systematic review and meta-analysis is to assess 30-days mortality post-TAVR in patients submitted to an urgent procedure and compare them with the elective TAVR population. Methods We systematically searched 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 30-days mortality post-procedurally. Only studies provided data about our primary endpoint were considered in this analysis. Secondary endpoints comprised acute kidney injury (AKI), permanent pacemaker implantation (PPM) and stroke during the first 30-days post-TAVR. 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 This systematic review acquired 497 results. After duplicates removal, we screened 454 reports and we read full-text articles of 35 studies. Fourteen studies were included in our analysis. A total of 43,051 patients undergoing TAVR were included in our analysis; 3,607 patients submitted to an urgent TAVR, while the rest 39,444 had an elective procedure. Our analysis showed that patients undergoing urgent TAVR have 244% higher risk for mortality during the first 30-days post-procedurally (RR: 2.44, 95%CI: 1.49, 3.99) (Figure). Data about AKI, PPM and stroke during the first 30-days post-TAVR were available for 10 studies. The risk for AKI appeared to be significantly higher in patients undergone urgent TAVR (RR: 2.68, 95% CI: 1.60, 4.47). No significant differences were observed in stroke incidence (RR: 1.04, 95% CI: 0.89, 1.20) and PPM (RR: 1.08, 95%CI: 0.95, 1.22) during 30-days follow-up. Conclusion Compared to elective procedures, urgent TAVR seems to have increased 30-days mortality and AKI, and comparable PPM and stroke rates. These findings provide valuable insights offering potential updates to current guidelines in this field. Further studies on long-term outcomes and in a larger patient population are needed.

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

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

Mortality Rates in Patients Undergoing Urgent Versus Elective Transcatheter Aortic Valve Replacement: A Meta-analysis.

Patients with severe aortic stenosis (AoS) often present with acute heart failure and compensation, frequently leading to cardiogenic shock. Transcatheter Aortic Valve Replacement (TAVR) has been recently performed as a bailout treatment in such patients. The aim of our meta-analysis is to compare urgent TAVR with elective procedures. We systematically screened three databases searching for studies comparing urgent vs elective TAVR. Primary endpoint is the 30-days mortality. Secondary endpoints included in-hospital mortality, device success, periprocedural vascular complications, 30-days stroke, 30-days acute kidney injury (AKI), permanent pacemaker implantation (PPM), moderate or severe paravalvular leakage, and 30-days bleeding. Seventeen studies were included, with a total of 84,495 patients. Urgent TAVR was associated with an increased risk for 30-days mortality [Risk Ratio (RR): 2.53, 95% Confidence Intervals (CI): 1.81-3.54)], in-hospital mortality (RR: 2.67, 95% CI: 1.94-3.68), periprocedural vascular complications (RR: 1.91, 95% CI: 1.28-2.85) and AKI (RR: 2.83, 95% CI: 1.93-4.14), compared with elective procedure. No differences were observed in the other secondary endpoints. Urgent TAVR was associated with higher in-hospital and 30-days mortality, possibly driven by the increased incidence of AKI and vascular complications in urgent TAVR. The results highlight the importance of early TAVR in stable AoS patients.

Short-term Outcomes of Urgent Transcatheter Aortic Valve Replacement in Symptomatic Aortic Stenosis That Requires Emergency Hospital Admission.

Objective This study retrospectively compared the outcomes of emergently admitted patients with aortic stenosis (AS) with or without urgent transcatheter aortic valve replacement (TAVR). Methods Patients hospitalized between February 2015 and December 2019 for symptomatic AS were retrospectively analyzed by comparing the received conservative management [continued medical therapy with or without elective surgical transcatheter replacement (SAVR) or TAVR scheduled after the index hospitalization] and urgent TAVR (TAVR during the index hospitalization). Results The cohort comprised 114 patients with symptomatic AS who required emergency admission. Urgent TAVR was performed for 37 patients, while conservative management was provided for 77 patients, including 1 who received urgent SAVR. Urgent TAVR was more likely to be performed in patients with a history of hospitalization for heart failure, high New York Heart Association class scores, a lower clinical frailty scale at admission, and a high aortic valve peak velocity (p=0.01, p<0.001, p<0.01 and p=0.02, respectively). Kaplan-Meier analyses with log-rank test revealed favorable outcomes of urgent TAVR in all-cause mortality and cardiovascular events within 60 days of admission (p<0.01, p<0.01, respectively). Conclusion Urgent TAVR had better short-term outcomes in patients with symptomatic AS who required emergency hospital admission than conservative management. When considering urgent TAVR, patients with typical heart failure symptoms due to AS with a history of heart failure hospitalization and relatively little frailty can be selected.

Urgent Transcatheter Aortic Valve Replacement for Acutely Decompensated Severe Aortic Stenosis.

Urgent Transcatheter Aortic Valve Replacement for Acutely Decompensated Severe Aortic Stenosis.

TAVR in patients with cardiogenic shock or severely decompensated aortic stenosis

Abstract Funding Acknowledgements Type of funding sources: None. Background Severe aortic stenosis (AS) can result in cardiogenic shock (CS) or severe cardiac decompensation. Although transcatheter aortic valve replacement (TAVR) is the routine procedure for elderly or inoperable patients with severe AS, its role as an emergency therapy for critically ill patients, especially due to CS, needs further investigation. Purpose The purpose of this study was to explore clinical characteristics and long-term survival of patients treated with emergency TAVR. We hypothesised that patients surviving the initial interventional and intensive care treatment would have a similar prognosis as elective TAVR patients. Methods All patients undergoing TAVR at our centre between 2013 and 2019 were screened for emergency TAVR or treatment on intensive care units (ICU) before TAVR. Selected patients were divided into groups with or without CS, defined as systolic blood pressure &amp;lt;90 mmHg or the use of inotropes and lactate &amp;gt;2 mmol/l. The remaining patients undergoing elective TAVR served as a comparison cohort. Results Out of 189 patients with emergency TAVR, 53 patients were in CS (shock group) and 136 patients did not fulfil CS criteria (urgent group). Patients in the shock group were more often male (75.5% vs. 56.6%, p=0.02), had a higher Society of Thoracic Surgeons score (15.6 [IQR, 7.7-30.5] vs. 5.4 [3.8-8.3], p&amp;lt;0.01), and lower left-ventricular ejection fraction (38.0% vs. 48.0%, p&amp;lt;0.01). The rate of coronary artery disease was similar (78.0% vs. 75.2%, p=0.69). Concerning the cause of acute decompensation, a specific condition which resulted in a clinical deterioration triggering hospitalisation could be identified in most patients. These included, among others, volume overload, acute coronary syndromes, arrhythmias, infections, and bleeding. Before TAVR, patients were treated on an ICU for 3 [2-5] days (shock group) and 2 [1-5] days (urgent group), p=0.01. In the shock group, mechanical ventilation was more frequent (52.8 vs. 14.7%, p&amp;lt;0.01), and more patients received valvuloplasty before TAVR (18.9 vs. 3.7%, p&amp;lt;0.01). The Valve Academic Research Consortium 3 (VARC-3) composite endpoint of technical failure occurred more often in emergency patients (shock, 13.2% vs. urgent, 9.6%) than in the 2,741 patients after elective TAVR (4.8%, p&amp;lt;0.01). Estimated 2-year mortality was higher in the shock compared to urgent group (hazard ratio, 2.1 [1.3-3.3], p&amp;lt;0.01). In a landmark analysis from day 90, 2-year mortality in these groups was comparable to elective TAVR patients (p=0.41, Figure). Conclusions TAVR in CS is associated with increased mortality compared to other cases of urgent TAVR. Procedural complication rates exceed those of elective TAVR patients. However, patients treated with emergency TAVR who survived 90 days after the procedure had a prognosis similar to elective TAVR patients.

30-day readmission following urgent and elective transcatheter aortic valve replacement: A Nationwide Readmission Database analysis.

Transcatheter aortic valve replacement (TAVR) is being increasingly used for decompensated severe symptomatic aortic stenosis. Data on urgent and elective TAVR readmission is scarce in the literature. Here, we have performed a retrospective cohort study with the Nationwide Readmission Database of 2016 to identify the rate of 30-day all-cause readmission, common causes of readmission, and distribution of morbidity in index admission and readmission after urgent and elective TAVR. We used International Classification of Diseases, Tenth Revision codes (02R.F38H, 02R.F38Z, 02R.F48Z) for identification of all TAVR procedures done in 2016 in patients >18 years old. We found 8379 patients who underwent urgent TAVR and 32,006 patients who underwent elective TAVR in 2016. The mean age of patients undergoing urgent TAVR was 79 ± 9.97 years with 44.6% women. The mean age of patients undergoing elective TAVR was 80.7 ± 8.25 years with 46.2% women. We found the 30-day all-cause readmission rate of 15.5% and 9.5% in patients undergoing urgent and elective TAVR, respectively (p< 0.001). The cardiac cause was the predominant cause of readmission in both groups (43.77% vs. 42.11%, p =0.57), followed by pulmonary cause, gastrointestinal (GI) cause, and renal cause. Among cardiac causes, congestive heart failure (CHF) was predominant cause of readmission and was similar in both groups (18.73 in urgent TAVR vs. 15.73 in elective TAVR, p =0.12). We found that the all-cause 30-day readmission rate was higher in patients who had undergone urgent TAVR. Further studies are needed to better understand this difference.

Cerebral Embolic Protection and Outcomes of Transcatheter Aortic Valve Replacement: Results From the Transcatheter Valve Therapy Registry.

Stroke remains a devastating complication of transcatheter aortic valve replacement (TAVR), which has persisted despite refinements in technique and increased operator experience. While cerebral embolic protection devices (EPDs) have been developed to mitigate this risk, data regarding their impact on stroke and other outcomes after TAVR are limited. We performed an observational study using data from the Society for Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. Patients were included if they underwent elective or urgent transfemoral TAVR between January 2018 and December 2019. The primary outcome was in-hospital stroke. To adjust for confounding, the association between EPD use and clinical outcomes was evaluated using instrumental variable analysis, a technique designed to support causal inference from observational data, with site-level preference for EPD use within the same quarter of the procedure as the instrument. We also performed a propensity score-based secondary analysis using overlap weights. Our analytic sample included 123 186 patients from 599 sites. The use of EPD during TAVR increased over time, reaching 28% of sites and 13% of TAVR procedures by December 2019. There was wide variation in EPD use across hospitals, with 8% of sites performing >50% of TAVR procedures with an EPD and 72% performing no procedures with an EPD in the last quarter of 2019. In our primary analysis using the instrumental variable model, there was no association between EPD use and in-hospital stroke (adjusted relative risk, 0.90 [95% CI, 0.68-1.13]; absolute risk difference, -0.15% [95% CI, -0.49 to 0.20]). However, in our secondary analysis using the propensity score-based model, EPD use was associated with 18% lower odds of in-hospital stroke (adjusted odds ratio, 0.82 [95% CI, 0.69-0.97]; absolute risk difference, -0.28% [95% CI, -0.52 to -0.03]). Results were generally consistent across the secondary end points, as well as subgroup analyses. In this nationally representative observational study, we did not find an association between EPD use for TAVR and in-hospital stroke in our primary instrumental variable analysis, and found only a modestly lower risk of in-hospital stroke in our secondary propensity-weighted analysis. These findings provide a strong basis for large-scale randomized, controlled trials to test whether EPDs provide meaningful clinical benefit for patients undergoing TAVR.

Urgent transcatheter aortic valve replacement may be performed with acceptable long-term outcomes.

The wide availability of transcatheter aortic valve replacement (TAVR) and broadening of its indications to most patients with aortic stenosis may increase its utilization in the urgent setting. However, a comparison of long-term outcomes of patients undergoing urgent TAVR when compared to elective TAVR have not been well studied. All patients that underwent TAVR from 2011 to 2018 were included. Primary outcomes included operative (30-day), 1-, and 5-year survival and readmissions. The total patient population undergoing TAVR was divided into urgent (n = 247) and elective (n = 946) cohorts. Thirty days mortality (6.5% vs. 2.3%; p = .001), acute kidney injury (2.8% vs. 0.6%; p = .003), and length of stay (12 vs. 3 days; p < .001) were higher for the urgent cohort. There was no significant difference between cohorts for 30-day all-cause (14.6% vs. 10.8%; p = .097) readmissions. Freedom from readmission for heart failure at 1-year (73.6% vs. 83.4%; p < .001) was lower for the urgent cohort. One- (79.0% vs. 87.1%; p < .001) and five-year (39.6% vs. 43.5%; p = .005) survival was lower for the urgent cohort. This difference was eliminated after risk adjustment (hazard ratio [HR]: 1.3; p = .158 and HR: 1.1; p = .639, respectively). Unadjusted survival was significantly worse for the urgent cohort up to 1 year. This trend continued for 5-year survival, however, after risk adjustment there was no significant difference in survival between cohorts. Although urgent TAVR is associated with increased periprocedural risk due to more comorbid disease, outcomes and long-term survival are encouraging and support the consideration of urgent TAVR as a viable alternative for this patient population.

Is urgent transcatheter aortic valve replacement better than balloon aortic valvuloplasty?

Is urgent transcatheter aortic valve replacement better than balloon aortic valvuloplasty?

Transcaval TAVR on A LVAD Patient Presenting with Cardiogenic Shock

Introduction Aortic insufficiency (AI) following left ventricular assist device (LVAD) placement is a serious, well established complication. Transcatheter aortic valve replacement (TAVR) has been successfully used in LVAD patients developing AI. However, femoral/iliac arterial access required for TAVR is not always possible due to arterial calcifications and small arterial size. Transcaval approach is a novel alternative percutaneous catheter route from the IVC, through the retroperitoneal space, into the abdominal aorta. Transcaval TAVR in LVAD patients with severe AI has not been described. CASE Patient is a 28 year old female with history of postpartum STEMI secondary to spontaneous LAD/LCX dissection requiring CABG with subsequent cardiogenic shock requiring emergent LVAD (HeartMate 3) placement. One month following LVAD implantation, she presents with intractable nausea and vomiting. Physical exam illustrates a cachectic female who was hypotensive, tachycardic, with cool extremities. Laboratory evaluation reveals elevated lactate, transaminases and creatinine. Abdominal CTA shows a prior dissection in the infrarenal abdominal aorta, occlusion of the right external iliac artery and stenosis in the left external iliac artery. On echocardiography, there is severe, continuous, aortic regurgitation increased in severity compared to baseline. Right heart catheterization illustrates right atrial pressure 18 mmHg, pulmonary artery pressure 53/25 mmHg, pulmonary wedge pressure 24 mmHg, and cardiac index 1.3 L/min/m2. Patient is referred for urgent TAVR via transcaval access due to her stenotic and small sized iliac arteries. A pigtail was inserted in the left femoral artery and advanced to the abdominal aorta and another pigtail was inserted in the right femoral vein and advanced to the IVC to align with the aorta one. From the IVC, an astato wire was crossed into the aorta using wats to electrify the wire. A Sapien 3 valve was deployed. The caval aortic fistula was closed with a covered aortic stent. Final angiography showed complete occlusion of the fistula. Post intervention, patient experienced immediate improvement with resolution of cardiogenic shock. At three months, she remained asymptomatic and echocardiogram showed a well seated valve with no AI. DISCUSSION We present an urgent transcaval TAVR performed for a LVAD patient presenting with cardiogenic shock due to AI. Transcaval TAVR is a promising intervention that can be successfully used in LVAD patients developing AI with challenging iliofemoral arterial access.

Outcomes of Urgent Transcatheter Aortic Valve Replacement in Patients With Acute Decompensated Heart Failure: A Single-Center Experience.

BackgroundData on urgent transcatheter aortic valve replacement (TAVR) as rescue therapy for acute decompensated heart failure (ADHF) due to severe aortic stenosis (AS) are limited. We sought to investigate the outcomes of patients who underwent urgent transcatheter aortic valve replacement (TAVR) in a single institution.MethodsThis is a retrospective cohort study of 602 patients with a history of heart failure (HF) due to AS who underwent TAVR between April 2012 and July 2017. We stratified patient cohort into urgent (n=139) and elective (n=463) TAVR. Urgent TAVR was defined as patients who were admitted for ADHF and underwent TAVR during the same hospitalization. Patients that underwent urgent TAVR for other reasons were excluded.ResultsRates of postoperative intra-aortic balloon pump requirement, atrial fibrillation, dialysis requirement, vascular complications, and stroke were similar between the two groups. Compared with elective TAVR, patients undergoing urgent TAVR had a higher rate of cardiac arrest (5.7% vs 1.3%, p=0.005), longer length of stay (LOS) (11 vs. 5, p<0.001), and significant 30-day mortality (8.6% vs 4.1%, HR 2.1, 95% CI 1.04-4.22). Patients who underwent urgent TAVR were also associated with long-term mortality (Log-rank p = 0.0162).ConclusionsIn our study, urgent TAVR for ADHF was associated with both short-term and long-term mortality as compared to elective TAVR. Further randomized studies are needed to investigate the appropriate management of this population.

Appraisal of urgent transcatheter aortic valve replacement

Urgent transcatheter aortic valve replacement (TAVR) is needed in unstable patients with severe aortic stenosis and acute decompensated heart failure who are refractory to initial medical management. The outcome of urgent TAVR is worse and heavily influenced by the severity of the clinical status prior to intervention. Careful patient evaluation, procedural planning, and postoperative management should be optimized to improve the clinical results.

889 Stretching the Limits of Transcatheter Aortic Valve Replacement (TAVR): Emergency TAVR Deployment Using Leaflet Calcification for Neo-Annulus Construction in an Extremely Large Aortic Annulus

A 73-year-old previously healthy man, presented with cardiogenic shock and ventricular tachycardia (VT) storm due to critical aortic stenosis (mean invasive gradient of 84 mm Hg across the aortic valve) with moderate aortic incompetence (AI) causing severe left ventricular dysfunction (ejection fraction 10%), underwent transcatheter aortic valve replacement (TAVR) within 3 hours of review by TAVR team. Urgent CT demonstrated a type 1 bicuspid aortic valve with an extremely large aortic annulus exceeding the maximum dimensions for all TAVR bioprostheses (area 988 mm2, perimeter 112.3 mm, minimum and maximum diameter of 33 mm and 38 mm respectively, LVOT diameter 29 mm) and extreme calcification of the valve leaflets. An urgent TAVR proceeded with a 29 mm self-expanding bioprosthesis (Abbott Portico Self-Expanding Valve). The dense, cauliflower-like leaflet calcification was used to anchor the prosthesis in a high position creating a neo-annulus from the valve tissue, modifying a technique that has been described for the management of type 0 bicuspid valves with a fibrotic ovoid orifice. Following deployment, initial significant prosthesis constraint with moderate paravalvular leak (PVL) with two main jets were noted on transesophageal echo. Multiple post-dilatations using an overfilled 28 mm Nucleus-X balloon were performed. The AI index at the end of the procedure was 0.41 indicating mild PVL. LVEF improved to 30%, 1-week post-TAVR. This case highlights that emergency TAVR can be life-saving in a challenging anatomy, illustrating a strategy of creating a high neo-annulus using extreme leaflet calcification where the true native annulus size exceeds current device capabilities.

Intra-procedural monitoring protocol using routine transthoracic echocardiography with backup trans-oesophageal probe in transcatheter aortic valve replacement: a single centre experience.

The aim of this study is to describe our 9-year experience in transcatheter aortic valve replacement (TAVR) using transthoracic echocardiography (TTE) as a routine intra-procedural imaging modality with trans-oesophageal echocardiography (TEE) as a backup. From January 2008 to December 2017, 1218 patients underwent transfemoral TAVR at our Institution. Except the first 20 cases, all procedures have been performed under conscious sedation, with fluoroscopic guidance and TTE imaging monitoring. Once the TTE resulted suboptimal for final result assessment or a complication was either suspected or identified on TTE, TEE evaluation was promptly performed under general anaesthesia. Only 24 (1.9%) cases required a switch to TEE: 6 cases for suboptimal TTE prosthetic valve leak (PVL) quantification; 12 cases for haemodynamic instability; 2 cases for pericardial effusion without haemodynamic instability; 4 cases for urgent TAVR. The 30-days and 1-year all-cause mortality were 2.1% and 10.2%, respectively. Cardiac mortality at 30-days and 1-year follow-up were 0.6% and 4.1%, respectively. Intra-procedural and pre-discharge TT evaluation showed good agreement for PVL quantification (k agreement: 0.827, P = 0.005). TTE monitoring seems a reasonable imaging tool for TAVR intra-procedural monitoring without delay in diagnosis of complications and a reliable paravalvular leak assessment. However, TEE is undoubtedly essential in identifying the exact mechanism in most of the complications.

Association between Red Blood Cell Transfusion and 30-day Readmission Following Transcatheter Aortic Valve Replacement

ABSTRACT Background: We sought to evaluate the association between post-procedural packed red blood cell (PRBC) transfusion following transcatheter aortic valve replacement (TAVR) and 30-day all-cause readmission. We assessed incidence, causes and predictors of 30-day readmission. Methods: We retrospectively analyzed 417 patients who underwent TAVR and survived the index hospitalization. A propensity-score adjusted multivariable logistic regression model was utilized to relate PRBC transfusion to 30-day readmission and to identify predictors of 30-day readmission. Results: The overall 30-day readmission rate was 19.4% and was for non-cardiac causes in 54.3% of patients. Of patients who received PRBC transfusion and those who were not transfused, 30.9% and 21.7% were readmitted within 30 days, respectively (p = 0.08). After propensity adjustment, the odds of readmission were not different among transfused and non-transfused patients (1.33 [95% CI 0.74, 2.40, p = 0.34]). However, among non-anemic patients, transfusion was associated with a greater likelihood of readmission (50% vs. 11.8%, OR 4.92 [95% CI 1.74, 13.91], p = 0.003), in contrast to anemic patients in whom it was not (OR 0.96, [95% CI 0.53, 1.73], p = 0.89; interaction p = 0.002). Independent predictors of 30-day readmission included history of atrial fibrillation (OR: 2.06; CI: 1.23, 3.46, p = 0.006), urgent TAVR procedure (OR: 2.29; CI: 1.20, 4.38, p = 0.020), discharge to nursing home or rehabilitation facility (OR: 1.95; CI: 1.11, 3.44, p = 0.014) and any post-operative complication (OR: 2.08; CI: 1.19, 3.63, p = 0.007). Conclusions: Pre-procedure atrial fibrillation and urgent procedures are novel predictors of early readmission following TAVR. PRBC transfusion did not independently predict 30-day readmission following TAVR.

TCT-690 Safety and Efficacy of Urgent Transcatheter Aortic Valve Replacement in Patients admitted with Decompensated Heart Failure

TCT-690 Safety and Efficacy of Urgent Transcatheter Aortic Valve Replacement in Patients admitted with Decompensated Heart Failure