Compared to high gradient aortic stenosis (AS), patients with low-flow, low-gradient AS have higher mortality after transcatheter aortic valve replacement (TAVR), but distinct outcome predictors in ...this patient subset are yet to be determined. The present study investigated the prognostic impact of aortic valve calcification (AVC) in patients with low-flow, low-gradient AS undergoing TAVR.
This retrospective single-center analysis includes all patients undergoing TAVR for severe low-flow, low-gradient AS (n = 526), ie, low EF low gradient AS (LEF-LG AS; n = 290) and paradoxical low-flow, low-gradient AS (PLF-LG AS; n = 236), in whom AVC was quantified from contrast-enhanced multislice computed tomography images. AVCdensity was defined as calcium volume per annulus area. Patients were trichotomized according to sex-specific AVCdensity tertiles in both subgroups. All-cause mortality was assessed by Kaplan-Meier analyses and independent outcome predictors were determined by multivariable analyses.
In both subgroups, patients with high AVCdensity had higher mean transvalvular gradients at baseline and higher rates of PVL after TAVR. High AVCdensity was associated with lowest 1- and 3-year mortality after TAVR in the LEF-LG AS but not in the PLF-LG AS group. According to multivariable analysis AVCdensity was independently associated with better survival in LEF-LG AS patients (HR 0.73 0.60-0.88, P = .0011), but not in those with PLF-LG AS (HR 0.91 0.73-1.14, P = .42).
Quantification of AVC may not only be of diagnostic but also of prognostic value, as it facilitates the selection of LEF-LG AS patients with higher probability of beneficial outcome after TAVR.
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We aimed to assess the prevalence and features of prosthesis-patient mismatch (PPM) following transcatheter aortic valve implantation (TAVI) and its prognostic impact considering baseline left ...ventricular ejection fraction (LVEF).
Data from 1,309 patients undergoing TAVI for severe aortic stenosis were derived from a single-centre dedicated TAVI registry. PPM was assessed according to echocardiography at discharge and was defined in accordance with VARC-2. Median follow-up time was 2.03 years. Moderate and severe PPM was detected in 22.9% and 12.9%, respectively. Patients with severe PPM had smaller annuli and more often received transcatheter heart valve (THV) sizes ≤23 mm. Supra-annular THV design showed the lowest rate of PPM. In patients with LVEF <40%, but not in those with LVEF ≥40%, severe PPM was associated with an increased three-year mortality rate (no vs. severe PPM for LVEF ≥40%: 34.6% vs. 29.5%, p=0.96; LVEF <40%: 45.1% vs. 68.0%, p=0.041) and was independently predictive of all-cause mortality according to multivariate analysis in these patients (HR 2.97; 95% CI: 1.58-5.59, p<0.001).
The presence of severe PPM depends on annular dimensions and THV size and design and is an independent predictor of mortality in patients with reduced LVEF. Hence, the risk of PPM should be considered within the process of THV selection.
Aims
To identify predictors of paravalvular regurgitation (PVR) and permanent pacemaker implantation (PPI) following TAVR with a next-generation self-expanding device.
Methods and results
Device ...landing zone (DLZ) calcification, angiographic implantation depth, and baseline and procedural characteristics were analyzed in 212 patients being treated with the ACURATE
neo
aortic bioprosthesis. PVR was none/trace in 57.1% and ≥ mild in 42.9% (37% mild, 6% moderate). DLZ calcification (705 (IQR 240–624) vs. 382 (IQR 240–624) mm
3
;
P
< 0.001) as well as absolute calcium asymmetry (233 ± 159 vs. 151 ± 151 mm
3
;
P
< 0.001) was significantly higher in patients with PVR ≥ mild. On multivariate analysis, calcification of the aortic valve cusps (AVC) > 410.6 mm
3
was independently associated with PVR ≥ mild. PPI rate was 10.3% (
n
= 20). Patients with and without need for PPI had similar total DLZ calcium volume (740 (IQR 378–920) vs. 536 (IQR 315–822) mm
3
;
P
= 0.263), but exhibited different calcium distribution patterns: LVOT calcium > 41.4 mm
3
in the sector below the left coronary cusp (LVOT
LC
) was associated with increased PPI risk (26.9 vs. 7.7%;
P
= 0.008).
Conclusions
The quantity of AVC calcium predicts residual PVR. Multivariable analysis identified LVOT
LC
calcium, pre-existing RBBB, and age > 82.7 years as independent predictors of PPI. Based on these risk factors, a patient’s individual PPI risk can be stratified ranging from 3.8 to 100%.
Objectives
We herein report a single-center experience with the Portico TAVI system. Main focus was set on outcomes in patients with impaired left ventricular (LV) function and predictors for ...permanent pacemaker (PPM) implantation.
Methods
Between 05/2014 and 10/2017, 106 consecutive patients received TAVI using the Portico device. For comparison of patients with/without impaired LV function, and determination of multi-slice computed tomography and electrocardiogram correlates for PPM implantation subgroups were built (Subgroup I: LVEF ≥ 50%,
n
= 69, Subgroup II: LVEF < 50%,
n
= 37; Subgroup A: no PPM implantation,
n
= 89; Subgroup B: PPM implantation,
n
= 17). Data were retrospectively analyzed.
Results
Device success was 95.3% (101/106) with resulting transvalvular peak/mean pressure gradients of 10.6 ± 5.6/5.4 ± 3.1 and PVL ≥ moderate in 5/106 patients (4.7%). 30-day mortality was 4.7% (5/106; subgroup I 3/69, 4.3%; subgroup II 2/37, 5.4%;
p
= 1.0). Regarding VARC-2 adjudicated clinical endpoints stroke (3/106, 2.8%; subgroups I/II: 2/69 vs. 1/37,
p
= 1.0) and acute kidney injury (9/106, 8.5%; subgroups I/II: 6/69 vs. 3/37,
p
= 1.0), no significant differences were found. Postprocedural PPM implantation occurred in 17.9% (19/106) of the patients. Logistic regression for PPM implantation demonstrated predictive character of left coronary cusp (LCC) calcium load in zone 1 (annular plane to coronary ostia) (
p
= 0.05, threshold 193 mm
3
) and total calcium load of zone 1 (
p
= 0.05, threshold 751.2 mm
3
).
Conclusions
The Portico valve demonstrates a satisfying safety outcome, especially for patients with impaired LV function. Results of the CE-mark trial were confirmed, except for higher PPM rates. PPM rates are in accordance with other reports on this TAVI platform.
Methods From 09/2008-05/2016, a total of 500 patients (age 75.6±8.3 years, male gender 60.4%, logistic EuroSCORE 25.3±17.0%, functional mitral regurgitation (FMR) 66.4%) were treated by MC ...implantation. Yet, FMR, cardiomyopathy, history of heart failure and decreased left ventricular ejection fraction were significantly more common in subgroup 1 (FMR 71.4% vs. 59.6% in subgroup 3, p<0.001).
Balloon aortic valvuloplasty (BAV) is routinely performed preceding transcatheter aortic valve implantation (TAVI). Among risks inherent in BAV is low cardiac output due to rapid ventricular pacing ...(RVP), especially in patients with severely impaired left ventricular function. We herein report early experience utilizing a non-occlusive balloon for BAV (TrueFlow™, BARD, Peripheral Vascular, Tempe, AZ, US), which does not require RVP.
Between 11/2016 and 10/2017, 27 consecutive patients received TAVI using a non-occlusive balloon valvuloplasty catheter for predilatation and a self-expandable transcatheter heart valve (77.8% female, 81.7 ± 6.6 years, logEuroSCORE I 15.8 ± 10.3%, STS Prom Score 2.5 ± 0.5%). Hemodynamic measurements and acute outcome data were analyzed according to updated Valve Academic Research Consortium definitions.
Procedure time, fluoroscopy time and amount of contrast agent were 74.5 ± 17.4 min, 16.7 ± 6.9 min and 156.9 ± 92.7 ml. Device success and early combined safety were 100% and 92.6% (25/27). Effective BAV without RVP after the first inflation was achieved in 92.6% of the patients (25/27). Continuous recording of hemodynamics documented no relevant systemic pressure drop during BAV. Postdilatation with a regular balloon was required in 10/27 patients. No death was observed during 30-day follow-up. Resultant mean transvalvular gradient was 6.0 ± 3.5 mm Hg. In one patient a moderate paravalvular leakage was seen.
In this series of TAVI utilizing a novel non-occlusive balloon, safety and efficacy were demonstrated. Adequate predilatation was achieved in all cases without need for RVP and with stable hemodynamics. These results will have to be confirmed in larger patient cohorts.
•BAV with a non-occlusive balloon preceding TAVI allows for combination of advantages of BAV and absence of RVP•Especially in patients with impaired LV function and anatomical circumstances necessitating BAV, this could be a helpful tool•Clinical efficacy of the herein investigated balloon has to be proven in larger patient cohorts
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