Background Transcatheter aortic valve replacement (TAVR)-in-TAVR is a possible treatment for transcatheter heart valve (THV) degeneration. However, the displaced leaflets of the first THV will create ...a risk plane (RP) under which the passage of a coronary catheter will be impossible. The aim of our study was to evaluate the potential risk of impaired coronary access (CA) after TAVR-in-TAVR. Methods and Results We prospectively performed coronary angiography after TAVR with different THVs in 137 consecutive patients, looking where the catheter crossed the valve frame. If coronary cannulation was achieved from below the RP, the distance between valve frame and aortic wall was measured by aortic angiography. CA after TAVR-in-TAVR was defined as feasible if the catheter passed above the RP, as theoretically feasible if passed under the RP with valve-to-aorta distance >2 mm, and as unfeasible if passed under the RP with valve-to-aorta distance ≤2 mm. Seventy-two patients (53%) received a Sapien 3 THV, 26 (19%) received an Evolut Pro/R THV, and 39 (28%) received an Acurate Neo THV. CA after TAVR-in-TAVR was considered feasible in 40.9% (68.1%, 19.2%, and 5.1%, respectively;
<0.001), theoretically feasible in 27.7% (8.3%, 42.3%, and 53.8%, respectively;
<0.001), and unfeasible in 31.4% (23.6%, 38.5%, and 41.1%, respectively;
=0.116). Independent predictors of impaired CA after TAVR-in-TAVR were female sex (odds ratio OR, 3.99; 95% CI, 1.07-14.86;
=0.040), sinotubular junction diameter (OR, 0.62; 95% CI, 0.48-0.80;
<0.001), and implantation of a supra-annular THV (OR, 6.61; 95% CI, 1.98-22.03;
=0.002). Conclusions CA after TAVR-in-TAVR might be unfeasible in >30% of patients currently treated with TAVR. Patients with a small sinotubular junction and those who received a supra-annular THV are at highest risk of potential CA impairment with TAVR-in-TAVR.
Large thrombus burden (LTB) lesions in the context of primary percutaneous coronary intervention (p-PCI) have been related to unsuccessful angiographic reperfusion and unfavorable clinical outcomes. ...However, the hazard of LTB treatment on myocardial damage has not been evaluated. We investigated the impact of LTB on myocardial damage using contrast-enhanced cardiac magnetic resonance (CE-CMR) in the setting of p-PCI. In 327 patients, who underwent p-PCI without thrombus aspiration within 12 hours from symptom onset, we prospectively assessed the impact of LTB on infarct size and microvascular damage using CE-CMR. LTB was defined by the presence of Thrombolysis In Myocardial Infarction thrombus score ≥3 in patent infarct-related artery (IRA); or by “cut-off” occlusion pattern and/or large reference vessel diameter (≥3.5 mm) in occluded IRA. One hundred ninety-seven patients (60.2%) showed LTB and 130 (39.8%) did not. Distal embolization occurred in 18.8% patients with versus 6.9% without LTB (p = 0.003). At CE-CMR, patients with LTB had larger infarct size index (27.5 ± 11.1 vs 22.1 ± 17.5, p = 0.009) and more often transmural necrosis (70.5% vs 55.4%, p = 0.008) compared with patients without LTB. Excluding patients with distal embolization, patients with LTB still had larger necrosis. At multivariate analysis, occluded (IRA) at baseline, anterior infarction, and presence of LTB predicted transmural necrosis. In conclusion, LTB in the setting of p-PCI is related to larger myocardial damage as detected by CE-CMR, regardless of angiographic detectable distal embolization.
Transcatheter aortic valve replacement (TAVR) has been recognized as a well-established alternative to surgical aortic valve replacement (SAVR) for symptomatic aortic stenosis with high surgical ...risk. With this updated systematic review and meta-analysis, we evaluated TAVR vs. SAVR in low- and intermediate-risk subjects. Studies comparing TAVR and SAVR in low-risk patients (defined as STS ≤ 8% or EuroSCORE ≤ 20%) were identified with electronic searches. The principal endpoint was all-cause mortality at short term (< 3 months), 1, and 2 years. Other outcomes of interest were cardiac mortality, neurological events, paravalvular leakage (PVL), myocardial infarction (MI), major bleeding, acute kidney injury (AKI), vascular complications, and new pacemaker (PM) implantation. Seventeen articles including 9805 (4956 TAVR and 4849 SAVR) patients were eligible. There was no significant difference in all-cause mortality at short term odds ratio (OR) 0.83, 95% confidence interval (CI) 0.63–1.09, 1 year (OR 1.01, 95% CI 0.86–1.20) and 2 years (OR 0.86, 95% CI 0.64–1.16) between treatment groups. Subgroup analyses stratified by surgical risk score (low-risk subgroup: STS < 4% or EuroSCORE < 10%, intermediate-risk subgroup: the others) did not show interaction on primary endpoints. Compared to SAVR, TAVR had similar rates of neurological events, significantly lower risk of MI and AKI, but higher risk of vascular complications, new PM implantation and moderate/severe PVL. In low- and intermediate-risk patients, TAVR and SAVR have similar short- and mid-term all-cause mortality. Compared to SAVR, TAVR carries higher rates of vascular complications, PM implantation and moderate/severe PVL, but lower risk of MI and AKI.
Objectives
We aimed to analyze the baseline features and clinical outcomes of patients younger than 80 years undergoing transfemoral transcatheter aortic valve implantation (TAVI) or surgical aortic ...valve replacement (SAVR) enrolled in the OBservational Study of Effectiveness of SAVR‐TAVR procedures for severe Aortic steNosis Treatment (OBSERVANT) real‐world study, focusing on variables guiding Heart Team decision toward TAVI.
Background
Patients treated with TAVI, independently of surgical risk score, are mostly older than 80 years.
Methods
OBSERVANT is a multicenter, observational, prospective cohort study that enrolled patients with symptomatic severe aortic stenosis (AS) who underwent SAVR or TAVI from December 2010 to June 2012 in 93 Italian participating hospitals. For this analysis, baseline characteristics, therapeutic approach and outcomes up to 5 years of follow‐up of 4,801 patients under 80 years of age were collected. Patients were stratified by age classes (<65, 65–74, and 75–79 years).
Results
Patients <80 years of age with severe symptomatic AS undergoing TAVI (n = 483) had significantly higher Logistic EuroSCORE (10.84% vs. 5.22%, p < .001) and prevalence of comorbidities compared to subjects undergoing SAVR (n = 4,318). The decision to perform TAVI over SAVR was driven by anatomical factors, mainly previous cardiac surgery (odds ratio OR 24.73, confidence interval CI 12.71–48.10, p < .001) and the presence of porcelain aorta (OR 17.44, CI 6.67–45.55, p < .001), and clinical factors, mainly moderate–severe frailty score (OR 5.49, CI 3.33–9.07, p < .001), oxygen dependency (OR 7.42, CI 2.75–20.04, p < .001) and need for dialytic treatment (OR 5.24, CI 1.54–17.80, p < .008). Among patients undergoing TAVI, those under 65 years had the highest baseline risk profile (despite a low Logistic EuroSCORE) and the highest 5‐year mortality compared to those 65–74 and 75–79‐year‐old (65.22% vs. 48.54% vs. 55.24%, log‐rank p = .061).
Conclusion
Among patients under 80 years of age with symptomatic severe AS, only 10% underwent TAVI. These patients were at higher baseline risk compared to those undergoing SAVR. The decision to perform TAVI was driven by the presence of both anatomical and clinical factors beyond surgical risk scores. Patients under 65 years of age, despite the low Logistic EuroSCORE, had the highest preoperative risk profile and carried the worse outcome.
The purpose of this study was to examine the impact of residual mitral regurgitation (MR) on mortality in patients undergoing transcatheter aortic valve replacement (TAVR).
MR is common in patients ...undergoing TAVR. Data on optimal management of patients with significant MR after TAVR are limited.
The registry consisted of 16 TAVR centers (n = 7,303). Outcomes of patients with ≥ moderate versus lesser grade MR after TAVR were compared.
In 1,983 (27.2%) patients, baseline MR grade was ≥ moderate. MR regressed in 874 (44.1%) patients and persisted in 1,109 (55.9%) after TAVR. Four-year mortality was higher for those with MR persistence, but not for those with MR regression after TAVR, compared with nonsignificant baseline MR (43.8% vs. 35.1% vs. 32.4%; hazard ratio HR: 1.38; p = 0.008; HR: 1.02; p = 0.383, respectively). New York Heart Association functional class III to IV after TAVR was more common in those with MR persistence vs. regression (14.4% vs. 3.9%; p < 0.001). In a propensity score–matched cohort (91 patients’ pairs), with significant residual MR after TAVR who did or did not undergo staged mitral intervention, staged intervention was associated with a better functional class through 1 year of follow-up (82.4% vs. 33.3% New York Heart Association functional class I or II; p < 0.001), and a numerically lower 4-year mortality, which was not statistically significant (64.6% vs. 37.5%; HR: 1.66; p = 0.097).
Risk stratification based on improvement in MR and symptoms after TAVR can identify patients at increased mortality risk after TAVR. These patients may benefit from a staged transcatheter mitral intervention, but this requires further proof from future studies. (Transcatheter Treatment for Combined Aortic and Mitral Valve Disease. The Aortic+Mitral TRAnsCatheter AMTRAC Valve Registry AMTRAC; NCT04031274).
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Three-Dimensional Electroanatomical Voltage Mapping and Histologic Evaluation of Myocardial Substrate in Right Ventricular Outflow Tract Tachycardia Domenico Corrado, Cristina Basso, Loira Leoni, ...Barbara Tokajuk, Pietro Turrini, Barbara Bauce, Federico Migliore, Andrea Pavei, Giuseppe Tarantini, Massimo Napodano, Angelo Ramondo, Gianfranco Buja, Sabino Iliceto, Gaetano Thiene Twenty-seven patients (15 men and 12 women, age 33.9 ± 8 years) with right ventricular outflow tract (RVOT) tachycardia and no right ventricular (RV) dilation/dysfunction were studied by electroanatomical voltage mapping (EVM) and endomyocardial biopsy (EMB) before catheter ablation. Right ventricular EVM was normal in 20 of 27 patients (74%, group A), whereas the other 7 patients (26%, group B) showed RVOT electroanatomical scars that correlated with fibrofatty myocardial replacement at EMB (p < 0.001). Three of 7 patients (43%) from group B received an implantable defibrillator during the follow-up, compared with no patients from group A (p = 0.012). Electroanatomical voltage mapping is able to identify RVOT tachycardia due to concealed arrhythmogenic RV cardiomyopathy/dysplasia.
Acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) is a life-threatening condition frequently encountered in patients with multivessel coronary artery disease (CAD). Despite ...prompt revascularization, in particular, percutaneous coronary intervention (PCI), and therapeutic and technological advances, the mortality rate for patients with CS related to AMI remains unacceptably high. Differently form a hemodynamically stable setting, a culprit lesion-only (CLO) revascularization strategy is currently suggested for AMI-CS patients, based on the results of recent randomized evidence burdened by several limitations and conflicting results from non-randomized studies. Furthermore, mechanical circulatory support (MCS) devices have emerged as a key therapeutic option in CS, especially in the case of their early implantation without delaying revascularization and before irreversible organ damage has occurred. We provide an in-depth review of the current evidence on optimal revascularization strategies of multivessel CAD in infarct-related CS, assessing the role of different types of MCS devices and highlighting the importance of shock teams and medical care system networks to effectively impact on clinical outcomes.
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