Transcatheter aortic valve replacement (TAVR) has become a safe and effective therapy for patients with severe aortic stenosis (AS). In recent trials, the hemodynamic performance and clinical ...outcomes of the latest generation of TAVR devices demonstrated at least parity with surgical outcomes in patients of similar risk. Many initial obstacles with TAVR have largely been overcome, including frequent access site complications and concerns about strokes and paravalvular leaks. Using a multidisciplinary heart team approach, patient selection, procedural planning, and device implantation have been refined and optimized such that clinical outcomes are generally predictable and reproducible. Future research will focus on the durability of TAVR devices, further enhancements in clinical outcomes, and adjunctive therapies. On the basis of initial results from ongoing clinical trials, the indication for TAVR will likely expand to lower-risk patients. This review provides an overview of recent progress in this field, and highlights future opportunities and directions.
Abstract Objectives This study sought to determine the impact of quantity and location of aortic valve calcification (AVC) on paravalvular regurgitation (PVR) and rates of post-dilation (PD) ...immediately after transcatheter aortic valve replacement (TAVR). Background The impact of AVC in different locations within the aortic valve complex is incompletely understood. Methods This study analyzed 150 patients with severe, symptomatic aortic stenosis who underwent TAVR. Total AVC volume scores were calculated from contrast-enhanced multidetector row computed tomography imaging. AVC was divided by leaflet sector and region (Leaflet, Annulus, left ventricular outflow tract LVOT), and a combination of LVOT and Annulus (AnnulusLVOT). Asymmetry was assessed. Receiver-operating characteristic analysis was performed with greater than or equal to mild PVR and PD as classification variables. Logistic regression was performed. Results Quantity of and asymmetry of AVC for all regions of the aortic valve complex predicted greater than or equal to mild PVR by receiver-operating characteristic analysis (area under the curve = 0.635 to 0.689), except Leaflet asymmetry. Receiver-operating characteristic analysis for PD was significant for quantity and asymmetry of AVC in all regions, with higher area under the curve values than for PVR (area under the curve = 0.648 to 0.741). On multivariable analysis, Leaflet and AnnulusLVOT calcification were independent predictors of both PVR and PD regardless of multidetector row computed tomography area cover index. Conclusions Quantity and asymmetry of AVC in all regions of the aortic valve complex predict greater than or equal to mild PVR and performance of PD, with the exception of Leaflet asymmetry. Quantity of AnnulusLVOT and Leaflet calcification independently predict PVR and PD when taking into account multidetector row computed tomography area cover index.
Contrast exposure during left atrial appendage occlusion may be harmful in those with chronic kidney disease or allergy. This single-center registry (n = 31) demonstrates the feasibility and safety ...of zero-contrast percutaneous left atrial appendage occlusion using echocardiography, fluoroscopy, and fusion imaging, with 100% procedural success and no device complications at 45 days.
Fingolimod, a sphingosine-1-phosphate receptor agonist, is used for the treatment of multiple sclerosis and exerts antiapoptotic properties. We hypothesized that sphingosine-1-phosphate receptor ...activation with fingolimod during acute myocardial infarction (MI) inhibits apoptosis, leading to increased myocardial salvage, reduced infarct size, and mitigated left ventricular (LV) remodeling in a porcine model of ischemia/reperfusion.
Ischemia/reperfusion was induced in pigs by balloon occlusion of the left anterior descending artery, followed by reperfusion. Animals randomly received fingolimod or saline (control). In short-term experiments, fingolimod treatment activated the cardioprotective reperfusion injury salvage kinase and survivor activating factor enhancement pathways in the infarct border zone 24 hours after MI, leading to decreased cardiomyocyte apoptosis and reduced myocardial oxidative stress. These effects were abolished by specific inhibitors of both pathways, demonstrating that fingolimod-induced cardioprotection was mediated by reperfusion injury salvage kinase and survivor activating factor enhancement pathways. In long-term experiments, fingolimod significantly improved myocardial salvage, reduced infarct size, and improved systolic LV function measured by cardiac magnetic resonance 1 week and 1 month after MI. Importantly, fingolimod mitigated the development of adverse post-MI LV remodeling 1 month after MI. Specifically, fingolimod treatment led to a significant reduction in LV mass, LV dilatation, and neurohormonal activation, and it preserved LV geometry. Furthermore, fingolimod decreased interstitial fibrosis, cardiomyocyte hypertrophy, and chronic activation of Akt and extracellular receptor kinase 1/2 in the remote noninfarcted myocardium.
Sphingosine-1-phosphate receptor activation with fingolimod during acute MI reduced infarct size via the reperfusion injury salvage kinase and survivor activating factor enhancement pathways, improved systolic LV function, and mitigated post-MI LV remodeling. Our data strongly support a cardioprotective role for sphingosine-1-phosphate receptor activation during MI.
Iliofemoral anatomy plays an important role in determining transfemoral (TF) transcatheter aortic valve replacement candidacy. Herein, we present the novelty of endovascular eSheath balloon dilation ...to facilitate valve delivery. This technique, in addition to or instead of intravascular lithotripsy, may facilitate TF valve delivery in patients who do not otherwise meet traditional criteria for TF access.
Aims
Advances in diagnostic imaging have increased the recognition of coexisting transthyretin cardiac amyloidosis (ATTR‐CA) and severe aortic stenosis (AS), with a reported prevalence between 8–16%. ...In this prospective study, we aimed to evaluate the implications of ATTR‐CA on outcomes after transcatheter aortic valve replacement (TAVR).
Methods and results
At two academic centres, we screened patients with severe AS undergoing TAVR for ATTR‐CA. Using Kaplan–Meier analysis, we compared survival free from death and a combined endpoint of death and first heart failure hospitalization between patients with and without ATTR‐CA. Cox proportional‐hazards models were used to determine the association of ATTR‐CA with these endpoints. The rate of heart failure hospitalization was compared amongst those with and without ATTR‐CA. Overall, 204 patients (83 years, 65% male, Society of Thoracic Surgeons score 6.6%, 72% New York Heart Association class III/IV) were included, 27 (13%) with ATTR‐CA. Over a median follow‐up of 2.04 years, there was no difference in mortality (log rank, P = 0.99) or the combined endpoint (log rank, P = 0.79) between patients with and without ATTR‐CA. In Cox proportional‐hazards models, the presence of ATTR‐CA was not associated with death. However, patients with ATTR‐CA had increased rates of heart failure hospitalization at 1 year (0.372 vs. 0.114 events/person‐year, P < 0.004) and 3 years (0.199 vs. 0.111 events/person‐year, P = 0.087) following TAVR.
Conclusion
In moderate‐risk patients with severe AS undergoing TAVR, there was a 13% prevalence of ATTR‐CA, which did not affect mortality. The observed increase in heart failure hospitalization following TAVR in those with ATTR‐CA suggests the consequences of the underlying infiltrative myopathy.
Clinical trials of transcatheter mitral valve and tricuspid valve repair and replacement devices have begun in earnest, with the ultimate goal of providing definitive, nonsurgical treatment for the ...millions of patients with severe, symptomatic regurgitation, many of whom are too high risk or inoperable for a surgical approach. Computed tomography (CT) angiography offers the potential for detailed anatomic assessment in this patient population, but its optimal implementation for patients with mitral and tricuspid disease requires patient-centered protocol specification reflecting the goal of the scan, an understanding of complex anatomy and pathophysiology, and particulars of CT scanner capabilities. In this paper, the need for new interventional approaches to mitral and tricuspid valve disease is discussed, followed by a detailed review of how to perform a high-quality CT angiography examination, taking into consideration scanner- and patient-specific variables when preparing a pre-mitral or tricuspid protocol. The many possible clinical challenges affecting the performance of cardiac and vascular CT angiography for pre-procedure mitral and tricuspid repair/replacement are reviewed and specific tips, trouble-shooting approaches, and recommendations are provided for how to conduct the best-quality study, be it at an experienced imaging center with the most advanced scanner or at a novice center using an earlier generation CT platform.
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•Clinical trials have begun of numerous transcatheter mitral valve and tricuspid valve repair and replacement devices.•Cardiac and vascular assessment before transcatheter intervention requires high-quality, anatomy-specific CT angiography protocols.•The many possible clinical challenges affecting CT angiography are reviewed and specific tips and trouble-shooting approaches provided.•As this field rapidly advances, so too will the requirement for high-quality CT angiography protocols.
Mitral regurgitation (MR) is the most common valvular heart disease worldwide with a 5-year mortality rate of 50 % with medical therapy alone. Several transcatheter mitral valve replacement (TMVR) ...devices are being investigated in clinical trials. Early evidence has demonstrated clinical benefits with a reduction in heart failure symptoms, low rates of residual MR, and reverse remodeling of the left ventricle (LV) over time. However, high anatomical screen failure rates limit its applicability. The primary reasons for the anatomical screen failure are risk of LV outflow tract obstruction, large mitral valve annulus size, and the presence of mitral annular calcification. Our clinical experiences using an atrial only fixation TMVR technology delivered via a transfemoral-transseptal approach is described.
Three consecutive patients with severe functional MR underwent TMVR implantation using an atrial only fixation technology and a low-profile transseptal delivery system.
Technical success was achieved in 100 % of the patients with a clinically significant reduction in MR. Longer-term follow-up (up to 6-months) has demonstrated a sustained reduction in MR and significant improvement in quality of life for all patients.
Longer-term outcomes in our patients showed persistent reduction in MR, sustained implant performance, and notable improvements in NYHA Class and quality of life. There were no major adverse events. Follow-up CT data showed no evidence of device-related thrombosis, with stable valve position and integrity. The atrial fixation TMVR technology may have benefits in preserving the dynamics of the native mitral valve annulus thereby reducing the overall risk of LVOT obstruction.
We present a single-center experience of three consecutive patients with severe functional MR treated with the AltaValve using a low-profile transseptal delivery system. A clinically significant reduction in mitral regurgitation was achieved in all patients, and longer-term follow-up has demonstrated sustained clinical benefits.
This study presents a single-site experience of 5 patients with severe tricuspid regurgitation (TR) who underwent implantation of a novel transcatheter tricuspid valve replacement device.
Functional ...TR is the most common etiology of severe TR in the developed world and is associated with unfavorable clinical outcomes. Although numerous transcatheter repair devices are currently in early clinical trials, most result in incomplete degrees of TR reduction and functional improvement.
Transcatheter tricuspid valve replacement was performed in 5 patients with compassionate use of the novel GATE System. All patients had symptomatic, massive and/or torrential TR at baseline. All patients had computed tomography, transthoracic and transesophageal echocardiographic assessment of the tricuspid valve and right heart anatomy. All patients had a surgical transatrial approach performed with valve implantation guided by fluoroscopy and intraprocedural transesophageal echocardiography.
Baseline characteristics of the patients showed a substantial burden of comorbidities. All patients had successful implantation of the transcatheter valve, with significant reduction of TR to ≤2+. Baseline poor right ventricular (RV) function measured by global longitudinal strain and RV change in pressure divided by change in time were associated with post-implantation RV failure and poor clinical outcomes in this small group. Four of the 5 patients were followed for 3 to 6 months following the initial implantation and showed evidence of RV remodeling, increased cardiac output, and reduction in New York Heart Association functional class.
Implantation of a first-generation TTVR device was technically feasible in patients with more than severe TR. Transcatheter tricuspid valve replacement was associated with RV remodeling, increased cardiac output, and improvement in New York Heart Association functional class in most patients. Further studies are needed to refine patient population selection for this device and to determine long-term outcomes.
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