bluuebunny/crossref_metadata_2025 huggingface dataset:
Tricuspid regurgitation and atrial fibrillation at baseline independently predict two-year survival after transcatheter aortic valve implantation (TAVI)
Authors: Baez L , Moebius-Winkler S , Diab M , Ibrahim K , Kraeplin T , Schulze P C , Franz M
Published: October 2022

Background

Transcatheter aortic valve implantation (TAVI) is the accepted state-of-the-art treatment for elderly patients suffering from severe symptomatic aortic stenosis (AS). Co-morbidities at baseline are of great impact not only for individual peri-procedural risk stratification but also for the determination of long-term prognosis. The latter is of certain clinical interest, since a variety of co-existing disorders can be effectively treated in addition to TAVI.

Purpose

The current study aimed to elucidate the prognostic value of a wide range of baseline characteristics and co-morbidities with respect to long-term survival of TAVI patients in a prospective real-world single-center registry study.

Methods

A total of 445 patients with severe AS, which were treated by transfemoral TAVI, were included. A wide range of clinical, laboratory, functional and imaging parameters were prospectively assessed at baseline prior to TAVI. Mortality was recorded at 30 days, 1 year and 2 years after TAVI.

Results

The mean age of patients in this typical TAVI cohort was 78.7±7.3 years, 52% were female and the mean STS score was 5±3.9%. The mortality rates were as follows: 3.6% after 30 days, 16.4% after 1 and 22.6% after 2 years. Multivariate analysis could identify the following independent predictors of 2-year mortality assessed at baseline: sex, age, AS entity other than high-gradient, atrial fibrillation (Afib), renal function, relevant TR, systolic pulmonary artery pressure (PAPsys) and six-minute walk distance (SMWD). Among those, the strongest predictive value could be shown for Afib (OR 2.505, CI 1.509–4.157, p<0.001) and TR (OR 2.179, CI 1.105–4.299, p=0.025). Kaplan-Meier survival analysis displayed significantly worse 2-year survival rates in patients suffering from relevant TR (31.6% versus 17.4%, p<0.001) and Afib (29.4% versus 14.8%, p<0.001).

Conclusions

Taken together, the results of the current study demonstrate the prognostic value of cardiovascular co-morbidities assessed prior to TAVI. We identified relevant TR and Afib as the strongest independent predictors of long-term mortality in our cohort. Since both conditions are effectively treatable, special emphasis should be placed on the question, which patient might benefit from treatment, e.g., by transcatheter edge-to-edge repair of TR or rhythm control, in addition to TAVI.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Else Kröner-Fresenius-Stiftung, Research Program “Else Kröner-Forschungskolleg AntiAge”
Large comprehensive evaluation of new- vs. old-generation ACURATE neo self-expanding valve during TAVI procedures: a decrease in paravalvular leakage with an increase in post-procedural gradients?
Authors: Karameh H , Harari E , Almagor Y , Jubeh R , Shuvy M , Hellou E , Taha L , Butnaru A , Wolak A , Glikson M , Dvir D
Published: October 2022

Background

Contemporary data comparing new- versus old-generation transcatheter heart valve (THV) devices are lacking regarding several THV devices. We aimed to compare the safety and efficacy of old-generation device (OGD) ACURATE neoTM versus the newer generation device (NGD) ACURATE neo2TM THVs (Boston Scientific) in patients undergoing transcatheter aortic valve implantation (TAVI).

Methods

An analysis of patients undergoing transfemoral TAVI with old-generation device ACURATE neoTM versus newer generation device ACURATE neo2TM from 2016 to 2021. The primary end-point was early safety events at 30-days post-valve implantation. Significant post-implantation paravalvular leakage (PVL) was considered as ≥moderate.

Results

A total of 249 patients were included in the evaluation; mean age was 81±7.2, and 95 (38.2%) were males. Of the total population 87 (35%) underwent TAVI with the NGD. Early safety events occurred in 21.8% NGD versus 19.1% in OGD (RR= 0.67, P=0.13). Permanent pacemakers were implanted within 30 days in 4.6% versus 6.2% in NGD versus OGD respectively (RR=1.343, P=0.77). Major vascular complications occurred in 5.7% in NGD versus 9.4% in OGD 9.4% (RR=1.6, P=0.46). More than mild PVL occurred significantly more often in OGD (P<0.0001). Echocardiographic mean gradient post-procedure was 9 mmHg± 5 in OGD versus 11±4 mmHg in the NGD (P=0.0159).

Conclusion

New-generation ACURATE neo2TM devices were associated with less significant PVL. However, this new generation valve was also associated with higher residual gradients. This trend of decrease in PVL with an increase in gradients will be further studied.

Funding Acknowledgement

Type of funding sources: None.
Periprocedural outcomes of transcatheter aortic valve replacement (TAVR) in patients with and without cardiac amyloidosis-analysis from 2016–2019 national inpatient sample
Authors: Kambalapalli S , Baral N , Seri A , Paul T
Published: October 2022

Background

Cardiac Amyloidosis is often misdiagnosed due to its non-specific presenting symptoms. There is a lack of evidence on the clinical outcomes in patients with cardiac amyloidosis undergoing transcatheter aortic valve replacement (TAVR).

Purpose

To study periprocedural outcomes in patients hospitalised primarily for TAVR with and without cardiac amyloidosis.

Methods

This is a retrospective observational study involving index hospitalizations for TAVR between January 1, 2016 to December 31, 2019 from the National Inpatient Sample (NIS), the largest all-payer public database of hospital care data in the United States. Our study sample included discharged adult patients (≥18 years) primarily hospitalised for TAVR using ICD-10 codes. Confounders were adjusted using multivariable regression analysis.

Results

During 2016–2019, there were 43270 principal hospitalizations (unweighted sample) identified for TAVR, among them 4999 patients had a history of cardiac amyloidosis. Mean age was 79.3±8.4 years. Among patients hospitalised for TAVR, 54.4% (n=23539) were males, 45.6% (n=19731) were females (p<0.001), 1.71% (n=740) developed cardiogenic shock, 1.53% (n=662) required mechanical ventilation with an in-hospital mortality of 1.3% (n=563). There were 87% Whites, 4.2% Blacks, 4.8% Hispanics, 1.3% Asians, and 2.7% were other races. A total of 23,819 (55.1%) hospitalizations had a Charlson Comorbidity Index (CCI) of three or higher.

After undergoing TAVR, compared to the non-cardiac amyloidosis cohort, the cardiac amyloidosis cohort had less females (27.8% vs 45.6%, p=0.01), had similar age (mean age: 80.2 vs 79.3; p=0.665), higher incidence of congestive heart failure (CHF) (100% vs 74%, p=0.012), higher mechanical ventilation requirement (11.1% vs 1.5%, p=0.001)) but with a similar length of hospital stay (3.9% vs 3.9%, p=0.99). Multivariate regression analysis revealed that TAVR in cardiac amyloidosis cohort did not significantly increase the odds of in-hospital mortality than the non-cardiac amyloidosis cohort (aOR: 5.2; 95% CI: 0.7, 38.3; p=0.103). However, females had higher odds of mortality post-TAVR compared to males (aOR: 1.45; 95% CI: 1.22, 1.73; p<0.001) after controlling for age, sex, race, regional hospital location, hospital bed capacity, income, and CCI. There is an increasing trend of index TAVR hospitalizations with cardiac amyloidosis with 109.4 per 100,000 hospitalizations in 2016, 139.7 per 100,000 in 2017, 157.5 per 100,000 in 2018, 201.4 per 100,000 in 2019 (p trend<0.001).

Conclusions

After TAVR, cardiac amyloidosis is associated with higher incidence of CHF increased need for mechanical ventilation, similar in-hospital mortality rate in comparison to non-cardiac amyloidosis cohort. There was an increasing trend in the index hospitalizations for TAVR with cardiac amyloidosis from 2016–2019.

Funding Acknowledgement

Type of funding sources: None.
Meta-analysis comparing outcomes in patients undergoing transcatheter aortic valve implantation with versus without percutaneous coronary intervention
Authors: Costa G , Marinho V , Costa M , Goncalves L , Teixeira R
Published: October 2022

Background

Patients having transcatheter aortic valve implantation (TAVI) routinely undergo coronary angiography before the procedure to define the coronary anatomy and to evaluate the extend of coronary artery disease (CAD). Whether percutaneous coronary intervention (PCI) prior/concomitant with TAVI confers any additional clinical benefit in patients with CAD remains unclear.

Purpose

To compare the outcomes of PCI prior to TAVI in patients with significant coronary artery disease and severe aortic stenosis.

Methods

We systematically searched PubMed, Embase and Cochrane databases, in November 2021, for both retrospective and prospective studies comparing TAVI with PCI versus TAVI alone. Random-effects meta-analysis was performed.

Results

Eleven studies were included in which one was a randomized clinical trial. A total of 2530 patients were included, providing a 145 pooled death events (64 in TAVI with PCI and 81 in TAVI only). In terms of 30-day clinical outcomes, our pooled analysis revealed a similar all-cause mortality (pooled OR, 1.24; 95% CI [0.80, 1.93], P=0.34; I2=27% - Figure), cardiovascular mortality (pooled OR, 1.44; 95% CI [0.56, 3.75], P=0.45; I2=57%) and stroke (pooled OR, 1.07; 95% CI [0.53, 2.13], P=0.86; I2=0%). However, our analysis revealed a higher rate of myocardial infarction (pooled OR, 4.28; 95% CI [1.56, 11.69], P<0.01; I2=0%) and major bleeding events (pooled OR, 1.40; 95% CI [1.02, 1.93], P=0.04; I2=0%) in the TAVI with PCI group. A 1-year clinical outcomes analysis revealed a trend for lower all-cause mortality in TAVI only group (pooled OR, 1.37; 95% CI [0.98, 1.91], P=0.06; I2=0%), similar cardiovascular death rate (pooled OR, 1.15; 95% CI [0.70, 1.89], P=0.59; I2=6%) and major bleeding events (pooled OR, 1.62; 95% CI [0.95, 2.76], P=0.07; I2=0%).

Conclusion

Our pooled data suggests that PCI with TAVI in patients with severe aortic stenosis and concomitant CAD grants no additional clinical advantage.

Funding Acknowledgement

Type of funding sources: None.
Redo isolated tricuspid valve surgery: prediction of in-hospital mortality using the TRI-SCORE
Authors: Dreyfus J , Bohbot Y , Coisne A , Lavie-Badie Y , Riant E , Modine T , Le Tourneau T , Tribouilloy C , Donal E , Habib G , Selton-Suty C , Iung B , Obadia J F , Audureau E , Messika-Zeitoun D
Published: October 2022

Background

Redo isolated tricuspid valve surgery (ITVS) is rarely performed. The TRI-SCORE reliably predicts in-hospital mortality after ITVS on native valve but has not been tested in the setting of redo interventions.

Purpose

We aimed to compare the predictive value of the TRI-SCORE to other surgical risk scores for redo ITVS.

Methods

Using a mandatory administrative database, we identified all consecutive adult patients who underwent a redo ITVS at 12 French tertiary centers between 2007 and 2017. Baseline characteristics and outcomes were collected from chart review and the TRI-SCORE, Logistic EuroSCORE, EuroSCORE II and STS were calculated.

Results

We identified 70 patients who underwent a redo ITVS (mean age 54±15 years, 63% female). Prior intervention was a repair in 51% and a replacement in 49%. A tricuspid valve replacement was performed in all patients. In-hospital mortality was 10%. The TRI-SCORE was the only risk score associated with in-hospital mortality (p=0.01). Area under the receiver operating characteristic curve for the TRI-SCORE was 0.83, much higher than with logistic EuroSCORE (0.58), EuroSCORE II (0.61) or STS (0.59). The table presents the observed and predicted values of in-hospital mortality according to TRI-SCORE categories.

Conclusion

The TRI-SCORE accurately predicted in-hospital mortality after redo isolated tricuspid valve surgery and may guide the clinical decision-making process especially as transcatheter therapies are emerging.

Funding Acknowledgement

Type of funding sources: None.
Transcatheter aortic valve replacement in patients with a concomitant aortic aneurysm
Authors: Gill A , Al-Taweel O , Fakhra S , Nadeem-Tariq A , Hawwass D , Ahsan C
Published: October 2022

Background

Although there is extensive literature present on transcatheter aortic valve replacement (TAVR), there is limited data on TAVR patients with a concomitant aortic aneurysm.

Purpose

In this study, we investigate the short-term, in-hospital outcomes of patients undergoing TAVR with and without an aortic aneurysm.

Methods

This was a retrospective cohort study comparing adult patients undergoing TAVR with and without an aortic aneurysm from 2016 to 2018. We queried the National Inpatient Sample database to identify patients admitted for a principal procedure of TAVR, principal diagnosis of aortic stenosis and secondary diagnosis of aortic aneurysm. We analyzed the categorical and continuous variables by Pearson's chi-squared and Student t-test respectively. Multivariable logistic regression, adjusted for age, gender and comorbidities, was used to compare mortality. The comorbidities adjusted for included coronary artery disease, chronic kidney disease, chronic obstructive pulmonary disease, hypertension, obesity and type 2 diabetes mellitus.

Results

109,170 patients met our inclusion criteria. Patients undergoing TAVR with an aortic aneurysm had 1.97 times higher odds of suffering in-hospital mortality compared to TAVR patients without an aortic aneurysm (aOR 1.97, 95% CI: 1.05–3.73; p=0.036). When separated by race, patients with an aortic aneurysm had higher mortality rates amongst White (3.4% vs 1.7%, p<0.001) and Hispanic (5.2% vs 2.6%, p=0.11, Figure 1) patients. TAVR patients with an aortic aneurysm were predominantly male and had higher average Charlson Comorbidity Index scores (Table 1). Furthermore, these patients also had higher rates of comorbidities such as coronary artery disease, chronic obstructive pulmonary disease and prior myocardial infarction, but decreased rates of chronic kidney disease, hypertension, obesity and type 2 diabetes mellitus (Table 1). In terms of operative complications, TAVR patients with an aortic aneurysm were more likely to have intraoperative cardiac arrest (1.1% vs 0.4%, p<0.001, Table 1). There was no significant difference between our two cohorts in postoperative cardiac arrest and postoperative cerebral infarction.

Conclusion

Patients undergoing TAVR with an aortic aneurysm had higher odds of suffering in-hospital mortality compared to patients undergoing TAVR without an aortic aneurysm. These patients are also at an increased risk of intraoperative cardiac arrest. Surgical intervention with a concomitant aortic aneurysm poses its own unique set of clinical challenges. Our findings emphasize the importance of risk-benefit analysis and collaborative discussion amongst the medical team prior to choosing the appropriate treatment modality. Additional studies should explore if certain races are at increased risk of operative complications and mortality.

Funding Acknowledgement

Type of funding sources: None.
Membranous septum length as predictor for permanent pacemaker implantation after TAVI
Authors: Jung S , Ammon F , Smolka S , Moshage M , Marwan M , Achenbach S
Published: October 2022

Background

High-degree atrioventricular (AV) block and permanent pacemaker (PPM) implantation represent major complications after transcatheter aortic valve implantation (TAVI). Extension of indication for TAVI towards subjects with lower surgical risk requires to reduce the likelihood for the requirement of permanent pacemaker (PPM) implantation. Data on the role of membranous septum length as potential predictor for AV block after TAVI are scarce.

Purpose

We examined the role of membranous septum length as potential predictor for AV block and the need for PPM implantation in a large cohort of consecutive subjects after TAVI.

Methods

In a cohort of 1365 patients without prior permanent pacemaker who underwent transfemoral TAVI, clinical and procedural characteristics were assessed systematically. Based on cardiac computed tomography performed prior to TAVI, membranous septum length was measured orthogonal to the anulus plane (see figure).

Results

Median age of subjects was 81 (IQR 7) years, 50% were male. Logistic euroSCORE was 12.8 (IQR 15.7), STS score 3 (2.7). 9,8% of subjects had a pre-interventional complete right bundle branch block (RBBB). 71% of patients received a balloon-expandable, 29% a self-expandable valve. In n=153 patients (11.2%), PPM implantation was necessary due to high-degree AV block. Median membranous septum length was 2.9 mm (IQR 2.5mm) in subjects who received a PPM versus 4.3 mm (IQR 3.2 mm) in subjects who did not need a PPM (p=0.061). In univariate regression analysis, pre-interventional complete RBBB (p<0.001, OR 7.8), implantation of a self-expandable prosthesis (p=0002, OR 1.7) and membranous septum length (p=0.027, OR 0.9 per 1 mm) were identified as significant predictors for PPM implantation. In multivariate regression analysis, all parameters remained significant, including membranous septum length (p=0.009, OR 0.9 per 1 mm).

Conclusion

In a large cohort of consecutive patients, we were able to confirm the significant independent predictive value of membranous septum length, in addition to pre-interventional complete RBBB or implantation of a self-expandable prosthesis, regarding the occurrence of post-procedural AV block with the need for PPM implantation. The results may contribute to improved risk stratification for potential PPM implantation after TAVI.

Funding Acknowledgement

Type of funding sources: None.
Prognostically distinct phenotypes of metabolic health beyond obesity in aortic stenosis
Authors: Chew N , Zhang A , Kong G , Lee K L , Ng C H , Chong B , Ngiam N , Loh P H , Kuntjoro I , Wong R , Kong W , Yeo T C , Poh K K
Published: October 2022

Background

Whilst current evidence are in favour of metabolic health and non-obesity in the reduction of incident cardiovascular disease, little is known regarding the prognosis across the metabolic phenotypes once cardiovascular disease occurs. This study examined the prognosis of patients with significant aortic stenosis (AS) based on the presence of metabolic health and obesity.

Methods

This retrospective cohort on consecutive patients presenting with moderate-to-severe AS to a tertiary hospital between 2010 and 2015. Patients were allocated into 4 groups based on obesity and metabolic health: metabolically healthy obese (MHO), metabolically healthy non-obese (MHNO), metabolically unhealthy obese (MUO) and metabolically unhealthy non-obese (MUNO). Metabolic health was defined in accordance to Program Adult Treatment Panel III criteria. The primary outcome was all-cause mortality. Cox regression examined independent associations between mortality and metabolic phenotypes, adjusting for aortic valve area, ejection fraction, age, sex, chronic kidney disease and AVR as a time-dependent covariate.

Results

Of 727 patients, the majority (51.6%) were MUNO, followed by MUO (32.7%), MHNO (11.4%), and MHO (4.3%). MHNO had the highest mortality (43.0%), followed by the MUNO (37.5%), MUO (30.0%) and MHO (6.9%) groups (p=0.001). Compared to MHNO, MHO (HR 0.159, 95% CI 0.038–0.668, p=0.012) and MUO (HR 0.614, 95% CI 0.403–0.937, p=0.024) were independently associated with lower all-cause mortality rates, after adjusting for confounders. In obese patients, metabolic health had favourable survival compared to metabolically unhealthy (p=0.015), but this protective impact of metabolic health was not observed in overweight or normal weight individuals. Obesity had favourable survival compared to overweight and normal weight, in both metabolically health (p=0.002) and unhealthy (p=0.007) patients,

Conclusion

MHO patients with AS have the most favourable prognosis whilst the seemingly healthy MHNO group had the worst survival. There should be a paradigm shift towards prioritising metabolic health rather than weight reduction in patients with significant AS.

Funding Acknowledgement

Type of funding sources: None.
Albuminuria predicts worsening renal function at 1 month after transcatheter aortic valve implantation
Authors: Tobe A , Tanaka A , Tokuda Y , Shirai Y , Yamamoto T , Tokoro M , Furusawa K , Ishii H , Usui A , Murohara T
Published: October 2022

Background

Worsening renal function (WRF) at short term after transcatheter aortic valve replacement (TAVR) is reportedly associated with subsequent poor clinical outcomes. We previously reported preoperative albuminuria predicted mid-term WRF after TAVR. However, the impact of albuminuria on short-term WRF after TAVR is unknown.

Methods

Overall, 206 patients who underwent TAVR for severe aortic stenosis were investigated retrospectively. Patients were divided into two groups according to the preoperative urinary albumin-to-creatinine ratio (ACR): high (ACR ≥30 mg/g) and low (ACR <30 mg/g). The incidence of 1-month WRF, defined as a decrease in estimated glomerular filtration rate (eGFR) ≥10% from baseline after TAVR, was investigated.

Results

More than half of the examined patients (n=106/206 [51.5%]) had a high ACR. Patients with a high ACR had significantly lower eGFR at baseline than those with a low ACR (49.3 [32.5–57.8] vs. 51.4 [37.7–65.8] mL/min/1.73 m2, p=0.03). Patients with a high ACR more frequently had acute kidney injury (8.5% vs. 1.0%, p=0.01) and 1-month WRF than those with a low ACR (29.2% vs. 12.0%, p=0.002). Multivariate analysis showed a high ACR was independently associated with 1-month WRF (odds ratio, 3.72; 95% confidence interval, 1.72–8.08; p<0.001). Meanwhile, eGFR <60 mL/min/1.73 m2 was not an independent predictor of 1-month WRF (odds ratio, 0.48; 95% confidence interval, 0.22–1.04, p=0.06).

Conclusions

Patients with preoperative albuminuria (ACR ≥30 mg/g) more frequently developed AKI and 1-month WRF after TAVR. Albuminuria was independently associated with 1-month WRF, suggesting albuminuria to be a universal predictor of deterioration of renal function at various time points.

Funding Acknowledgement

Type of funding sources: None.
Prevalence and prognostic implications of discordant grading and flow-gradient patterns in moderate aortic stenosis
Authors: Stassen J , Ewe S , Singh G K , Amanullah M R , Hirasawa K , Butcher S , Sin K Y K , Ding Z P , Sia C H , Chew N W S , Kong W K F , Poh K K , Delgado V , Marsan N A , Bax J J B
Published: October 2022

Background

The prognostic implications of discordant grading in severe aortic stenosis (AS) are well known. However, the prevalence of different flow-gradient patterns and their prognostic implications in moderate AS are unknown.

Purpose

To investigate the occurrence and prognostic implications of different flow-gradient patterns in patients with moderate AS.

Methods

Patients with moderate AS (aortic valve area 1.0–1.5 cm2) were divided in 4 groups, based on transvalvular mean gradient (MG), stroke volume index (SVi) and left ventricular ejection fraction (LVEF): concordant moderate AS (MG ≥20 mmHg); normal-flow, low-gradient discordant moderate AS (MG <20 mmHg, SVi ≥35 ml/m2); “classical” low-flow, low-gradient discordant moderate AS (MG <20 mmHg, SVi <35 ml/m2 and LVEF <50%) and “paradoxical” low-flow, low-gradient discordant moderate AS (MG <20 mmHg, SVi <35 ml/m2 and LVEF ≥50%). The primary endpoint was all-cause mortality.

Results

Of 1974 patients (age 73±10 years, 51% men) with moderate AS, 788 (40%) had discordant grading. Patients with discordant grading showed significantly higher mortality rates than patients with concordant grading (p<0.001), even in the subgroup of patients having preserved LVEF (p=0.028) or preserved SVi (p=0.002). Of the patients with discordant grading, 71% had normal-flow, low-gradient moderate AS, 14% had “classical” low-flow, low-gradient moderate AS, and 14% had “paradoxical” low-flow, low-gradient moderate AS (Figure 1). Patients with normal-flow, low-gradient moderate AS, “classical” low-flow, low-gradient moderate AS, and “paradoxical” low-flow, low-gradient moderate AS had worse survival rates than patients with concordant grading (p<0.001) (Figure 2). On multivariable analysis “paradoxical” low-flow, low-gradient (HR: 1.533; 95% CI: 1.133–2.075; p=0.006) and “classical” low-flow, low-gradient (HR: 1.926; 95% CI: 1.442–2.572; p<0.001) but not normal-flow, low-gradient moderate AS were independently associated with all-cause mortality.

Conclusion

Discordant grading is frequently (40%) observed in patients with moderate AS. Low-flow, low-gradient patterns account for an important proportion of the discordant cases and are associated with increased mortality. These findings underline the need for better phenotyping patients with discordant moderate AS.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): ESC Training Grant App000064741
Hypoattenuated leaflet thickening is associated with silent brain injury
Authors: Nagy A I , Bartykowszki A , Apor A , Suhai F , Varga A , Manouras A , Szilveszter B , Panajotu A , Jermendy A , Turani M , Molnar L , Papp R , Merkely B , Maurovich-Horvat P
Published: October 2022

Background

The association between hypoattenuated leaflet thickening (HALT) following transcatheter aortic valve implantation (TAVI) and stroke remains contradictory. Whether HALT carries an increased risk of subclinical brain injury (SBI) has not been investigated.

Purpose

We investigated whether HALT is associated with SBI on MRI. Furthermore, we assessed whether post-TAVR SBI impacts the patients' cognition and outcome.

Methods

153 patients undergoing TAVR were prospectively enrolled. Brain MRI was performed shortly post-TAVR and 6 months (6M) later to assess the occurrence of acute silent cerebral ischaemic lesions (SCIL) and chronic white matter hyperintensities (WMH). HALT was screened by cardiac CT angiography 6M post-TAVR. Neurocognitive evaluation was performed before, shortly after and 6M following TAVR.

Results

At 6M, 115 patients had diagnostic CTA and 10 had HALT. HALT status, baseline and follow-up MRIs were available in 91 cases. At 6M, new SCIL was evident in 16%, new WMH in 66%. New WMH was more frequent (100% vs 62%; p=0.047) with higher median volume (319 vs 50 mm3; p=0.039) among HALT-patients. In uni- and multivariate analysis, HALT was associated with new WMH volume (beta: 0.72; 95% CI: 0.2–1.39; p=0.009).

The patients' cognitive trajectory from pre-TAVR to 6M showed significant association with the 6M SCIL volume (beta: −4.69; 95% CI: −9.13 to −027; p=0.038), but was not related to the presence or volume of new WMH. During a 3.1-year follow-up neither HALT, nor the related WMH burden was related with increased mortality (HALT HR: 0.86, 95% CI: 0,202–3,687; p=0.84; new WMH HR: 1.09; 95% CI: 0,701–1,680; p=0.71).

Conclusions

6M post-TAVR, HALT was linked with greater WMH burden, but did not carry an increased risk of cognitive decline or mortality over a 3.1-year follow-up.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): János Bolyai Scholarship of the Hungarian Academy of Sciences
Incidence and predictors of transthyretin cardiac amyloidosis in patients with degenerative aortic stenosis
Authors: Abadie B , Held M , Puri R , Krishnaswamy A , Yun J , Hanna M , Reed G , Kapadia S , Jaber W
Published: October 2022

Background

The approval of new therapies for treating transthyretin (TTR) cardiac amyloidosis has led to significant interest in identifying patients at high risk for this disease. Investigators have identified a correlation between severe degenerative aortic stenosis (AS) and TTR cardiac amyloidosis in older patients, with several studies finding up to 20% of patients who undergo transcatheter aortic valve replacement (TAVR) having TTR cardiac amyloidosis. These initial TAVR studies were conducted when TAVR was performed almost exclusively in high surgical risk populations. Therefore, the true incidence of TTR cardiac amyloidosis in an all-comers with severe degenerative AS referred for TAVR is unknown.

Purpose

To identify the true burden of TTR cardiac amyloidosis in a contemporary population of severe degenerative AS undergoing TAVR screening.

Methods

All patients ≥70 years with severe native valve degenerative AS seen in a multidisciplinary valve clinic were referred for technetium-99m pyrophosphate cardiac scintigraphy (PYP scan) for evaluation of cardiac amyloidosis. Diagnosis was made via combination of planar grade and heart to contralateral lung ratio, confirmed on single positron emission computed tomography/computed tomography (SPECT/CT). Patients with a positive PYP scan were referred to a heart failure clinic where they underwent testing for AL amyloidosis.

Results

Over a 10 month period, 247 patients seen in valve clinic underwent a PYP scan. Of this cohort, 203 patients ultimately underwent TAVR, 15 surgical aortic valve replacement, and 2 balloon valvuloplasty with 27 patients having not yet undergone a procedure. The positivity rate was 4% (10/247) with 1 patient having an equivocal result. The patients with a positive PYP scan had higher rate of low-flow low-gradient (LFLG) AS (64% vs 29%, p=0.006) and classical LFLG AS (27% vs 8%, p=0.02). Echocardiographic measures associated with a positive PYP scan include a lower global longitudinal strain (−10.0% vs −16.1%, p=0.008), lower average e' (4.5 vs 6.5, p=0.003), and an increased E/A ratio (1.8 vs 1.1, p=0.018).

Conclusions

The incidence of TTR amyloidosis in a contemporary, severe AS population ≥70 years undergoing TAVR screening appears much lower than previously described in the literature. Echocardiographic traits may be able to predict which patients with severe AS should undergo evaluation for TTR cardiac amyloidosis.

Funding Acknowledgement

Type of funding sources: None.
Leukocyte extracellular vesicles as the first biomarkers to predict outcomes in patients undergoing percutaneous aortic valve replacement
Authors: Gasecka A , Van Der Pol E , Kochman J , Huczek Z , Wilimski R , Grabowski M , Filipiak K J , Nieuwland R
Published: October 2022

Background

Transcatheter aortic valve implantation (TAVI) is a novel treatment for aortic stenosis (AS), associated with better outcomes than surgical aortic valve replacement in high-risk patients. However, up to 29% of patients annually experience major adverse cardiac and cerebrovascular events (MACCE) after TAVI. MACCE are mostly caused by atherothrombosis, i.e. formation of platelet aggregates (thrombi) on ruptured atherosclerotic plaques. Because platelets release extracellular vesicles (EVs) during thrombus formation, we hypothesized that EVs are a biomarker to predict MACCE after TAVI.

Methods

This was a multicentre, prospective clinical study. Venous blood was collected 1 day before TAVI and at hospital discharge (n=57, mean age 79.9+6.4 years, 49% male). Flow cytometry (Apogee A60-Micro) was used to determine concentrations of plasma EVs labelled with markers for endothelial cells (CD146), leukocytes (CD45), platelets and megakaryocytes (CD61) and activated platelets (CD62p). Analysis of flow cytometry data files was fully automated. Rosetta Calibration (Exometry) and Flow-SR were used for diameter and refractive index determination. Wilcoxon signed rank test was used to compare EV concentrations before and after TAVI. The predictive value of EVs for MACCE and the cut-offs were calculated using a receiver operating characteristic curve. Logistic regression model incorporating EV concentrations and clinical characteristics was used to determine the best model for MACCE prediction.

Results

Concentrations of EVs from activated platelets increased, whereas from leukocytes decreased after TAVI, compared to the measurement before (p=0.06, p=0.04, respectively). Among 55 patients discharged from the hospital, 14 patients experienced MACCE (25%) during the median 15 months of observation. Increased baseline concentration of leukocyte EVs and male gender were the only independent predictors of MACCE in multivariable analysis (OR 4.01, 95% CI 0.77–23.77, p=0.04 for leukocyte EVs; OR 6.84, 95% CI 1.41–33.17, p=0.03 for male gender).

Conclusions

We identified increased concentrations of leukocyte EVs as new candidate biomarkers to predict MACCE after TAVI. Leukocyte EVs could be used to augment risk stratification in this patient cohort. The next step is to validate the clinical applicability of EVs to predict post-TAVI MACCE in a large-scale clinical trial.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Young Investigator Grant of the Polish Society of Cardiology
Early intervention versus conservative management of asymptomatic severe aortic stenosis: a systematic review and meta-analysis
Authors: Costa G , Cardoso J , Goncalves L , Teixeira R
Published: October 2022

Background

Aortic stenosis (AS) is the most common valvular disease in developed countries. However, the specific timing of intervention for asymptomatic patients with severe AS remains controversial.

Purpose

To compare the outcomes of early aortic valve replacement (AVR) versus watchful waiting (WW) in asymptomatic patients with AS.

Methods

We systematically searched PubMed, Embase and Cochrane databases, in December 2021, for both interventional or observational studies comparing early AVR with WW in the treatment of asymptomatic severe AS. Random-effects meta-analysis was performed.

Results

Thirteen studies were included in which two were randomised clinical trials. A total of 4,679 patients were included, providing a 1,268 pooled death events (327 in early AVR and 941 in WW). Our meta-analysis showed a significantly lower all-cause mortality for the early-AVR compared with WW group, although with a moderate amount of heterogeneity between studies in the magnitude of the effect (pooled odds ratio [OR], 0.41; 95% confidence interval [CI] 0.34, 0.50, P<0.01; I2=60%). An early surgery strategy displayed a significantly lower cardiovascular mortality (pooled OR, 0.33; 95% CI [0.19, 0.56], P<0.01; I 2=64%) and heart failure hospitalisations (pooled OR 0.19; 95% CI [0.10, 0.39], P<0.01, I2=7%). However, both groups had similar rates of stroke (pooled OR 1.30; 95% CI [0.73, 2.29], P=0.36, I2=0%) and myocardial infarction (pooled OR 0.49; 95% CI [0.19, 1.27], P=0.14, I2=0%).

Conclusions

Our pooled data suggest that an early-AVR strategy is preferable for asymptomatic patients with severe AS.

Funding Acknowledgement

Type of funding sources: None.
Early aortic valve replacement improves exercise capacity in truly asymptomatic patients with severe aortic stenosis
Authors: Banovic M , Boskovic N , Bojanic M , Nedeljkovic I , Jovanovic M , Penicka M , Bartunek J
Published: October 2022

Background

Exercise capacity is a strong predictor of morbidity and mortality overall. In severe aortic stenosis (AS) ustained pressure overload during watchful waiting is associated with LV structural and functional deterioration and impaired clinical outcome both pre- and post aortic valve replacement (AVR). The effect of early surgical aortic valve replacement (SAVR) in asymptomatic patients with severe AS and normal left ventricular function on exercise capacity in unknown.

Aim

We investigated whether the early surgical AVR in truly asymptomatic patients with severe aortic stenosis and normal LVEF improves the exercise capacity.

Methods

This is a sub-analysis or the AVATAR trial (NCT02436655), which is international prospective randomized controlled trial that evaluated the safety and efficacy of early SAVR in the treatment of asymptomatic patients with severe AS, according to common criteria (valve area ≤1 cm2 with aortic jet velocity >4 m/s or a mean transaortic gradient ≥40 mm Hg), and with normal left ventricular function. Patients underwent cardiopulmonary exercise testing (supine bicycle, ramp protocol, 15 W/min) at the baseline and 12 months following the randomization. Patients who had positive exercise testing at baseline visit were excluded. We compared the value of workload (in WATs), VO2 max, VO2 AT, VE/VCO2 and PETCO2 slope at the inclusion and at 12 months.

Results

Total of 157 patients (mean age, 67 years; 57% men) were randomly allocated to early surgery (n=78) or conservative treatment (n=79). Mean LVEF and Vmax in early surgery and conservative treatment group were 70% and 4.5m/s and 69% and 4.5m/s, respectively. After 12 months in patients with conservative treatment there was a slight decrease in the values of workload, VO2 max, VO2 AT, VE/VCO2 and PETCO2 slope, but without statistical significance. However operated patients showed a significant increase in workload (115.4±38.4 watts at 12 months vs 104.8±42.2 at inclusion, p=0.038) and VO2 max (19.7±6.8 at 12 months vs 16.2±5.4 at the inclusion, p=0.048), while there was slight increase in the values of VO2 AT, VEVCO2 and PETCO2 but without statistical significance.

Conclusion

Early SAVR improve the functional capacity in asymptomatic patients with severe aortic stenosis and normal left ventricular ejection fraction

Funding Acknowledgement

Type of funding sources: None.
Single centre experience in transcatheter mitral valve implantation: valve in valve, valve in ring and valve in MAC
Authors: Alvarez H A , Joner M , Xhepa E , Erlebach M , Schunkert E , Kastrati A , Lange R , Ruge H
Published: October 2022

Background

Mitral valve replacement/repeair procedures increase year. Redo procedure and severely calcified mitral ring are risk factors for high mortality. Transmitral valve implantation (TMVI) represents a less invasive procedure in high-risk population, but still with increase mortality. We seek to evaluate a one single center experience the safety and efficacy in patients undergoing transeptal TMVI with degenerated bioprostheses or ring and high surgical risk candidates with heavily mitral anulus calcification (MAC).

Methods

One-single centre, retrospective observational analysis, included patientes from 2012 to 2021 treated with a valve in mitral position. Valve-in-valve (ViV), valve in ring (ViR) and valve in MAC were included. Periprocedural, and in-hospital complications were documented and analyzed.

Results

Seventy-nine patients were included. ViV was done in 59 patients, ViR in 8 patients, ViMAC in 10 patients and Valve in native anatomy in 2 patients. Baseline, procedural characteristics and complications and reported on table. No significant statistical difference was observed in baseline characteristics. STS Score was 7.77+5.37 in ViV patients, 5.77+3.02 in ViR patients, 8.70+4.47 in ViMAC patients and 6.29+0.55 in native anatomy (p=0.634). Procedural success was observed in 96.6% of ViV, 87.5% in ViR, 80% in ViMAC and 100% in native anatomy (p=0.124). Procedural related death was observed only in one ViV patient. Conversion to surgery and valve embolisation was observed in one ViV (1.7%) and ViR (12.5%) patient, respectively. In-hospital death was observed in 5.1% ViV patients, 12.5% ViR, 20% ViMAC and none of the native anatomy patients.

Conclusion

TMVI is still challenging but feasible and safe. Carefully planning and heart team approach in experiences centers is important to address this issue and reduce as much as possible any complication.

Funding Acknowledgement

Type of funding sources: None.
Improving assessment of different flow state of aortic stenosis: implication for prognosis in patients undergoing transcatheter aortic valve replacement
Authors: Fusini L , Muratori M , Tamborini G , Ghulam Ali S , Gripari P , Mantegazza V , Roberto M , Trabattoni P , Agrifoglio M , Bartorelli A L , Pontone G , Pepi M
Published: October 2022

Background

Low-flow low-gradient (LF-LG) aortic stenosis (AS) may occur with preserved or depressed left ventricular ejection fraction (EF), and both situations represent the most challenging subset of patients with AS to manage and generally have a poor prognosis with conservative therapy but a high operative mortality if treated surgically. Few and controversial data exist on the outcomes of these patients compared to normal-flow high-gradient (NF-HG) AS following transcatheter aortic valve replacement (TAVR).

Purpose

This study aims to better characterize patients with different transvalvular flow-gradient patterns undergoing TAVR and to examine the prognostic value of these flow state.

Methods

Overall, 1208 patients with severe symptomatic AS undergoing TAVR were categorized according to flow-gradient patterns as follow: 976 patients NF-HG (DPmean >40 mmHg), 107 paradoxical LF-LG (pLF-LG: DP mean <40 mmHg, EF >50%, and SVi <35 mL/m2), and 125 classical LF-LG (DP mean <40 mmHg, EF <50%, SVi <35 mL/m2).

Results

TAVR was feasible in all AS subtypes. When compared with NF-HG and pLF-LG, LF-LG had a worse symptomatic status (NYHA III–IV 86% vs 62% and 67%, respectively, p<0.001), a higher prevalence of eccentric hypertrophy (Figure 1, left), a higher level of LV global afterload reflected by a higher valvuloarterial impedance and a higher pulmonary pressure (Table). Valvular function after TAVR was excellent over time with respect to aortic pressure gradient (mean and peak) and aortic valve area regardless of flow state group. While intraoperative (p=0.935) and 30-day mortality (p=0.911) did not differ significantly among the 3 groups, LF-LG had a lower overall 5-year survival (LF-LG 50%, pLF-LG 65%, NF-HG 84%, p<0.001) (Figure 1, right). LF-LG AS was associated with a hazard ratio for 5-year mortality of 2.416 (95% CI: 1.658–3.520, p<0.001).

Conclusions

TAVR is an effective procedure in all patients with severe AS regardless of transvalvular flow-gradient patterns. However, special care should be given to characterized hemodynamic of AS, as patients with pLF-LG had similar survival rate than patients with NF-HG, whereas survival in LF-LG patients was 2-fold higher. Therefore, being able to identify patients less likely to improve after TAVR may help to guide treatment decision.

Funding Acknowledgement

Type of funding sources: None.
Extent and determinants of dynamic mitral regurgitation unmasked by handgrip exercise in patients with primary mitral regurgitation
Authors: Spieker M , Lagarden H , Sidabras J , Veulemans V , Akhyari P , Horn P , Kelm M , Westenfeld R
Published: October 2022

Background

Bicycle exercise is the exercise modality of choice to unmask the dynamic nature of mitral regurgitation (MR). Handgrip exercise may serve as alternative exercise intervention, as it can be performed physically accomplished by the majority of patients. Until now, there are only scarce data on the prevalence and magnitude of dynamic MR during handgrip exercise.

Purpose

To assess extent and predictors of exercise-induced dynamic MR during handgrip exercise in patients with primary MR.

Methods

We prospectively included patients with primary MR and at least mild severity that underwent echocardiography at rest and during three minutes of handgrip exercise according to a standardized protocol.

Results

The final patient cohort included 166 patients. Mean age was 72±12 years, 57% were female and 53% had atrial fibrillation. At rest, MR severity was graded as mild in 57% of patients, moderate MR in 27% and severe in 16%. Handgrip exercise led to an increase in at least one grade in MR severity in 31 patients (19%), while 15 patients (9%) experienced a decrease of MR severity (Fig. 1B). Twenty patients (14%) of those with non-severe MR at rest, developed severe MR during handgrip exercise (Fig. 1B). According to a pre-defined cutoff of increase in effective orifice regurgitant area (EROA) >10 mm2 during exercise, 19% of patients revealed a marked exercise-induced increase in MR, irrespective of the severity of MR at rest. Patients with marked exercise-induced increases in MR severity (EROA >10 mm2) had elevated left- (53±22ml/m2 vs. 44±19ml/m2; p=0.036), and right atrial volumes (43±19ml/m2 vs. 34±18ml/m2; p=0.014), more often pathology of the anterior mitral leaflet (e.g. prolapse; flail leaflet) (65% vs. 33%; p<0.001), and increased mitral annulus diameter (38±5mm vs. 36±4mm; p=0.003). The exercise-induced changes in EROA correlated with changes in estimated systolic pulmonary pressure from rest to exercise (r=0.438 (0.287 to 0.568); p<0.001) (Fig. 1C).

Conclusion(s)

In patients with primary MR, handgrip echocardiography unmasks marked exercise-induced increases of MR severity in every fifth patient independent of the severity at rest. A relevant number of patients with non-severe MR at rest developed severe MR during exercise. Dynamic MR is associated with bi-atrial dilatation, increased mitral annulus diameter, and pathology of the anterior mitral valve leaflet. Moreover, changes in MR severity during handgrip exercise correlate with changes in pulmonary pressures.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): This work was supported by the Forschungskommission of the Medical Faculty of the Heinrich Heine University Düsseldorf Maximilian Spieker for a Clinician Scientist Track.
Development and validation of a diagnostic echocardiographic mass (DEM) score in the complex approach to cardiac masses
Authors: Angeli F , Paolisso P , Magnani I , Fabrizio M , Rinaldi A , Armillotta M , Stefanizzi A , Amicone S , Tattilo F P , Suma N , Bodega F , Canton L , Galie N , Foa A , Pizzi C
Published: October 2022

Background

Cardiac masses (CM) are an extremely heterogeneous clinical entity, including benign and malignant neoformations. 2D Echocardiography is nowadays the first-line approach to define nature and management of CM.

Purpose

The purpose of our study was to identify the echocardiographic predictors of malignancy and create a multiparametric score to further increase the diagnostic yield and accurately suggest the nature of CM.

Material and methods

249 consecutive patients undergoing a complete echocardiographic assessment for suspected cardiac mass were enrolled from January 2004 to December 2020. A definitive diagnosis was achieved by histological examination or, in case of cardiac thrombi, with radiological evidence of thrombus resolution after an appropriate anticoagulant treatment. Logistic regression was performed to evaluate the ability of echocardiography to discriminate benign versus malignant masses.

Results

A scoring system was developed in a derivation cohort of 178 (70%) and validated in 71 (30%) patients. A weighted score [Diagnostic Echocardiographic Mass (DEM) Score] ranging from 0 to 9 was obtained from 6 variables: infiltration, polylobate mass, moderate-severe pericardial effusion, inhomogeneity, sessile and non-left localization. The AUC for the score was 0.965 (95% CI 0.938–0.993). In a logistic regression analysis using the DEM score as a predictor, the likelihood of malignancy increased more than 4 times for a 1-unit increase of the score (OR=4.468; 95% CI 2.733–7.304). The prognostic validity of the score was confirmed by its ability to predict survival during follow-up (median time of 31 months).

Conclusions

The application of a multiparametric echocardiographic score in the approach to CM accurately predicts mass malignancy thereby reducing the need for second-level investigations, and minimizing the diagnostic delay in such a complex clinical scenario.

Funding Acknowledgement

Type of funding sources: None.