bluuebunny/crossref_metadata_2025 huggingface dataset:
Aortic valve tissue quantification in bicuspid aortic valve stenosis
Authors: Ye Z , Foley T , Sarano M , Michelena H
Published: October 2024

Background

The relative contribution of calcific versus noncalcific aortic valve tissue volume to aortic stenosis (AS) in bicuspid aortic valve (BAV) is unclear.

Purpose

We aimed to assess the association of aortic valve tissue volume quantified by contrast-enhanced CT with echocardiographic AS severity, and diagnostic implication of noncalcific tissue volume for severe AS.

Methods

We retrospectively identified 234 patients with BAV who had echocardiographic AS severity and contrast-enhanced CT evaluation within six months and left ventricular ejection ≥50%, including 150 severe AS (aortic valve area≤1 cm2 or indexed valve area≤0.6cm2/m2 plus mean grdient≥40mmHg or peak velocity≥4 m/s), 84 nonsevere AS (61 with at least mild AS: peak veloicty≥2.0 m/s plus mean gradient ≥10mmHg, and 23 with normal aortic valve function). Contrast-enhanced CT aortic valve calcific volume and noncalcific (fibrosis) volume were quantified using patient-specific Hounsfield unit thresholds (Figure). Noncontrast CT aortic valve calcium score (AVCscore) was quantified by the Agaston method. CT measurements were indexed to echocardiographic aortic valve annulus area and square-root transformed for the analysis.

Results

Of 234 patients, the mean age was 64±11 years, and 64% were men. There were positive correlations of indexed calcific volume, noncalcific volume, and inverse correlations of percentages of noncalcific volume (noncalcific volume divided by the sum of calcific and noncalcific volume) with peak velocity and mean gradient (|r|=0.30 to 0.68). Among 150 patients with severe AS, 28 had an AVCscore below the severe AVC threshold (1200 AU in women and 2000 AU in men) while exhibited a higher percentage of noncalcific volume compared to 122 patients with severe AVCscore (67±15% vs. 39±15%, p<0.001). After excluding 122 patients with severe AS and severe AVCscore, the indexed noncalcific volume was associated with severe AS (β±S.E: 0.18±0.07, p=0.005) with an area under the curve of 0.71; in contrast, AVCscore was not (p=0.55).

Conclusion

Both calcific and noncalcific aortic valve tissue volume contribute to AS severity in patients with BAV. Notably, noncalcific tissue volume is a key factor in determining severe AS in patients without severe AVCscore, suggesting its potential diagnostic value.Figure
Prognostic role of exercise stress echocardiography in asymptomatic severe aortic stenosis
Authors: Agostini R , Mori F , D'alfonso M G , Ciampi Q , Saad A K , Zagatina A , Colonna P , Merli E , Van De Heyning C M , Russo M , Padang R , Pellikka P A , Picano E
Published: October 2024

Background

Guidelines recognize the role of exercise stress testing in evaluating functional capacity in patients with asymptomatic severe aortic stenosis (AS). The study aimed to identify the prognostic role of exercise stress echocardiography (ESE) in asymptomatic severe AS.

Methods

We enrolled 153 asymptomatic patients (70±13 years; 88 male, 57%) with severe AS, aortic valve area (AVA) <1.0 cm2, mean aortic gradient ≥ 40 mmHg, ejection fraction (EF) ≥55%. All were referred for ESE in 7 quality-controlled centers from 5 countries. Rest and ESE assessment also included global longitudinal strain (GLS) and left atrial volume index (LAVI). B-lines were assessed by LUS with the 4-site simplified scan of the third intercostal space. A 4-point ESE score was based on 4 parameters (0 for normal, 1 for abnormal), with the following pre-determined cutoffs of abnormality: ∆-maximal aortic gradient (MAG) ≥20 mmHg; GLS at peak ≤ 19%, according to receiver operating characteristics curve analysis, stress B-lines ≥2; stress LAVI ≥ 34 mL/m2. Follow-up was completed in 142/153 patients (92%).

Results

At rest, AVA was 0.85±0.14 cm2, maximal aortic gradient: 79±14 mmHg, and peak aortic velocity: 4.42 ± 0.41 m/s. Mean EF at rest: 63.4±5.3% During a median follow-up of 1802 days (IQ range 651-2302), 41 events occurred in 39 patients: 15 all-cause deaths, 17 acute HF, 1 stroke, 1 myocardial infarction, and 7 coronary revascularization. Patients experiencing events displayed a greater increase in MAG during peak ESE, more B-lines with exercise, greater degree of LAVI dilation with exercise and slightly lower GLS compared to those without events (Table). Increase in ESE score was associated with a significant rise (p=0.001) in event incidence from score 0 (n=0/13, 0%) to score 1 (n=2/21, 9.5%), score 2 (n=10/42, 23.8%), and ≥3 (n=27/66, 40.9%), see figure.

Conclusions

In asymptomatic severe AS cases with preserved LV EF, comprehensive ESE provides early marker of potential cardiac decompensation at follow-up. The composite ESE index, including MAG, GLS, LAVI, and B-lines, holds promise as a prognostic predictor.TableFigure
Good agreement between cardiac magnetic imaging protocols using free-breathing and breath-holding techniques for flow quantification in valvular heart disease
Authors: Gao S , Bech-Hanssen O , Lagerstrand K M , Polte C , Polte C L
Published: October 2024

Background

Cardiac magnetic resonance (CMR) evaluation of valvular heart disease is an important diagnostic tool when echocardiography is inconclusive. Flow quantification is usually performed during breath hold, which can be challenging in valvular heart disease patients often suffering from dyspnea and heart failure.

Purpose

The purpose of the present study is to evaluate a free-breathing protocol of flow measurement in the aortic, pulmonary and tricuspid valves in healthy subjects (HS) and patients with tricuspid regurgitation (TR).

Methods

Phase contrast flow volume measurements were performed in 20 HS and 25 patients with TR using standard breath-holding (BH) and a free-breathing (FB) technique. Two venc-adjusted volume acquisition were acquired in the aortic, pulmonary and tricuspid valve during BH and one during FB. Mean, standard deviation (SD) and limits of agreement (LoA) for aortic forward flow volume (AoFF), pulmonary forward flow volume (PuFF) and tricuspid inflow volume (TrIF) were evaluated.

Results

Figure 1 presents flow volume (ml) of AoFF, PuFF and TrIF during BH (mean of 2 measurements) and FB.

Conclusions

The present study demonstrated good agreements between phase contrast flow measurements using FB and BH techniques. These parameters are used in the evaluation of aortic, mitral, pulmonary and tricuspid regurgitations using CMR imaging. Thus, free-breathing CMR acquisition can be an important complement in the assessment of valvular heart disease and may be applied in patients with difficulty to hold their breath.
Permanent pacemaker implantation is associated with an increased risk of heart failure hospitalization in transcatheter aortic valve implantation patients with reduced systolic function
Authors: Nass J , Liu D , Hu K , Dormann A , Buravezky L , Sokalski V , Lau K , Morbach C , Lengenfelder B , Ertl G , Frantz S , Nordbeck P
Published: October 2024

Background

The impact of permanent pacemaker implantation (PPI) on outcome of patients following transcatheter aortic valve implantation (TAVI) is not fully understood.

Purpose

This study aimed to assess the impact of PPI on risk of two-year mortality and hospitalization due to heart failure (HF) in TAVI patients.

Methods

A total of 1275 consecutive patients who underwent TAVI at our hospital between 2009 and 2021 were enrolled in this study (mean age 81.4±5.6 years, 51.8% male). The primary endpoint was defined as two-year all-cause death after TAVI. The second endpoints included cardiovascular (CV) death and HF related hospitalization after TAVI.

Results

Among the 1275 patients following TAVI, 297 (23.3%) patients received PPI, with 134 receiving PPI before TAVI and 163 receiving PPI after TAVI. The patients were categorized into two groups: no PPI group (n=978) and PPI group (n=297). Compared to patients without PPI, patients who received PPI were more likely to be male (60.9% vs. 49.1%, P<0.001), higher prevalence of atrial fibrillation (51.2% vs. 43.3%, P=0.016), coronary artery disease (61.6% vs. 53.8%, P=0.017), use aldosterone receptor antagonists (MRAs, 25.3% vs. 15.2%, P<0.001), and lower left ventricular ejection fraction (LVEF, 54.9±13.1% vs. 57.5±11.4%, P<0.001). There were no significant differences in all-cause mortality (16.6% vs. 18.5%), CV mortality (11.3% vs. 13.5%), as well as HF hospitalization rate (18.5% vs, 21.2%) between the two groups (P>0.05).

In this cohort, 1012 (79.4%) TAVI patients had a preserved LVEF (≥50%), 122 (9.6%) had a mildly reduced LVEF (41-49%), and 141 (11.1%) had reduced LVEF (≤40%). Their primary and secondary outcomes were similar among LVEF subgroups (all P>0.05). In the subgroup of reduced LVEF, the HF related hospitalization rate after TAVI was significantly higher in TAVI patients with PPI compared to those without PPI (30.6% vs. 13.0%, P=0.003). Multivariable Cox regression models demonstrated a 3-fold increased risk of HF related hospitalization in TAVI patients with PPI in comparison to those without PPI in the subgroup of LVEF≤40% (HR 3.057, 95% CI 1.311-7.130, P=0.010) after adjusting for age, sex, TAVI approach, atrial fibrillation, coronary artery disease, and the use of MRAs.

Conclusion

All-cause mortality and CV mortality are similar between TAVI patients with and without PPI. However, in the subset of TAVI patients with reduced LVEF (≤40%), PPI is associated with an increased risk of HF hospitalization. Efforts are thus needed to reduce the risk of HF hospitalization in these patients.
Right chambers deformation after tricuspid edge-to-edge percutaneous repair
Authors: Bassa R , Bourdin J P , Anguita Gamez M , Mahia P , Gomez De Diego J J , Marcos-Alberca P , Olmos C , Paredes Vazquez J , Vilacosta I , Fernandez-Ortiz A , Jimenez Quevedo P , Nombela-Franco L , Perez-Villacastin J , De Agustin A , Pozo Osinalde E
Published: October 2024

Background

The development of new analysis software has allowed to broaden myocardial deformation study to right chambers. There are already reference values for right ventricle (RV) and more recently for right atrium (RA). Tricuspid edge-to-edge repair (TEER) potentially causes changes in right chambers mechanics.

Purpose

Our aim is to evaluate the impact of TEER in the myocardial deformation of RV and RA.

Methods

Observational retrospective study including all the consecutive patients undergoing TEER in our tertiary centre. Additionally, a control group of healthy volunteers was included. Baseline and 3 months postprocedural echocardiograms were analyzed with a dedicated software to obtain RV, free wall (FW-) and 4 chambers (4C-) global longitudinal strain (GLS), and RA, reservoir (SrRA), conduit (ScdRA) and centrality (SctRA) strains , deformation values. Interobserver variability was evaluated in the control group with the intraclass correlation coefficient (ICC). Differences in baseline values between cases and control group were evaluated with Mann-Whitney U test. Evolutive changes in deformation parameters were studied using paired Wilcoxon W test.

Results

15 healthy controls and 29 patients undergoing TEER (79.3% female, 79 [75-82] years-old) were included. Baseline tricuspid regurgitation (TR) was severe in 21 (72.4%), whereas the others were massive or torrential, and the most frequent mechanism was functional (22, 75,9%). Interobserver agreement in the control group was excellent for FW-GLS (0.88; p <0.001), SrRA (0.99; p <0.001) y ScdRA (0.93; p <0.001), good for SctRA (0.68; p= 0.019) and insufficient for 4C-SGL (0.36; p= 0.20). RV deformation values were significantly worse in patients than in controls (Table). However, solely FW-GLS showed improvement 3 months after the procedure (-15.7 vs -20.5 %; p= 0.022).

Conclusions

Right chamber deformation analysis is feasible and significantly reduced in patients undergoing TEER. Nevertheless, percutaneous treatment of TR has scarce effect in mechanics at early phases. Longer follow up may be required to evaluate the impact in right strain parameters.

Table. Right chambers myocardial deformation values in healthy controls and patients undergoing TEER.Figure
Calculation of intraprocedural hemodynamics with computational functional dynamic in mitral valve edge-to-edge repair
Authors: Kirchner J , Gercek M , Rudolph F , Omran H , Kassar M , Friedrichs K , Rudolph V , Graeni C , Praz F , Rudolph T K
Published: October 2024

Background

Hemodynamic outcomes in patients undergoing transcatheter edge-to-edge-repair of the mitral valve (M-TEER) are difficult to predict. Computational functional dynamic (CFD) is frequently used in biomedical engineering to simulate blood flow patterns under various conditions. The authors developed a standardized workflow for individualized analyses and investigated the hemodynamic of mitral regurgitation volumes and gradients by using CFD.

Methods

20 patients from two high volume centers who suffered from severe mitral regurgitation (MR) and underwent full cycle cardiac computed tomography (CT) prior procedure were enrolled. Baseline computed tomography and intraprocedural data were analyzed. Based on the specific valve morphology, individualized CFD-simulations were performed to calculate MR volumes prior to intervention and estimate hemodynamics after M-TEER.

Results

CFD-analyses of 20 patients (mean age 80±4 years, 60% male) showed excellent correlation between baseline PISA method-based MR volumes (45±23ml) measured in transesophageal echocardiography (TEE) and CFD-based calculation (45±26ml; R=0.917; P<0.001) as well as between TEE-measured mean baseline effective regurgitant orifice area (EROA; 27±16mm²) and CFD-measured EROA (24±18mm²; R=0.869; P<0.001)). After device implantation, correlation between intraprocedural TEE-measured and CFD-estimated correlation for residual MR volumes (R=0.949; P<0.001) and EROA (R=0.841; P<0.001) remained robust. Post-interventional mean diastolic pressure gradient (TEE) was 3.6±2.8mmHg which was in close correlation with the CFD estimated gradient (3.0±1.8mmHg, R=0.905; P<0.001).

Conclusions

This is the first study to use a CFD-standardized workflow for predicting hemodynamic changes in patients undergoing M-TEER using data from two different centers. In the future, CFD-based analyses might serve as a key-diagnostic tool for predicting residual MR volumes and gradients for M-TEER-procedures.Comparison of TEE and CFD flow patternBland-Altman-Blots
Multimodal machine learning-based technical success prediction in patients undergoing transcatheter aortic valve implantation
Authors: Tomii D , Shiri I S , Nakase M N , Balzer S B , Samim D S , Plaz F P , Lanz J L , Stortecky S S , Reineke D R , Windecker S W , Grani C G , Pilgrim T P
Published: October 2024

Background

Procedural success is fundamental to achieving optimal clinical outcome, and prediction of procedural success and failure is of key importance in the selection of the appropriate treatment strategy in patients with severe aortic stenosis requiring aortic valve replacement.

Purpose

We aimed to develop a prediction model for procedural success in patients undergoing transcatheter aortic valve implantation (TAVI) using multimodal information and employing machine learning algorithms.

Method

In a prospective TAVI registry, patient baseline demographics, clinical history, medication, laboratory, procedural characteristics, electrocardiogram, angiography, transthoracic and transesophagel echocardiography, and computed tomography information were collected prospectively and extracted as numeric data. Data preprocessing included the imputation of missing values and the elimination of features with high collinearity. We incorporated several feature selection (FS) and classification algorithms for model development. Datasets for each target were randomly split into train/validation sets (70/10%) and hold-out test sets (20%). All machine learning processes, including preprocessing, feature selection, parameter, and hyperparameter optimization, were carried out on training and validation sets in 10-fold cross-validation. Different metrics, including area under the curve (AUC) in receiver operating characteristic curve analyses, sensitivity, and specificity, were calculated for model evaluation on the holdout test set. Procedural success was defined as technical success in the Valve Academic Research Consortium-3 (VARC-3). Technical failure differentiated between vascular and cardiac complications.

Results

In a total of 2,576 patients undergoing TAVI with a contemporary device between March 2012 and June 2023, 242 (9.4%) had technical failure: 70 (2.7%) had cardiac and 178 (6.9%) had vascular technical failure. The sensitivity and specificity for overall technical failure were 0.71 and 0.77, respectively, with AUC of 0.76 (95% CI: 0.69-0.84) achieved by the recursive feature elimination and AdaBoost algorithm. For cardiac technical failure, the ANOVA FS and Random Forest (RF) model yielded sensitivity and specificity of 0.71 and 0.77, with an AUC of 0.76 (95% CI: 0.65 to 0.87). Vascular technical failure showed AUC of 0.76 (95% CI: 0.69 to 0.84), with sensitivity and specificity of 0.72 and 0.73, respectively, with achieved using the ANOVA FS and RF model.

Conclusion

The initial results of the novel prediction model for technical success are promising. Further improvements and external validation are warranted to support the use of the proposed model in clinical practice.Central Illustration
Ventricular interaction and clinical outcomes in patients undergoing transcatheter tricuspid valve repair
Authors: Tanaka T , Sugiura A , Vogelhuber J , Oeztuerk C , Zimmer S , Nickenig G , Weber M
Published: October 2024

Background

Excessive volume overload of the right ventricle (RV) due to tricuspid regurgitation (TR) can cause a leftward shift of the interventricular septum and changes left ventricular (LV) geometry, which leads to decreases LV distensibility and results in cardiac output. This unfavorable ventricular interaction might have prognostic impacts of patients undergoing transcatheter tricuspid valve repair (TTVr).

Purpose

We investigated the association between the ventricular interaction and clinical outcomes in patients undergoing TTVr.

Methods

We retrospectively assessed 304 patients who underwent TTVr. The ventricular interaction was assessed using LV eccentricity index which was defined as LV antero-posterior dimension / LV septo-lateral dimension at end-diastole in the parasternal short-axis view (Figure 1). Increased ventricular interaction was defined as LV eccentricity index ≥1.2. The primary outcome was a composite of all-cause mortality and heart failure hospitalization within one year after TTVr.

Results

The mean LV eccentricity index at baseline was 1.23 ± 0.20, and 168 of 304 patients (55.3%) had increased ventricular interaction. Patients with increased ventricular interaction were more likely to have massive or torrential TR, reduced RV function, larger RV areas, and lower cardiac index. Increased ventricular interaction at baseline was associated with an increased risk of the composite outcome (HR 2.14; 95%CI 1.36–3.37; p=0.001; Figure 2A), which was consistent after adjusting for age, male sex, renal function, LV ejection fraction, RV function, and residual TR.

Echocardiography at baseline showed that 83 of 168 patients (49.4%) with increased ventricular interaction at baseline had an improvement in the ventricular interaction (i.e., LV eccentricity index ≥1.2 at baseline but <1.2 at discharge), which was associated with a lower risk of the composite outcome than persisted ventricular interaction (i.e., LV eccentricity index ≥1.2 at both baseline and discharge) (Figure 2B), irrespectively of baseline characteristics and residual TR. Smaller RV area and residual TR ≤2+ were related to the improved ventricular interaction.

Conclusion

Ventricular interaction, defined as LV eccentricity index ≥1.2, is associated with an increased risk of clinical outcomes after TTVr. However, the post-procedural improvement in ventricular interaction after TTVr may be linked to better prognosis.Figure 1Figure 2
Outcomes of percutaneous coronary interventions after transcatheter aortic valve replacement
Authors: Pivato C A , Tartaglia F , Cerrato E , Nombela L , Pilgrim T , Stefanini G
Published: October 2024

Background

The number of percutaneous coronary interventions (PCI) after transcatheter aortic valve replacement (TAVR) is expected to increase with the extension of this treatment toward younger and lower-risk patients. However, little is known about the prognosis of this evolving subset of patients.

Purpose

This study aims to assess the clinical outcomes of patients undergoing PCI after TAVR.

Methods

Patients undergoing PCI after TAVR were retrospectively included from 20 centers across 7 European Countries from July 2008 to November 2023. The patients and procedural characteristics at the time of PCI, post-discharge antithrombotic regimen, and clinical outcomes were collected by each center. The primary endpoint was major adverse cardiovascular events (MACE), a composite of cardiovascular death, myocardial infarction, or stroke.

Results

A total of 464 patients underwent PCI at a median interval of 106 days (interquartile range: 40-502) after TAVR (45.4% balloon-expandable, 49.6% self-expandable, and 5.0% mechanically-expandable valve). The cohort had a mean age of 80.9±6.2 years, a mean Euroscore II of 5.5±6.2, and 48% had undergone prior PCI or coronary artery bypass graft. Indications for PCI included chronic coronary syndrome (64.6%), non-ST elevation myocardial infarction (20.5%), unstable angina (7.9%), ST elevation myocardial infarction (5.7%), and other acute reasons (1.2%). PCI was complex in approximately 20% of the cases and radial access was utilized only in about 47.4% of them. Still, PCI success rate was 96.7%, achieving complete revascularization in 70.5% of cases. There were 19 periprocedural myocardial infarctions (4.3%). The predominant antithrombotic regimen was 12-month dual antiplatelet therapy (49.1% of patients). MACE incidence over one year of follow-up was 11.8% (95% CI: 9.0%-15.4%), with no differences among TAVR valve types (p-value=0.260). The incidences of the individual component of MACE were 8.7% for cardiovascular deaths, 5.3% for myocardial infarctions, and 2.3% for strokes.

Conclusion

At present, patients undergoing PCI after TAVR represents a high-risk subgroup. Nonetheless, elucidating actionable factors could potentially improve their outcomes. This preliminary analysis did not reveal any association with the type of implanted valve.
Evolution and prognostic relevance of right ventricular morphofunctional parameters in patients undergoing isolated tricuspid valve surgery
Authors: Luque M , Mane F , Azzam I K , Melo C , Mahia P , Marcos-Alberca P , Gomez De Diego J J , Olmos C , Vilacosta I , Gomez-Polo J C , Maroto L , Carnero M , Perez-Villacastin J , De Agustin A , Pozo Osinalde E
Published: October 2024

Background

Right ventricular (RV) function is key in evolution after isolated tricuspid valve surgery (ITVS). Right ventricular-pulmonary artery coupling (RV-PA coupling), determined with echocardiography as the ratio TAPSE/sPAP, has merged as a relevant functional parameter in many clinical scenarios.

Purpose

Our aim is to evaluate the prognostic relevance of RV-PA coupling in patients undergoing ITVS.

Methods

We carried out a retrospective study involving all the patients undergoing ITVS at our tertiary centre. Several RV function measurements were assessed from the baseline echocardiogram (TAPSE, fractional area change (FAC), systolic pulmonary artery pressure (sPAP), tricuspid annulus tissue Doppler velocity (RVS´) and free-wall global longitudinal strain (FW-GLS)) and RV-PA coupling was calculated. Association between RV morphofunctional variables and mortality during one year follow-up was determined.

Results

45 patients were included (68 years-old, 51,1% female). The most common TR etiology was functional (51.1%) and 42.2% had previous left-sided valvular surgery. The median Tri-Score was 2 (1-4) points and the most frequent procedure was biological valve replacement (65%). Baseline echocardiographic parameters were as follows: basal 52 (48 – 53.5) mm, mid 40 (36-45.5) mm and longitudinal 73 (68-80) RV diameters, TAPSE 18.1 (15.5-20.7) mm, RVS´ 10.1 (9-12.5) cm/s, FAC 0.5 (0.43-0.57), sPAP 35 (31.5-37.5) mmHg, and FW-GLS - 21.1 (17.2-25) %. During the follow-up 8 (18%) patients died. Solely TAPSE (16 vs 19, p= 0.047) and RV-PA coupling (0.35 vs 0.5; p= 0.035) showed significant differences in mortality among RV echocardiographic parameters. An RV-PA coupling <0.375 mm/mmHg appeared to be the best mortality predictor (RR 1.45; p= 0.04) one year after the intervention (Figure).

Conclusions

In our series RV-PA coupling has proved to be the best echocardiographic prognostic factor in ITVS, so it could be considered a relevant parameter in risk stratification previous to this surgery.

Figure. Kaplan Meier curves of mortality after ITVS by RV-PA coupling.Figure
Five-year outcomes with self-expanding versus balloon-expandable transcatheter aortic valve replacement in patients with left ventricular systolic dysfunction
Authors: Nakase M , Tomii D , Maznyczka A , Heg D , Okuno T , Samim D , Stortecky S , Lanz J , Reineke D , Windecker S , Pilgrim T
Published: October 2024

Background

The importance of transcatheter heart valve (THV) design on clinical outcome in patients with aortic stenosis (AS) and left ventricular (LV) systolic dysfunction remains unknown.

Objectives

We aimed to compare 5-year outcomes of patients with severe AS and reduced LV ejection fraction (LVEF), undergoing transcatheter aortic valve replacement (TAVR) with balloon-expandable vs. self-expanding THVs.

Methods

In an institutional TAVR registry, patients with LVEF <50% who underwent TAVR with either balloon-expandable or self-expanding THVs were included. A 1:1 propensity-score matching was performed to account for baseline differences between groups.

Results

A total of 759 patients were included between August 2007 and December 2022, and propensity-score matching resulted in 134 pairs. Technical success was achieved in over 85% of patients, and was similar in both groups. Self-expanding THVs were associated with a lower mean transvalvular gradient (7.1 ± 3.7 mmHg vs. 9.9 ± 4.3 mmHg; P <0.001) and a higher incidence of ³mild-to-moderate paravalvular regurgitation (36.3% vs. 11.3%; P <0.001) compared to balloon-expandable THVs. At 5 years, patients treated with a self-expanding THV had higher all-cause mortality than those with a balloon-expandable THV (67.8% vs. 55.8%, Adjusted Hazard Ratio: 1.44; 95% CI: 1.02-2.03; P = 0.037). There were no significant differences in other clinical outcomes up to 5 years between groups.

Conclusions

In the setting of LV systolic dysfunction, patients treated with a self-expanding THV had higher risk of 5-year mortality compared to patients treated with a balloon-expandable THV.
Socioeconomic disparity in utilization of transcatheter aortic valve replacement
Authors: Lee Y , Kook H , Kim B K , Kim W H , Shin J H , Lim Y H , Shin J
Published: October 2024

Introduction

Transcatheter aortic valve replacement (TAVR) is a major therapeutic option, rapidly replacing surgical aortic valve replacement (SAVR) in patients with aortic stenosis (AS) in recent years. However, the use of TAVR may vary with the socioeconomic status (SES) since new technologies are more likely to have the lower accessibility in some medico-social environments. In South Korean patients with AS, we investigated the difference in the use of TAVR based on SES and whether the difference influences clinical outcomes of patients with AS.

Methods

Between 2010 and 2020, 30,142 patients newly diagnosed with AS in a tertiary or regional center were investigated through the Korean National Health Insurance System (KNHIS). Patients were received either medical, SAVR or TAVR therapy for AS. The patients were categorized into 3 groups based on the insurance premium level (IPL) of the KNHIS (IPL1, <100 KW; IPL2, 100-249 KW; IPL3, ≥250KW).

AS-related death was defined as death by AS, heart failure or ventricular arrhythmia. Cardiovascular (CV) death was defined as AS-related death or death by myocardial infarction or stroke. The study period was divided at year 2015, when the partial coverage for TAVR was implemented by the KNHIS.

Results

The numbers of patients referred to the tertiary/regional centers have continuously grown for the 11 years but the referring rate has grown even faster since 2015. The proportions of TAVR has increased while that of SAVR has decreased since 2015. TAVR was more frequently chosen by patients with a higher IPL (5.5%, 8.0% and 12.5%, respectively in the IPL1, IPL2 and IPL3, p<0.001), whereas the medical therapy appeared not affected by the IP levels. The patients in the IPL2 (odd ratio [OR] 1.33 [1.20-1.47]) and IPL3 (OR 1.65 [1.45-1.86]) had a higher chance to undergo TAVR than those in the IPL1 whereas the patients in the IPL3 was a lower chance to undergo SAVR than those in the IPL1 (OR 0.86 [0.78-0.94]). In patients with severe AS, the disparities between the IPL1 and IPL3 exaggerated (OR 1.99 [1.70-2.33]) (Figure 1). Higher IPLs were associated with lower risks of CV death and AS-related death. Time-varying Cox proportional hazard models showed that TAVR was associated with a lower risk of CV death than both medical therapy and SAVR in the entire study period and in year 2015 or later, whereas TAVR was associated with a lower risk of AS-related death than the both only in year 2015 or later, after adjustment of relevant covariates including the IPL (Figure 2). The choice of TAVR significantly medicated the associations between IPLs and the risk of CV death (responsible for 3.0% in the IPL2 and 4.1% in the IPL3).

Conclusion

The SES based on the IPL is independently associated with the choice of TAVR in patients with AS and the association has become stronger since 2015. The disparity in use of TAVR could mediate more frequent CV deaths in patients with the lower IPL.Figure 1Figure 2
Contemporary implantation protocols enable markedly lower pacemaker rate for selfexpandable TAVR
Authors: Ahoopai M , Geyer M , Minke T , Rogmann M A , Ruf T F , Goessler T A M , Tamm A R , Hell M M , Masseli F , Oberhoffer M , Lurz P , Von Bardeleben R S
Published: October 2024

Background

Even in a low-risk cohort, the Evolut low-risk trial has reported a still rather high pacemaker implantation rate over 20%. In the recent years, contemporary implantation protocols have been introduced aiming on a higher implantation position.

Purpose

Data on a reduction of pacemaker rate in contemporary implantation practice is still limited.

Methods

We retrospectively analyzed baseline-characteristics and pacemaker-implantation rates after TAVR in patients being treated with a Medtronic Evolut Prosthesis for aortic valve stenosis in our center in the years 2018 (conventional implantation in 3-cusp view) vs. 2023 (contemporary implantation in cusp overlap technique).

Results

160 Patients were retrospectively included. We found out, that contemporary implantation lead to a marked reduction of pacemaker rate (8.7 vs. 20.9%, p=0.047; HR 0.36[IQR 0.14-0.96; p=0.041]). While most baseline-parameters including age (83.5 (79.2/87.3) vs. 82.8 (79.4/86.2), p=0.654), LVEF (55.0 (54.3/57.8) vs. 55.0 (51.0/59.0), p=0.992) and overall risk score (Euroscore II 3.5 (2.5/4.7) vs. 3.6 (2.3/5.7), p= 0.726) had no relevant impact on pacemaker rate, female patients were less prone to receive a pacemaker (8.6% vs. 21.3%, p=0.030). Of all conduction disturbances before procedure, a pre-existing RBBB was strongly associated with a relevantly higher pacemaker rate (50.0% vs. 11.3% (p<0.001), HR 7.88 (IQR 2.73/22.74; p<0.001)). Furthermore, more severe leaflet calcification (p=0.049), a deeper implantation depth (6.0 (5.0/6.5) vs. 5.0 (4.0/60.), p=0.042), larger annular dimensions (perimeter 79.7 (75.2/87.7) 76.8 (71.9/80.7), vs. p=0.047) and prostheses sizes (Evolut 34 vs. smaller sizes 28.1 vs. 12.5%, p=0.053), higher BNP (547 (314/1488) vs. 396 (208/856)), p=0.039 and body weight (78.0 (71.3/90.0) vs. 73.0 (63.5/84.5), p=0.030) were attributed to a higher pacemaker rate.

Conclusions

In our retrospective database we demonstrated that a contemporary implantation protocol enabling higher implantation position leads to a significant reduction in pacemaker rate, even in the high-risk collective of patients with pre-existing RBBB (58.3 vs. 15.2%, p=0.002 compared to 33.3 vs. 6.3%, p=0.081).
A propensity score matched analysis of transcatheter aortic valve replacement in failed bioprosthetic valves
Authors: Loew K , Steffen J , Knufinke N , Froehlich C , Fischer J , Haum M , Theiss H , Stark K , Hausleiter J , Massberg S , Deseive S
Published: October 2024

Introduction

While recently published data indicate similar long-term results of transcatheter aortic valve replacement (TAVR) compared to surgical procedures, surgical aortic valve replacement (SAVR) remains the standard of care in low-risk patients. However, since life expectancy increases, a non-negligible number of patients experience bioprosthetic valve dysfunction with the need for reintervention, but long-term data of TAVR in failed bioprosthetic valves is scarce.

Purpose

The aim of the study was to analyse long-term data of patients with TAVR in failed bioprosthetic valves compared to patients with native valve TAVR. The primary endpoint was 6-year all-cause mortality and the main secondary endpoint was echocardiographic valve function.

Methods

Patients undergoing TAVR for severe aortic valve disease between December 2012 and December 2020 were retrospectively analysed. Prior TAVR or aortic valve homografts led to exclusion from the study. A 2:1 propensity score matching by the optimal neighbor matching algorithm was performed to overcome differences in baseline characteristics.

Results

Between December 2012 and December 2020, 3,423 patients received TAVR for severe aortic valve disease and met inclusion criteria for the study. Of those, 3,287 patients underwent native valve TAVR, whereas 136 patients experienced bioprosthetic valve dysfunction and were treated with TAVR-in-SAV. After 2:1 propensity score matching, baseline characteristics without any relation to prior SAVR were similar between both groups. Concerning postprocedural echocardiographic function, a less pronounced gradient reduction (57.0 vs. 71.0 %, p < 0.01, Figure 1) and a higher number of patients with elevated mean pressure gradient > 20 mmHg could be found after prior SAVR (19.4 vs. 3.0 %, p < 0.01). However, there was no difference regarding 6-year all-cause mortality between both groups (log rank test p = 0.8, Figure 2).

Conclusions

Besides a less pronounced gradient reduction and higher mean aortic pressure gradients after TAVR-in-SAV compared to patients with native valve TAVR, no differences in 6-year all-cause mortality could be observed in a propensity score matched analysis.Reduction of mean pressure gradient6-year all-cause mortality
Cardiac damage predicts the outcome of calcific aortic valve disease regardless of the severity of aortic stenosis
Authors: Moore M K , Jones G T , Whalley G , Prendergast B D , Williams M J A , Coffey S
Published: October 2024

Title: Cardiac damage predicts the outcome of patients with calcific aortic valve disease in both mild and moderate aortic stenosis

Background

Although the burden of calcific aortic valve disease (CAVD) is increasing, there is no current universal consensus for prognostic prediction. A staging system based on cardiac damage has been proposed to better stratify risk and evaluate the benefit of aortic valve intervention (AVI).

Purpose

We sought to evaluate this staging system’s prognostic value in mild and moderate aortic stenosis (AS).

Methods

Data from clinically indicated echocardiograms performed between 2010 and 2018 in patients aged over 18 years were extracted and linked to national outcome data. A time to first event analysis was performed with a primary outcome of mortality or heart failure hospitalization. Stages were categorized as described in previous literature: no extravalvular damage (stage 0); left ventricular damage (stage 1); left atrial damage (stage 2); elevated right ventricular pressures (stage 3); or right ventricular damage (stage 4).

Results

Amongst 24,699 patients in the study cohort, 513 had moderate AS and 920 had mild AS. Associated cardiac damage in those with moderate AS was graded as follows: Stage 0 - 9.4%; Stage 1 - 53.7%; Stage 2 - 31.1%; Stage 3 - 3.2%; Stage 4 - 2.6%. Increasing severity of CAVD correlated closely with increased risk of the primary outcome in both moderate (HR 1.62 per stage; 95% CI 1.36 – 1.92) and mild AS (HR 1.93 per stage; 95% CI 1.69 – 2.21), whilst increasing stage of cardiac damage was associated with mortality when censoring at the time of AVI in both moderate (HR 1.97 per stage; 95% CI 1.66 – 2.34) and mild AS (HR 2.06 per stage; 95% CI 1.81 – 2.35).

Conclusion

Cardiac dysfunction predicts prognosis to a similar extent in both mild and moderate AS. These data suggest that adverse outcomes may not be fully attributable to the haemodynamic consequences of valve disease, and therefore may not be reversed by valve intervention. Strategies to treat cardiac dysfunction in parallel with management of the anatomical valve pathology may be required.Mortality in mild AS by CAVD stageMortality in moderate AS by CAVD stage
Prognostic implications and alterations in left atrial deformation following transcatheter aortic valve implantation for severe aortic stenosis
Authors: Butcher S C , Hirasawa K , Meucci M C , Stassen J , Kuneman J H , Pereira A R , Van Der Kley F , De Weger A , Van Rosendael P J , Ajmone Marsan N , Playford D , Delgado V , Bax J J
Published: October 2024

Background

Left atrial reservoir strain (LARS) as a single parameter estimate of left ventricular (LV) diastolic dysfunction (DD), may provide important prognostic insights into patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI).

Purpose

To evaluate the prognostic implications of pre- and post TAVI LARS-defined DD (LARS-DD) grade in patients undergoing TAVI for severe AS and its association with new-onset atrial fibrillation.

Methods

Pre-TAVI LARS-DD was evaluated by speckle-tracking echocardiography and was assigned as grade 0 to 1 (LARS ≥24%), grade 2 (LARS ≥19 to <24%) and grade 3 (LARS <19%). Patients were followed-up for the primary endpoint of all-cause mortality from the date of TAVI. For the secondary endpoint, patients with pre- and post-TAVI LARS measurements, no history of atrial fibrillation and with clinical/ECG follow-up following the post-TAVI follow-up echocardiogram were evaluated for the occurrence of new-onset atrial fibrillation.

Results

A total of 601 patients (median age 81 [76-85] years, 53% male) undergoing TAVI for severe AS were included. Overall, 169 patients (28%) were LARS-DD grade 0/1, 96 patients (16%) were LARS-DD grade 2 and 336 (56%) were LARS-DD grade 3. Over a median follow-up of 40 (IQR 26 to 58) months, a total of 258 (43%) patients died (Figure 1). In a comprehensive multivariable Cox regression model adjusted for age, sex, EuroSCORE II, New York Heart Association class III to IV symptoms, LV ejection fraction, atrial fibrillation, LA volume index and LV stroke volume index, LARS-DD grade was independently associated with all-cause mortality (adjusted HR 1.28 per one grade increase above LARS-DD grade 0/1, 95% CI 1.07 to 1.53, P=0.007). For the secondary endpoint of new-onset atrial fibrillation, a total of 285 patients were evaluated (Figure 2). On multivariable Fine and Gray regression analyses adjusting for age and LA volume index, post-TAVI LARS (SDHR 1.14 per 1% <20%, 95% CI 1.05 to 1.23, P=0.0009), rather than pre-TAVI LARS (SDHR 1.00 per 1% <20%, 95% CI 0.91 to 1.11, P=0.93) was associated with the occurrence of new-onset atrial fibrillation.

Conclusions

Increasing LARS-DD grade was independently associated with long-term post-TAVI survival in patients with severe AS and may enhance risk stratification. In addition, post-TAVI LARS, but not pre-TAVI LARS, was closely related to the occurrence of new-onset atrial fibrillation, likely better reflecting intrinsic LA dysfunction.Figure 1:All-Cause MortalityFigure 2:New-Onset Atrial Fibrillation
Independent association between radial secondary access and stroke in patients undergoing transcatheter aortic valve implantation
Authors: Potratz M , Plaka D , Kirchner J , Scholtz W , Rudolph V , Bleiziffer S , Schramm R , Rudolph T , Scholtz S
Published: October 2024

Background

Radial access has become the primary approach for invasive coronary angiography due to its lower complication rate than femoral access. Transcatheter aortic valve implantation (TAVI) frequently requires a secondary access, which has traditionally been femoral access. However, radial access for TAVI is feasible and gaining popularity, but data on its safety and complication rates is still limited.

Purpose

To evaluate the occurrence of stroke rate in patients undergoing a TAVI procedure with femoral or radial secondary access.

Methods

A prospective single-center TAVI registry of 2327 patients who received a TAVI procedure between 2019 and 2022 was conducted. All procedures had the primary access over the femoral route. 337 (14.5%) patients had a secondary access over the radial route, whereas 1990 (85.5%) received a femoral secondary access. The primary endpoint was the occurrence of stroke within the hospital stay. Both groups were compared using the t-test or the Mann-Whitney U test according to the distribution of the data. In a second step, a multivariable model was created in which parameters were included that were associated with the endpoint in the previous analysis, as well as parameters that are known to be associated with stroke.

Results: Patients were 81.1 ± 6.3 years old, with a Euroscore II of 5.3 ± 6. A total of 610 (26.2%) patients received a balloon-expandable valve. The primary endpoint (stroke within 30 days of the TAVI procedure) was met by 94 (4%) of all patients. Stroke occurred more often in the group with radial secondary access (6.6% (22) vs. 3.6%(72), p = 0.012). Other significant differences between the two groups included (radial vs. femoral access): burden of atrial fibrillation (36.8% vs. 44.6%, p = 0.007), arterial hypertension (87.4% vs. 92%, p = 0.007), Euroscore II (4.6 vs. 5.5, p = 0.006), and frailty (25.2% vs. 40%, p < 0.001). There were no significant differences between the two groups in terms of secondary diagnosis of diabetes or coronary artery disease, age, occurrence of NYHA class III/IV, gender, or cerebral artery disease.

In the multivariate analysis including Age, Euroscore II, NYHA class, gender, secondary diagnosis of arterial Hypertension, diabetes or cerebral artery disease, arterial fibrillation, Frailty and radial secondary access, only radial secondary access was independently associated with in-hospital stroke (p = 0.01).

Conclusion

Radial secondary access was significantly associated with an increased risk of in-hospital stroke following transcatheter aortic valve implantation (TAVI) in our study population. Intense manipulation of the guidewire and catheter to reach the ascending aorta at the beginning of the procedure and to reach the descending aorta for the final angiogram of the primary access vessel may be causative and should be minimized.
Exploring physiological determinants of ventilatory inefficiency in hypertrophic cardiomyopathy patients
Authors: Attanasio A , Guida G , Disabato G , Paglione G , Castelvecchio S , Tondi L , Camporeale A , Bandera F , Iannotta M , Guazzi M , Lombardi M , Spagnolo P , Piepoli M F
Published: October 2024

Background

The role of cardiopulmonary exercise test (CPET) in hypertrophic cardiomyopathy (HCM) has been previously examined, revealing two prognostic parameters: peak Vo2 and the VE/VCO2 slope. Specifically, individuals with a VE/VCO2 value above 31 (ventilator inefficiency) demonstrate a poorer prognosis.

Purpose

This study aims to analyze the physiological factors contributing to ventilatory inefficiency in individuals with HCM.

Methods

In this retrospective study, 43 patients HCM patients underwent resting transthoracic echocardiography, CPET combined with echocardiography during physical exertion, and cardiac magnetic resonance imaging. Ventilatory inefficiency was defined as a VE/VCO2 slope exceeding 31, leading to the identification of two groups: Group A (those with ventilatory inefficiency) and Group B (those without ventilatory inefficiency).

Results

Nine patients exhibited ventilatory inefficiency, while 34 had a normal VE/VCO2 slope. No statistically significant differences were found between the two groups concerning clinical and therapeutic characteristics. Subjects with ventilatory inefficiency showed reduced oxygen pulse (8.3 ± 2.6 vs 11.7 ± 4, p 0.013) and peak VO2 values (13 ± 5 vs 19 ± 5, p 0.005), lower left ventricle global longitudinal strain (-15±3 vs -17± 2, p 0,012), the exertional TAPSE/SPAP ratio (0.46 [0.32-0.48] vs 0.58 [0.47-0.80], p 0.001), exertional TAPSE (23 ± 3 vs 28 ± 4, p 0.001), and indexed stroke volume of the left ventricle assessed by cardiac magnetic resonance imaging (38±8 vs 48±10, p 0.011) (Table 1). The right ventricular function under physical exertion (peak TAPSE and TAPSE/sPAP) and left ventricular functional parameters (index stroke volume and global longitudinal strain) predicted the presence of ventilatory inefficiency.

Conclusions

This study highlights the role of exertional parameters in the origin of ventilatory inefficiency.Correlation tableFigure with scatter plot