Incidence, predictors, and midterm clinical outcomes of left ventricular obstruction after transcatheter aortic valve implantation

Acute Hemodynamic Compromise After Transcatheter Aortic Valve Replacement Due to Dynamic Left Ventricle Obstruction: A Systematic Review

Acute hemodynamic compromise after transcatheter aortic valve replacement (TAVR) because of dynamic left ventricle (LV) obstruction (LVO), also known as suicide LV, is an infrequent but severe complication of TAVR that is poorly defined in previous studies. Understanding this complication is essential for its prompt diagnosis and optimal treatment. We conducted a systematic literature review using PubMed, Embase, Web of Science, and Medline databases for studies describing acute hemodynamic compromise after TAVR because of dynamic LVO or suicide LV. Each study was reviewed by 2 authors individually for eligibility, and a third author resolved disagreements. From a total of 506 studies, 25 publications were considered for the final analysis. The majority of patients with this condition were women demonstrating a hypertrophic septum, a small ventricle, and hyperdynamic contractility on pre-TAVR echocardiographic assessment. An intraventricular gradient before TAVR was found in half of the cases. Acute hemodynamic compromise after TAVR because of dynamic LVO manifested mainly as significant hypotension and occurred most often immediately after valve deployment. The LV outflow tract was the most common site of obstruction. Advanced therapies were required in nearly 65% of the cases. In conclusion, acute hemodynamic compromise after TAVR because of dynamic LVO occurred almost invariably in women. Echocardiography before TAVR may offer essential information to anticipate this complication. LV outflow tract obstruction appears to carry the highest risk of developing this phenomenon. Advanced therapies should be promptly considered as a bailout strategy in patients with hemodynamic collapse refractory to medical therapy.

Impact of VA-ECMO on Dynamic LV Outflow Obstruction After Transcatheter Aortic Valve Replacement

Dynamic left ventricular outflow obstruction is a rare but severe complication of transcatheter aortic valve replacement. It presents as a paradoxical hemodynamic collapse after relieving the left ventricular afterload. Considering its unique pathophysiology, this entity dictates counterintuitive treatments. We describe a case of left ventricular outflow obstruction treated with venoarterial extracorporeal membrane oxygenation and discuss its management principles.

Multimodality imaging for patient selection, procedural guidance, and follow-up of transcatheter interventions for structural heart disease: a consensus document of the EACVI Task Force on Interventional Cardiovascular Imaging: part 1: access routes, transcatheter aortic valve implantation, and transcatheter mitral valve interventions

Transcatheter therapies for the treatment of structural heart diseases (SHD) have expanded dramatically over the last years, thanks to the developments and improvements of devices and imaging techniques, along with the increasing expertise of operators. Imaging, in particular echocardiography, is pivotal during patient selection, procedural monitoring, and follow-up. The imaging assessment of patients undergoing transcatheter interventions places demands on imagers that differ from those of the routine evaluation of patients with SHD, and there is a need for specific expertise for those working in the cath lab. In the context of the current rapid developments and growing use of SHD therapies, this document intends to update the previous consensus document and address new advancements in interventional imaging for access routes and treatment of patients with aortic stenosis and regurgitation, and mitral stenosis and regurgitation.

Preoperative planning for transaortic septal myectomy using cardiac computed tomography in patients with subaortic septal hypertrophy associated with aortic stenosis: case series

Background

Electrocardiogram-gated cardiac computed tomography (CT) imaging enables a more accurate understanding of the patient's cardiac anatomy. Preoperative planning for transaortic septal myectomy (TASM), based on cardiac CT, may be useful in patients with subaortic septal hypertrophy associated with severe aortic stenosis (AS).

Case summary

Two elderly patients (age >80 years) with subaortic septal hypertrophy associated with AS underwent surgical aortic valve replacement (SAVR) and concomitant TASM after preoperative planning based on cardiac CT. Both patients showed subaortic septal hypertrophy with blood flow acceleration, left ventricular (LV) hypercontractility, and a short distance from the coaptation point of the mitral valve to the septum, resulting in possible dynamic LV outflow tract (LVOT) obstruction after resolution of AS. Optimal mid-diastolic images, selected from the 70-80% phase, were used for preoperative TASM planning. Planned sizes for myectomy based on multi-planar reconstruction were 10 × 26 × 9 mm (width × length × depth) and 10 × 25 × 9 mm for patient 1 and 2, respectively, while resected tissue size was 10 × 24 × 8 mm and 9 × 24 × 8 mm in patient 1 and 2, respectively. After TASM procedure, SAVR was performed with bioprosthetic valve. Postoperative course of both patients was uneventful with no evidence of complete atrioventricular block, septal perforation, or blood flow acceleration at the LVOT.

Discussion

Preoperative planning based on cardiac CT images is safe and useful for guiding adequate myectomy and preventing associated complications in patients with subaortic septal hypertrophy associated with AS.

Noninvasive Hemodynamic Evaluation Following TAVI for Severe Aortic Stenosis

Background Various hemodynamic changes occur following transcatheter aortic valve implantation (TAVI) that may impact therapeutic decisions. NICaS is a noninvasive bioimpedance monitoring system aimed at hemodynamic assessment. We used the NICaS system in patients with severe aortic stenosis (AS) to evaluate short-term hemodynamic changes after TAVI. Methods and Results We performed hemodynamic analysis using NICaS on 97 patients with severe AS who underwent TAVI using either self-expandable (68%) or balloon-expandable (32%) valves. Patients were more often women (54%) and had multiple comorbidities including hypertension (83%), coronary artery disease (46%), and diabetes (37%). NICaS was performed at several time points-before TAVI, soon after TAVI, at hospital discharge, and during follow-up. Compared with baseline NICaS measurements, we observed a significant increase in systolic blood pressure and total peripheral resistance (systolic blood pressure 132±21 mm Hg at baseline versus 147±23 mm Hg after TAVI, P<0.001; total peripheral resistance 1751±512 versus 2084±762 dynes*s/cm⁵, respectively, P<0.001) concurrent with a decrease in cardiac output and stroke volume (cardiac output 4.2±1.5 versus 3.9±1.3 L/min, P=0.037; stroke volume 61.4±14.8 versus 56.2±15.9 mL, P=0.001) in the immediate post-TAVI period. At follow-up (median 59 days [interquartile range, 40.5-91]) these measurements returned to values that were not different from the baseline. A significant improvement in echocardiography-based left ventricular ejection fraction was observed from baseline to follow-up (55.6%±11.6% to 59.4%±9.4%, P<0.001). Conclusions Unique short-term adaptive hemodynamic changes were observed using NICaS in patients with AS soon after TAVI. Noninvasive hemodynamic evaluation immediately following TAVI may contribute to the understanding of complex hemodynamic changes and merits favorable consideration.

How to Image and Manage Prosthesis-Related Complications After Transcatheter Aortic Valve Replacement

PURPOSE OF REVIEW

In this review, we provide an overview of potential prosthesis - related complications after transcatheter aortic valve replacement, their incidences, the imaging modalities best suited for detection, and possible strategies to manage these complications.

RECENT FINDINGS

Therapy for severe aortic valve stenosis requiring intervention has increasingly evolved toward transcatheter aortic valve replacement over the past decade, and the number of procedures performed has increased steadily in recent years. As more and more centers favor a minimalistic approach and largely dispense with general anesthesia and intra-procedural imaging by transesophageal echocardiography, post-procedural imaging is becoming increasingly important to promptly detect dysfunction of the transcatheter valve and potential complications. Complications after transcatheter aortic valve replacement must be detected immediately in order to initiate adequate therapeutic measures, which require a profound knowledge of possible complications that may occur after transcatheter aortic valve replacement, the imaging modalities best suited for detection, and available treatment options.

Haemodynamic collapse immediately after transcatheter aortic valve implantation due to dynamic intraventricular gradient: a case report and review of the literature

Background

Dynamic intraventricular obstruction after transcatheter aortic valve implantation (TAVI) has been previously reported. There is a risk of haemodynamic collapse in the case of left ventricular outflow tract (LVOT) obstruction due to systolic anterior motion (SAM) of the mitral valve.

Case summary

An 83-year-old woman with aortic stenosis (AS) was referred to our hospital for TAVI. Transthoracic echocardiography revealed a severely calcified aortic valve with a peak velocity of 6.3 m/s across the valve. Acceleration of blood flow (peak velocity 2.6 m/s) at the LVOT due to a septal bulge was also seen. Transfemoral TAVI was performed, and a 29 mm Evolut PRO was implanted under general anaesthesia. After the implantation, a complete atrioventricular block with junctional rhythm developed, and refractory hypotension occurred immediately. Transoesophageal echocardiography revealed LVOT obstruction due to SAM of the mitral valve associated with severe mitral regurgitation (MR), which was not observed preoperatively. Fluid infusion and catecholamine administration were not effective. However, after performing temporary pacing from the right ventricular (RV) apex, the LVOT obstruction and severe MR improved. Her haemodynamics stabilized, and we could complete the procedure. A dual-chamber permanent pacemaker with beta-blocker administration as a longer-term treatment further improved the LVOT obstruction. The patient was finally discharged to a rehabilitation hospital.

Discussion

Alertness and recognition of potential LVOT obstruction after TAVI are important. Pacing from the RV apex, as well as dual-chamber pacing, comprise a less invasive and feasible therapeutic option in such cases.

Outcomes of Patients with Severe Aortic Stenosis and Left Ventricular Obstruction Undergoing Transcatheter Aortic Valve Implantation

Scarce data exist on clinical features and prognosis of patients with severe aortic stenosis (AS), concomitant with left ventricular obstruction (LVO). We aimed to evaluate the prevalence, characteristics, and outcomes in patients with severe AS and LVO undergoing transcatheter aortic valve implantation (TAVI). Consecutive patients with severe AS undergoing TAVI between January 2013 to December 2017 at our institution were included. Significant LVO was defined as resting peak left ventricular (LV) systolic gradient ≥30 mm Hg on pre-TAVI echocardiography. We analyzed the primary composite outcome of all-cause mortality and rehospitalization for heart failure (HHF) at 1-year in patients with LVO and those without LVO in the overall and propensity-matched populations. Among 1,729 patients who underwent TAVI, significant LVO was observed in 31 (1.8%) patients. This group was more likely to be female, had smaller aortic annulus and LV cavity, and received a smaller size of the transcatheter heart valve. The most common phenotype of LV hypertrophy causing LVO was concentric LV hypertrophy (58%), and mid-LV obstruction was more common than LV outflow tract obstruction (77% vs 23%, respectively). After adjustment for baseline differences, the primary outcome was not significantly different between patients with LVO and those without LVO (15% vs 16%, respectively; hazard ratio: 0.83; 95% confidence interval: 0.19 to 3.72; p = 0.809). In conclusion, in patients undergoing TAVI, concomitant LVO was relatively uncommon and occurred more often at mid-LV. The presence of pre-TAVI LVO was not associated with worse outcomes defined as increase all-cause mortality or HHF at 1-year.

The Mitral Coaptation to Ventricular Septal Space: Two- and Three-Dimensional Transesophageal Echocardiographic Assessment

OBJECTIVES

To assess the dimensions and changes in the CSEPT (space between the ventricular septum and mitral coaptation point) before and after cardiopulmonary bypass (CPB) and to compare patients with and without aortic valve stenosis (AS) undergoing cardiac surgery.

DESIGN

Retrospective review of intraoperative transesophageal echocardiographic examinations.

SETTING

Single academic medical center.

PARTICIPANTS

The study comprised 91 elective cardiac surgical patients-30 with AS scheduled for aortic valve replacement and 61 without AS (non-AS).

INTERVENTIONS

Two- and 3-dimensional (2D and 3D) analysis of the CSEPT before and after CPB.

MEASUREMENTS AND MAIN RESULTS

Assessment of the CSEPT distances and areas was performed using 2D and 3D imaging before and after CPB. Two-dimensional measures of CSEPT distances were performed using midesophageal 5-chamber and long-axis windows. Three-dimensional measures were performed offline using multiplanar reconstruction. The CSEPT space was smaller after CPB (p < 0.01). Before and after CPB, the midesophageal 5-chamber and long-axis windows were similar to each other, and both were larger than the pre-CPB 3D CSEPT distance. Patients with AS had smaller before and after CPB distances and areas compared with non-AS patients (p < 0.05). The change in CSEPT area in AS patients was 24%.

CONCLUSIONS

The CSEPT space is smaller after CPB and more so for patients with AS undergoing aortic valve replacement. Two-dimensional CEPT distances vary compared with 3D CSEPT distances. Additional study using Doppler analysis will elucidate the added value of 3D assessment of the CSEPT space.

Significance of echocardiographic evaluation for transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) is widely accepted as an alternative to surgical aortic valve replacement (SAVR) for the treatment of severe aortic stenosis (AS). Existing scientific evidence demonstrates that TAVI is superior to SAVR, and it is expected that indications for the clinical applications of TAVI will be expanded in the future. Echocardiography plays a key role in perioperative assessment of patients undergoing TAVI. Preprocedural echocardiographic evaluation is important to determine the severity of AS in addition to patients' anatomical suitability for TAVI. Furthermore, echocardiography is essential for intraoperative guidance, assessment of complications, postoperative evaluation, and prognostic prediction. Inaccurate echocardiographic measurements and evaluation can lead to less-than-optimal/inappropriate treatment strategies in patients with AS. Therefore, a thorough understanding of the limitations of echocardiographic evaluation is important. This review summarizes the role of echocardiographic evaluation in patients undergoing TAVI.