Transcatheter aortic valve implantation in patients with a reduced left ventricular ejection fraction: a single-centre experience in 2000 patients (TAVIK Registry)

A Clinical Audit on the Indications for Intervention With Transcatheter Aortic Valve Implantation Over Surgical Aortic Valve Replacement in Aortic Stenosis Patients in Mohammed Bin Khalifa Bin Salman Al Khalifa Specialist Cardiac Centre

Introduction Transcatheter aortic valve implantation (TAVI) is a novel treatment strategy used to treat patients with symptomatic aortic stenosis. It utilizes a percutaneous approach and is preferred over surgical aortic valve replacement (SAVR) in patients at high surgical risk. The aim of this study was to audit the indications of the intervention with TAVI over SAVR in Bahrain Defence Force Hospital, Mohammed Bin Khalifa Bin Sulman AlKhalifa Cardiac Centre (BDF-MKCC), as well as note the outcomes of patients who underwent TAVI. Methods The indications for allocating aortic stenosis patients to TAVI over SAVR in BDF-MKCC were studied with regard to the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery (ESC/EACTS) guidelines published in 2017. Data from 82 patients, which accounts for all patients who underwent TAVI, were collected retrospectively from electronic medical records and the percentage of compliance was calculated and analyzed. Results The compliance percentages of the 23 parameters for the intervention with TAVI that have been set by the ESC/EACTS are calculated, where BDF-MKCC were fully adherent to 12 out of the 23 standards. Moreover, the total number of patients that are compliant with all standards is 13 out of 82 (15.85%) compliant patients. Conclusion The centre showed non-compliance to many of the published standards. Hence, we created a checklist to ensure that the international guidelines are followed. We are looking forward to re-audit this aspect in the near future, to make certain that changes were done. We would also like to do a comparative study to compare the patients' outcomes before and after implementing the 2017 ESC/EACTS guidelines. Furthermore, we call for further studies to be conducted in this field and that is to evaluate the standards themselves as well as the safety of TAVI in those who are not eligible for it according to the ESC/EACTS.

The role of TAVR in patients with heart failure: do we have the responses to all questions?

Severe aortic stenosis (AS) is the most prevalent valvular heart disease in developed countries. Heart failure (HF) is a frequent comorbidity of this condition and represents a diagnostic and therapeutic challenge. The spectrum of both conditions has become progressively wider in the last decade; HF has been divided in three groups according to left ventricular ejection fraction (LVEF) and severe AS has been reclassified into four groups according to aortic valve (AV) gradient, AV flow measured by LV stroke index, and LVEF. Although all four AS types may be found in patients with signs and symptoms of HF, low-flow AS with low or normal gradient is the most common type in these patients. Several studies have documented that patients with low-flow severe AS have a higher mortality risk than patients with normal-flow and high-gradient AS not only during the natural progression of the disease, but also after either interventional or surgical AV replacement. Existing data support transcatheter AV replacement (TAVR) in patients with severe AS, irrespective of AV gradient, AV flow, and LVEF. Controversial issues, however, are still present on this topic, which has not been adequately addressed by large studies and trials. This clinical review summarizes the epidemiology of the different HF types in patients with severe AS, as well as the impact of HF and LVEF on clinical outcomes of AS patients either untreated or after AV replacement. In particular, we addressed the influence of AV gradient and AV flow on all-cause and cardiovascular mortality in AS patients after TAVR.

Management of patients with severe aortic stenosis in the TAVI-era: how recent recommendations are translated into clinical practice

Objective

Approximately 3.4% of adults aged >75 years suffer from aortic stenosis (AS). Guideline indications for aortic valve replacement (AVR) distinguish between patients with symptomatic and asymptomatic severe AS. The present analysis aims to assess contemporary practice in the treatment of severe AS across Europe and identify characteristics associated with treatment decisions, namely denial of AVR in symptomatic patients and assignment of asymptomatic patients to AVR.

Methods

Participants of the prospective, multinational IMPULSE database of patients with severe AS were grouped according to AS symptoms, and stratified into subgroups based on assignment to/denial of AVR.

Results

Of 1608 symptomatic patients, 23.8% did not undergo AVR and underwent medical treatment. Denial was independently associated with multiple factors, including severe frailty (p=0.024); mitral (p=0.002) or tricuspid (p=0.004) regurgitation grade III/IV, and the presence of renal impairment (p=0.017). Of 392 asymptomatic patients, 86.5% had no prespecified indication for AVR. Regardless, 36.3% were assigned to valve replacement. Those with an indexed aortic valve area (AVA; p=0.045) or left ventricular ejection fraction (LVEF; p<0.001) below the study median; or with a left ventricular end systolic diameter above the study median (p=0.007) were more likely to be assigned to AVR.

Conclusions

There may be considerable discrepancies between guideline-based recommendations and clinical practice decision-making in the treatment of AS. It appears that guidelines may not fully capture the complete clinical spectrum of patients with AS. Thus, there is a need to find ways to increase their acceptance and the rate of adoption.

Impact of Bioprosthetic Choice on Mortality After Transfemoral Transcatheter Aortic Valve Implantation in Patients With Reduced Versus Preserved Left-Ventricular Ejection Fraction

The outcome of transfemoral transcatheter aortic valve implantation (TF-TAVI) with a self-expanding (SEP) versus a balloon-expandable prosthesis (BEP) in patients with a reduced ejection fraction (rEF, ≤40%) has not been previously investigated. Patients with rEF have an increased risk of death after TF-TAVI compared to patients with a preserved ejection fraction (pEF), and prosthesis choice might influence the outcome of these patients. We, therefore, sought to compare all-cause mortality of patients with rEF using a SEP versus a BEP. We retrospectively analyzed data of 679 single-center TF-TAVI patients. Patients were censored at death or completion of 1-year follow-up, whichever occurred first. Patients with rEF (n = 141, 21%) had an increased 1-year mortality compared to patients with pEF (28% vs 19%, p = 0.007). SEP were implanted in 149 patients (49 with rEF, 33%), while BEP were implanted in 530 patients (92 with rEF, 17%). In patients with pEF, 1-year mortality was similar after SEP- and BEP-implantation (16% vs 19%, p = 0.516). In patients with rEF, however, 1-year mortality was higher after SEP- than after BEP-implantation (43% vs 21%, p = 0.004). These patients had a higher incidence of new permanent pacemaker implantation (26.5% vs 13%, p = 0.046) and paravalvular leak ≥II° (21% vs 10%, p = 0.07), but both factors could not explain the excess mortality after SEP-implantation in the multivariate analysis. In patients with rEF, the use of a SEP was an independent predictor of 1-year mortality (HR 2.44, 95% CI 1.27 to 4.27, p = 0.007). In conclusion, patients with rEF had a higher 1-year mortality after TF-TAVI when a SEP instead of a BEP was used.

Left atrial appendage closure in patients with a reduced left ventricular ejection fraction: results from the multicenter German LAARGE registry

Background

Interventional left atrial appendage closure (LAAC) effectively prevents thromboembolic events in atrial fibrillation patients. Impaired left ventricular ejection fraction (LVEF) increases not only the thromboembolic risk but also the complication rates of cardiac interventions. The LAAC procedure’s benefit in patients with an impaired LVEF, therefore, has yet to be investigated.

Methods

LAARGE is a prospective, non-randomized registry depicting the clinical reality of LAAC in Germany. Procedure was conducted with different standard commercial devices, and follow-up period was one year. In the sense of an as-treated analysis, patients with started procedure and documented LVEF were selected from the whole database.

Results

619 patients from 37 centers were categorized into one of three groups: LVEF > 55% (56%), 36–55% (36%), and ≤ 35% (8%). Prevalence of cardiovascular comorbidity increased with LVEF reduction (p < 0.001 for trend). CHA₂DS₂-VASc score was 4.3, 4.8, and 5.1 (p < 0.001), and HAS-BLED score was 3.7, 4.1, and 4.2 (p < 0.001). Implantation success was consistently high (97.9%), rates of intra-hospital MACCE (0.5%), and other major complications (4.2%) were low (each p = NS). Kaplan–Meier estimation showed a decrease in survival free of stroke with LVEF reduction during one-year follow-up (89.3 vs. 87.0 vs. 79.8%; p = 0.067), a trend which was no longer evident after adjustment for relevant confounding factors. Rates of non-fatal strokes (0.4 vs. 1.1 vs. 0%) and severe bleedings (0.7 vs. 0.0 vs. 3.1%) were consistently low across all groups (each p = NS).

Conclusions

LVEF reduction neither influenced the procedural success nor the effectiveness and safety of stroke prevention by LAAC.

Trial Registration

ClinicalTrials.gov Identifier: NCT02230748

Graphic abstract

Electronic supplementary material

The online version of this article (10.1007/s00392-020-01627-8) contains supplementary material, which is available to authorized users.

Meta-analysis of prognostic impact of peripheral arterial disease on mortality after transcatheter aortic valve implantation

INTRODUCTION

The aim of this study was to determine whether peripheral arterial disease (PAD) is an independent predictor of mortality in patients who undergo transcatheter aortic valve implantation (TAVI) and we performed meta-analysis of currently available studies.

EVIDENCE ACQUISITION

MEDLINE and EMBASE were searched through June 2018 using Web-based search engines (PubMed and OVID). We included comparative studies of patients with PAD versus those without PAD and cohort studies which investigated PAD as one of prognostic factors of mortality, which used the multivariable analysis and reported an adjusted odds and hazard ratio (OR/HR) for early (30-day or in-hospital) and late (including early) mortality after TAVI. Study-specific estimates were combined using inverse variance-weighted averages of logarithmic ORs/HRs in the random-effects model.

EVIDENCE SYNTHESIS

The primary meta-analysis which pooled all the ORs/HRs demonstrated that PAD was associated with a statistically significant increase in both early (OR, 1.21; P=0.02) and midterm (1-year to 7-year) mortality (HR, 1.31; P<0.00001). The secondary meta-analysis which exclusively pooled approach-adjusted/stratified ORs/HRs demonstrated that PAD was associated with a strong trend toward (though statistically non-significant) an increase in early mortality (OR, 1.18; P=0.07) and a still statistically significant increase in midterm mortality (OR, 1.24; P=0.0001). Meta-regression coefficients for the proportion of patients who underwent transfemoral TAVI were not statistically significant (P for early/midterm mortality =0.24/0.52).

CONCLUSIONS

The present meta-analysis clearly highlighted that PAD was an independent predictor of both early and midterm mortality in patients who underwent TAVI.

Transcatheter aortic valve replacement for pure aortic valve regurgitation: "on-label" versus "off-label" use of TAVR devices

INTRODUCTION

Transcatheter aortic valve replacement (TAVR) has become the mainstay of treatment for aortic stenosis in patients with high surgical risk. Pure aortic regurgitation (PAR) is considered a relative contraindication for TAVR; however, TAVR is increasingly performed in PAR patients with unfavorable risk profile. Herein, we aim to summarize available data on TAVR for PAR with special emphasis on "on-label" versus "off-label" TAVR devices.

METHODS AND RESULTS

Pubmed was searched for studies of patients undergoing TAVR for PAR. Primary outcome was 30 day-mortality. Pooled estimated event rates were calculated. Twelve studies including a total of 640 patients were identified until December 2017. Among these, 208 (33%) patients were treated with devices with CE-mark approval for PAR ("on-label"; JenaValve and J valve). Overall, the procedural success rate was 89.9% (95% CI 81.1-96.1%; I² 80%). Major bleeding was reported in 6.4% (95% CI 2.9-10.8%; I² 48%). All-cause mortality at 30 days was 10.4% (95% CI 7.1-14.2%; I² 20%). Stroke occurred in 2.2% (95% CI 0.9-3.9%; I² 0%). A permanent pacemaker was required in 10.7% (95% CI 7.3-14.6%; I² 23%). At 30 days after TAVR, ≥ moderate AR post-interventional was observed in 11.5% (95% CI 2.9-23.6%; I² 90%). In the "on-label"-group, success rate was 93.0% (95% CI 85.9-98.1%; I² 52%). 30-day-mortality was 9.1% (95% CI 3.7-16.0%; I² 36%). More than trace AR was present in 2.8% (95% CI 0.1-7.6%; I² 0%). Compared to first-generation devices, second-generation devices were associated with significantly lower 30-day-mortality (r = - 0.10; p = 0.02), and significantly higher procedural success rates (r = 0.28; p < 0.001). Compared to other second-generation devices, the use of J valve or JenaValve was not associated with altered mortality (r = 0.04; p = 0.50), rates of > trace residual AR (r = - 0.05; p = 0.65) but with a significantly higher procedural success (r = 0.15; p = 0.042).

CONCLUSION

Based on this summary of available observational data TAVR for PAR is feasible and safe in patients deemed inoperable. First-generation TAVR devices are associated with inferior outcome and should be avoided. The "on-label" use of PAR-certified TAVR devices is associated with a significantly higher procedural success rate and might be favorable compared to other second-generation devices.

Hemodynamics of paradoxical severe aortic stenosis: insight from a pressure-volume loop analysis

BACKGROUND

Controversy exists about the pathophysiology of different hemodynamic subgroups of AS. In particular, the mechanism of the paradoxical low-flow, low-gradient (PLFLG) AS with preserved ejection fraction (EF) is unclear.

METHODS

A total of 41 patients with severe, symptomatic AS were divided into the following 4 subgroups based on the echocardiographically determined hemodynamics: (1) normal-flow, high-gradient (NFHG) AS; (2) low-flow, high-gradient AS; (3) paradoxical low-flow, low-gradient (PLFLG) AS with preserved EF and (4) low-flow, low-gradient (LFLG) AS with reduced EF. As part of the comprehensive invasive examinations, the analyses of the PV loops were performed with the IntraCardiac Analyzer (CD-Leycom, The Netherlands).

RESULTS

PLFLG was characterized by small left ventricular volumes as well as a decreased cardiac index, a decreased systolic contractility and a lower stroke work, than the conventional NFHG AS. Alterations in effective arterial elastance (2.36 ± 0.67 mmHg/ml in NFHG versus 3.01 ± 0.79 mmHg/ml in PLFLG, p = 0.036) and end-systolic elastance (3.72 ± 1.84 mmHg/ml in NFHG versus 5.53 ± 2.3 mmHg/ml in PLFLG, p = 0.040) indicated impaired vascular function and increased chamber stiffness.

CONCLUSIONS

The present study suggests that the hemodynamics of PLFLG AS can be explained by two mechanisms: (1) stiffness of the small left ventricle with reduced contractility, and (2) increased afterload due to the impairment of vascular function. Both mechanisms have similarities to those of heart failure with preserved EF. This type of remodeling may explain the poor prognosis of PLFLG AS.

The impact of biventricular heart failure on outcomes after transcatheter aortic valve implantation

AIMS

We sought to assess the impact of different manifestations of heart failure (HF) at baseline on the short- and long-term outcomes of transcatheter aortic valve implantation (TAVI) for aortic stenosis (AS).

METHODS AND RESULTS

Of 361 patients undergoing TAVI between May 2013 and April 2015, 185 (51%) showed clinical signs of HF at the time of admission. HF was diagnosed as isolated left ventricular (LV) and biventricular in 63 (34%) and 122 patients (66%), respectively. Acute device success (VARC-2) was achieved in 97% of patients without HF, in all patients with LV HF, and in 97% of patients with biventricular HF. Follow-up for a median of 427 days revealed significantly poorer survival in patients with biventricular HF (1-year estimate, 72.1% [95% confidence interval, 64.0-80.2%]) than in patients with LV HF (84.5% [75.2-93.8%]; p = 0.0203) or no HF (94.3% [90.7-97.9%]; p < 0.0001). Survival in the latter two patient subgroups was statistically not different. A diagnosis of biventricular HF was associated with a hazard ratio of 2.62 (p = 0.0089) vs. no HF in the likelihood of death; NT-proBNP and the logistic EuroSCORE were not significantly associated with survival. Half of all deaths in patients with biventricular HF occurred within 42 days of TAVI.

CONCLUSION

Biventricular HF is a strong predictor of mortality following TAVI for severe AS. AS in patients with LV HF should be treated without delay to avoid progression to biventricular HF. Patients with AS and biventricular HF should be monitored closely after TAVI to possibly prevent early death.

Evolution of transcatheter aortic valve implantation over 7 years: results of a prospective single-centre registry of 2000 patients in a large municipal hospital (TAVIK Registry)

OBJECTIVES

Use of transcatheter aortic valve implantation (TAVI) to treat severe aortic stenosis (AS) has gained popularity, accompanied by an evolution of patient and clinical factors. We aimed to characterise changes and evaluate their impact on outcomes.

SETTING

In this single-centre, German TAVIK registry patients undergoing TAVI between 2008 and 2015 were documented prospectively.

PARTICIPANTS/INTERVENTIONS

2000 consecutive patients with AS undergoing TAVI were divided in four cohorts. 500 patients underwent TAVI in each of the following time bins: April 2008 to July 2010 (cohort I), July 2010 to April 2013 (cohort II), April 2012 to October 2013 (cohort III) and October 2013 to March 2015 (cohort IV).

RESULTS

The mean age was 81.8 years, without significant variation across cohorts. Compared with cohort I, prior MI (5.4%vs11.0%; p<0.001) and New York Heart Association class IV (10.0%vs3.6%; p<0.001) were less common in cohort IV. Across cohorts, there was a fall in EuroSCORE (24.3%-18.7%), frailty (48.4%-17.0%) and use of transapical access (43.6%-29.0%), while transfemoral access increased (56.4%-71.0%; p<0.001 for each). Periprocedurally, there was a fall in moderate/severe aortic regurgitation (3.2%-0.0%) and rate of unplanned cardiopulmonary bypass (4.0%-1.0%; both p<0.001). A similar trend applied to 30-day rate of major vascular complications (5.2%-1.8%; p=0.006), life-threatening bleeding (7.0%-3.0%; p<0.001) and cardiovascular mortality (4.4%-1.8%; p=0.020). One-year post-TAVI, mortality and stroke rates did not differ.

CONCLUSIONS

Evolution of TAVI between 2008 and 2015 saw a trend towards its usage in lower risk patients and rapid progression towards improved safety. Evaluation and refinement should now continue to further lessen stroke and pacemaker rates.

Predictors of Mortality and Symptomatic Outcome of Patients With Low-Flow Severe Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement

Background

Impaired left ventricular (LV) ejection fraction is a common finding in patients with aortic stenosis and serves as a predictor of morbidity and mortality after transcatheter aortic valve replacement. However, conflicting data on the most accurate measure for LV function exist. We wanted to examine the impact of LV ejection fraction, mean pressure gradient, and stroke volume index on the outcome of patients treated by transcatheter aortic valve replacement.

Methods and Results

Patients treated by transcatheter aortic valve replacement were primarily separated into normal flow (NF; stroke volume index >35 mL/m²) and low flow (LF; stroke volume index ≤35 mL/m²). Afterwards, patients were divided into 5 groups: “NF–high gradient,” “NF–low gradient” (NF‐LG), “LF–high gradient,” “paradoxical LF‐LG,” and “classic LF‐LG.” The 3‐year mortality was the primary end point. Of 1600 patients, 789 (49.3%) were diagnosed as having LF, which was characterized by a higher 30‐day (P=0.041) and 3‐year (P<0.001) mortality. LF was an independent predictor of all‐cause (hazard ratio, 1.29; 95% confidence interval, 1.03–1.62; P=0.03) and cardiovascular (hazard ratio, 1.37; 95% confidence interval, 1.06–1.77; P=0.016) mortality. Neither mean pressure gradient nor LV ejection fraction was an independent predictor of mortality. Patients with paradoxical LF‐LG (35.0%), classic LF‐LG (35.1%) and LF–high gradient (38.1%) had higher all‐cause mortality at 3 years compared with NF–high gradient (24.8%) and NF‐LG (27.9%) (P=0.001). However, surviving patients showed a similar improvement in symptoms regardless of aortic stenosis entity.

Conclusions

LF is a common finding within the aortic stenosis population and, in contrast to LV ejection fraction or mean pressure gradient, an independent predictor of all‐cause and cardiovascular mortality. Despite increased long‐term mortality, high procedural success and excellent functional improvement support transcatheter aortic valve replacement in patients with LF severe aortic stenosis.