Prognostic Value of Electrocardiographic Left Ventricular Hypertrophy After Transcatheter Aortic Valve Implantation: Insights from the OCEAN-TAVI Registry

Extremely Small 20-mm Versus Standard-Size Balloon-Expandable Transcatheter Heart Valves: Propensity-Matched Analysis From the OCEAN-TAVI Registry

BACKGROUND

The 20-mm balloon-expandable transcatheter heart valve (THV) represents the smallest available option for transcatheter aortic valve replacement (TAVR). Its current underutilization stems from concerns regarding prosthesis-patient mismatch, durability, and potential adverse outcomes.

OBJECTIVES

The purpose of this study was to compare the long-term outcomes between the 20-mm balloon-expandable THVs and standard-size balloon-expandable THVs.

METHODS

Patients who underwent transfemoral TAVR with SAPIEN THVs were sourced from the OCEAN-TAVI (Optimized Transcatheter Valvular Intervention) registry, an ongoing, multicenter cohort study that has enrolled over 7,000 TAVR patients in Japan. A 1:3 propensity-matched analysis, based on 24 baseline clinical and echocardiographic variables, was used to contrast the 20-mm with >20-mm balloon-expandable THVs.

RESULTS

Of 5,086 eligible patients, 284 (5.6%) received the 20-mm balloon-expandable THV. After propensity-matching, the 20-mm THV group (n = 276) and the >20-mm THV group (n = 828) demonstrated balanced baseline characteristics, with an absolute standardized difference <0.10. The average follow-up duration for patients who were alive was 955 ± 512 days, and the average time to death was 584 ± 543 days. The 20-mm group showed a higher frequency of prosthesis-patient mismatch (PPM) (moderate PPM: 29.2% vs 10.8%; severe PPM: 4.9% vs 1.5%; P < 0.001). Over a 5-year period, all-cause mortality and heart failure rehospitalization rates were comparable between the 2 groups (all-cause mortality: 34.2% vs 38.0%; HR: 1.01; 95% CI: 0.74-1.37; P = 0.970; heart failure rehospitalization: 15.2% vs 16.3%; HR: 0.81; 95% CI: 0.50-1.29; P = 0.371).

CONCLUSIONS

This registry-based study suggests that the initially observed inferior forward hemodynamics associated with the 20-mm THV do not translate into heightened long-term mortality or heart failure rehospitalization risks. (The OCEAN-TAVI registry [Optimized Transcatheter Valvular Intervention-Transcatheter Aortic Valve Implantation]; UMINID:000020423).

Electrocardiographic Strain and Relationship with Left Ventricular Remodelling and Clinical Outcomes in Patients with Aortic Stenosis Undergoing Transcatheter Aortic Valve Implantation

INTRODUCTION

Left ventricular (LV) remodelling and fibrosis are known to occur in patients with aortic stenosis (AS) and are linked to post-intervention outcomes. These myocardial changes may be detected upon the routine 12-lead electrocardiogram (ECG) by the presence of a LV strain pattern (LVS-ECG). Although LVS-ECG has been related to excessive cardiovascular morbidity and mortality in multiple patient populations, there is currently a dearth of data upon its impact in patients undergoing transcatheter aortic valve implantation (TAVI). The aim of the current study was to investigate the prevalence, predictors, and prognostic value of LVS-ECG.

METHODS

Between 2012 and 2019, 640 consecutive patients underwent TAVI at Haukeland University Hospital, Bergen. Of these, 600 patients with severe AS were included in the TAVI-NOR study. Patients with known bundle branch block (n = 85) or permanent pacing (n = 25) were excluded, leaving 490 patients (mean age 81 ± 6 years, 52% females) eligible for the analyses. LVS-ECG was defined as down-sloping, convex ST-segment depression with asymmetric T-wave inversion in V5 or V6.

RESULTS

LVS-ECG was present in 25.7% patients. Higher levels of NT-proBNP (OR 1.96; 95% CI: 1.08-3.55, p = 0.028), left ventricular ejection fraction (LVEF) <50% (OR 3.14; 95% CI: 1.61-6.13, p = 0.001), increase in LV mass index per SD (32 g/m2) (OR 1.37; 95 CI: 1.06-1.76, p = 0.014), and the presence of LV hypertrophy on ECG (OR 3.23; 95% CI: 1.97-5.32, p < 0.001) were independent predictors of LVS-ECG in the multivariable-adjusted analysis. Although all-cause mortality was significantly higher in patients with LVS-ECG compared to those without (54.8% vs. 44.2%, p = 0.041), the presence of LVS-ECG did not predict all-cause mortality during a mean follow-up of 64 ± 24 months (HR 1.05; 95% CI: 0.79-1.39, p = 0.742). Patients with LVEF <50% and concomitant LVS-ECG had a worse prognosis than those with LVEF >50% and no LVS-ECG (p < 0.001).

CONCLUSIONS

LVS-ECG may represent a simple marker of structural and functional LV remodelling that signals a propensity to excess mortality during long-term follow-up after TAVI, as it is strongly associated with other prognosticators such as reduced LVEF and increased levels of NT-proBNP.

The value of the dynamic changes in cardiac power output in aortic stenosis patients following transcatheter aortic valve implantation: an exercise stress echocardiography study

AIMS

Evidence for risk stratification using exercise stress echocardiography (ESE) in patients undergoing transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS) is currently lacking. Cardiac power output (CPO) has demonstrated prognostic value in patients undergoing TAVI for severe AS. This study investigated prognoses in patients undergoing TAVI for severe AS and to explore the additional information that ESE can provide for risk stratification.

METHODS

In this retrospective observational study, we included 96 consecutive patients who underwent TAVI for severe AS and patients with preserved left ventricular (LV) ejection fraction (≥ 50%) who underwent ESE at 3-6 months after TAVI. CPO was calculated as 0.222 × cardiac output × mean blood pressure/LV mass, where 0.222 was the conversion constant to W/100 g of the LV myocardium. All patients were followed up for all-cause mortality and hospitalization for heart failure.

RESULTS

Of the 96 patients, 3 were excluded and 93 patients (82.0 years; 45.2% male) were included in this study. During a median follow-up period of 1446 (1271-1825) days, the composite end point was reached in 17 patients. Multivariable Cox regression analysis revealed that CPO at rest and the change in CPO from rest to exercise (ΔCPO) were independently associated with the composite end point (hazard ratio = 0.278, p = 0.023). The addition of ΔCPO resulted in an incremental value of the model containing clinical and resting echocardiography variables (p = 0.030).

CONCLUSIONS

This study suggests that resting CPO and exercise-induced changes in CPO are useful for risk stratification of patients undergoing TAVI for severe AS.

Electrocardiography versus Echocardiography in Severe Aortic Stenosis with the Consideration of Coexistent Coronary Artery Disease

(1) Background: Coexistent coronary artery disease (CAD) might influence the ability of electrocardiogram (ECG) to identify echocardiographic left ventricular hypertrophy (ECHO-LVH) in patients with aortic stenosis (AS). We aimed to assess the relation between ECG-LVH (by the Sokolov-Lyon or Cornell criteria) and ECHO-LVH considering coexistent CAD. (2) Methods: We retrospectively analyzed the medical records of 74 patients (36 males) with severe AS who were hospitalized in the University Hospital in Cracow from 2021 to 2022. (3) Results: ECHO-LVH was present in 49 (66%) patients, whereas 35 (47.3%) patients had ECG-LVH. There was no difference between the rate of ECG-LVH in patients with vs. without ECHO-LVH. Single-vessel and multi-vessel CAD were diagnosed by invasive coronary angiography in 18% and 11% of patients, respectively. The sensitivity of the classical ECG-LVH criteria with regard to ECHO-LVH was low, reaching at best 41% for the Sokolov-Lyon and Cornell criteria. The results were similar and lacked a pattern when considering patients without significant stenosis, with single- and multi-vessel disease separately. Correlations between the left ventricular mass index and ECG-derived parameters were weak and present solely for the Lewis index (r = 0.31), R wave's amplitude >1.1 mV in aVL (r = 0.36), as well as the Cornell (r = 0.32) and Sokolov-Lyon (r = 0.31) voltage criteria (p < 0.01). The presence, location of stenoses, and CAD extent were not associated with the presence of either ECHO-LVH or ECG-LVH, irrespective of individual ECG-LVH criteria. (4) Conclusions: The sensitivity of classical ECG criteria for echocardiographic LVH in severe AS is low, regardless of coexistent CAD or its angiographic extent.