Impact of aortic aneurysms in trans-catheter aortic valve replacement: A single center experience

Aortic Dissection Following Transcatheter Aortic Valve Replacement

Transcatheter Aortic Valve Replacement (TAVR) continues to grow in popularity and has become the preferred mechanism for the treatment of aortic stenosis in most patients. Despite significant improvements in the safety of TAVR, complications remain inevitable. Aortic dissection, although rare, is a feared complication following TAVR. Aortic dissection after TAVR has been reported to occur in both the ascending and descending thoracic aorta and may occur acutely during valve placement or in a delayed fashion. Bicuspid aortic valve and ascending aortic aneurysm may increase the risk for Type A dissection following TAVR. Given the rarity of aortic dissection in TAVR, a high index of suspicion must be maintained to provide prompt diagnosis and management. Open surgical repair is the preferred treatment modality for type A aortic dissection, however endovascular management and conservative medical therapy can be utilized in select patients and are more commonly employed for type B dissection.

Transcatheter aortic valve replacement in patients with preoperative ascending aortic diameter ≥45 mm

Background

Current indication for concomitant replacement of ascending aorta (AA) in patients undergoing surgical aortic valve replacement is that AA diameter exceeds 45 mm. However, the impact of AA dilation (≥45 mm) in patients undergoing transcatheter aortic valve replacement (TAVR) remains unclear.

Methods

We retrospectively evaluated 467 consecutive patients who underwent transfemoral TAVR from January 2016 to April 2021. Cox proportional hazards regression was performed to identify risk factors for all-cause mortality. The primary endpoint was the all-cause mortality, and the secondary endpoints were the occurrence of the aortic dissection and/or rupture.

Results

One hundred patients (21.4%) presented preoperative AA ≥45 mm. The median age was 73 years for patients with AA ≥45 mm and 75 years for patients with AA <45 mm (P=0.021). The in-hospital mortality rate was 1.1%. There was no iatrogenic injury to the AA. Only one patient (0.2%) in AA <45 mm group experienced retrograde type B aortic dissection in the descending aorta. The median follow-up was 19 [16-34] months in patients with AA ≥45 mm and 27 [15-37] months in patients with AA <45 mm (P=0.152). No statistical difference was found between the two groups regarding the overall survival (92.5%±3.5% vs. 78.3%±6.8%, P=0.198). Only one patient in AA <45 mm group experienced type A aortic dissection 10 months after the procedure. In both univariable and multivariable analysis, AA ≥45 mm was not an independent predictor for all-cause mortality.

Conclusions

Transfemoral TAVR can be performed safely in patients with preoperative AA ≥45 mm with a low intraprocedural risk. The mid-term survival appears not to be affected by the presence of AA ≥45 mm, and adverse aortic events are rare.

Percutaneous treatment of abdominal aortic aneurysm and aortic valve stenosis with 'staged' EVAR and TAVR: a case series

Symptomatic aortic valve stenosis (AS) and abdominal aortic aneurysm (AAA) are critical clinical conditions, increasingly more prevalent with aging of the population. Calcific aortic stenosis is the most common structural cardiac disease in the elderly population, and medical management of severe aortic stenosis of the elderly population is associated with poor outcomes as compared to surgical treatment. Transcatheter aortic valve replacement (TAVR) is a treatment of choice in inoperable, often elderly, patients with symptomatic severe AS and in intermediate-to-high surgical risk patients. It is not yet clarified the incidence of AAA and its impact on procedural and clinical outcomes among patients undergoing TAVR. It is known that after AS resolution with aortic valve replacement or TAVR there is an increase in blood pressure that increases the risk of dissection or abdominal aortic aneurysm rupture if AAA repair is delayed. The purpose of this report is to describe the anatomical details and technical and procedural considerations when proposing totally endovascular strategies dedicated to the treatment of patients with AS and AAA.

Safety of Transcatheter Aortic Valve Replacement in Patients with Aortic Aneurysm: A Propensity-Matched Analysis

Introduction

There is a paucity of data regarding the outcomes of transcatheter aortic valve replacement (TAVR) among patients with thoracic or abdominal aortic aneurysms (AA). Using the Nationwide Inpatient Sample (NIS) database, we explored the safety of TAVR among patients with a diagnosis of AA.

Methods

We queried the National Inpatient Sample database (2012–2017) for hospitalized patients undergoing TAVR, using ICD-9 and ICD-10 codes for endovascular TAVR. Reports show that > 95% of endovascular TAVR in the US is via transfemoral access, so our population are mostly patients undergoing transfemoral TAVR. Using propensity score matching, we compared the trends and outcomes of TAVR procedures among patients with versus without AA.

Results

From a total sample of 29,517 individuals who had TAVR procedures between January 2012 and December 2017, 910 had a diagnosis of AA. In 774 matched-pair analysis, all-cause in-hospital mortality was similar in patients with and without AA OR 0.63 [(95% CI 0.28–1.43), p = 0.20]. The median length of stay was higher in patients with AA: 4 days (IQR 2.0–7.0) versus 3 days (IQR 2.0–6.0) p = 0.01. Risk of AKI [OR 1.01 (0.73–1.39), p = 0.87], heart block requiring pacemaker placement [OR 1.17 (0.81–1.69), p = 0.40], aortic dissection [OR 2.38 (0.41–13.75), p = 0.25], acute limb ischemia [OR 0.46 (0.18–1.16), p = 0.09], vascular complications [OR 0.80 (0.34–1.89), p = 0.53], post-op bleeding [OR 1.12 (0.81–1.57), p = 0.42], blood transfusion [OR 1.20 (0.84–1.70), p = 0.26], and stroke [OR 0.58 (0.24–1.39), p = 0.25] were similar in those with and without AA.

Conclusions

Data from a large nationwide database demonstrated that patients with AA undergoing TAVR are associated with similar in-hospital outcomes compared with patients without AA.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40119-022-00258-6.

Percutaneous Treatment of Concomitant Severe Aortic Stenosis and Thoracoabdominal Aortic Aneurysm

PURPOSE

Although rare in occurrence, symptomatic severe aortic stenosis and large thoracoabdominal aortic aneurysm (TAAA) found in combination pose a real therapeutic challenge, especially in elderly frail patients. Surgical approaches for combined treatment are complex and at high risk of complications while staged procedures carry the risk of an unfavorable evolution of the condition temporarily left untreated. Minimally invasive approaches may therefore prove a more suitable strategy for these patients.

CASE REPORT

We present the case of a 78-year-old woman with symptomatic severe aortic stenosis (AS) and a TAAA of 7.8 cm in diameter. Transcatheter treatment of both conditions was successfully performed in a staged manner. The first intervention consisted of combined transfemoral transcatheter aortic valve implantation (TAVI) immediately followed by a zone 3 thoracic endovascular aortic endoprosthesis deployment. In order to reduce the extent of intercostal arteries coverage and mitigate the risk of medullar ischemia, a second-stage percutaneous endovascular treatment of the TAAA was performed with a customized 4-fenestration prosthesis. Early and 12-month clinical and radiologic follow-up were favorable.

CONCLUSION

This case demonstrates how a strong multidisciplinary collaboration allows for successful resolution of complex clinical scenarios.

Transapical transcatheter aortic valve implantation in patients with aortic diseases

OBJECTIVES

Patients scheduled for transcatheter aortic valve implantation (TAVI) treatment frequently present with concomitant aortic diseases, in which case they are usually considered to be at high interventional risk and, in particular, unable to undergo the transfemoral TAVI approach. Since the establishment of the 'transfemoral first' strategy for TAVI, there has been an evidence gap with regard to the outcomes of such patients. We aimed to evaluate the mid-term outcomes after transapical TAVI in patients with diverse aortic diseases.

METHODS

Fifty-five consecutive elderly patients (78.4 years; standard deviation: 8.6 years) at intermediate surgical risk with severe aortic stenosis and aortic diseases (porcelain aorta 36%, ascending aneurysm 15%, descending aneurysm 26%, type-B dissection 4%, aortic thrombus 7%, Leriche syndrome 4%, aortic kinking 11%, aortic ulcer 2%, previous aortic operation 20%, aortic elongation/tortuosity 4%) underwent transapical TAVI treatment between January 2011 and November 2019 at our institution. We used the second-and third-generation self- and balloon-expanding valves. The follow-up time was 92.6 patient-years.

RESULTS

The Society of Thoracic Surgery-Predicted Risk of Mortality score was 7% (standard deviation: 4%). The 30-day mortality and all-stroke rates were 6% and 4%, respectively. The median survival time was 24.9 months (95% confidence interval 17.6-32.3). The median time of freedom from a composite of death and cardio-cerebral adverse events was 24.3 months (95% confidence interval 11.9-36.8). The rate of moderate/severe paravalvular leakage was 2%. The pacemaker rate was 10%. No early or late aortic syndrome occurred.

CONCLUSIONS

Transapical TAVI is a safe method and shows very promising early and mid-term outcomes, without early/late aortic syndrome, in patients with aortic diseases for whom transfemoral TAVI as the first-line transcatheter method might be contraindicated or not feasible.

Impact of diverse aortic pathologies on outcomes after transapical transcatheter aortic valve replacement

OBJECTIVES

Some patients who undergo transcatheter aortic valve replacement (TAVR) have a concomitant diverse aortic pathologies (AP). They are usually considered high-risk candidates for the procedure and require further assessment to determine the best vascular approach. The impact of these AP on TAVR is not well known as the information is scarce. We aimed to evaluate midterm clinical impact of different AP after transapical (TA)-TAVR.

METHODS

Twenty patients with atherosclerotic/occluding aortic diseases (A/OAD) (porcelain aorta, Leriche Syndrome, penetrating aortic ulcer, and aortic thrombus), 24 patients with aortic morphologic diseases (AMD) (thoracic/abdominal aortic aneurysms, aortic kinking, aortic type B dissection, aortic elongation/tortuosity, and previous aortic intervention), and 11 patients with combined aortic diseases (CAD) underwent TA-TAVR treatment between January 2011 and November 2019 at our center. We conducted up to 5-years clinical follow-up.

RESULTS

All patients were classified in the heart team as a high interventional risk. The 30-day mortality and stroke were 5% and 10% in the A/OAD, 8.3% and 0% in the AMD, and 0% and 0% in the CAD, respectively. The median time of freedom from a composite of death and cardio-cerebral adverse events was 22.1 months [95% confidence interval [CI]: 9.9-34.3] in A/OAD versus 34.3 months [95% CI: 15.6-53] in AMD versus 17 months [95% CI: 0-39.4] in CAD; p = .525. We registered neither procedural aortic injury nor aortic syndrome at follow-up. The moderate/severe paravalvular leakage rates were 5%, 0% and 0% in the A/OAD, AMD and CAD, respectively.

CONCLUSION

Independent of underlying AP, the TA-TAVR is a safe method and shows very promising early and midterm outcomes in patients with various AP.

Current and Future Aspects of Multimodal Imaging, Diagnostic, and Treatment Strategies in Bicuspid Aortic Valve and Associated Aortopathies

Bicuspid aortic valve (BAV) is the most frequent congenital cardiac abnormality leading to premature aortic valve apparatus dysfunction and is often associated with aortopathy. Therefore, current guidelines recommend a surgical aortic valve replacement (SAVR), even if many patients are deemed inoperable owing to their comorbidities and require alternatives such as transcatheter aortic valve replacement (TAVR). However, BAV variations remain challenging for procedural success. Therefore, the latest development in different imaging modalities (echocardiography, multislice-computertomographie, cardiovascular magnetic resonance) allows in-depth analysis for preprocedural risk stratification, follow up, and patient selection. Furthermore, we shed light on the latest developments in pre- and periprocedural fusion imaging as well as on current and future treatment options.