Predictors of 1-year mortality in patients with aortic regurgitation after transcatheter aortic valve implantation: an analysis from the multicentre German TAVI registry

Transcatheter aortic valve replacement in patients with severe aortic valve stenosis and concomitant mitral valve regurgitation - 5 years follow-up

Objectives

To investigate the change in severity of mitral regurgitation (MR) after transcatheter aortic valve replacement (TAVR) and its effect on 5-year mortality.

Background

There is inconsistency in literature on pre-existing MR influencing long-term survival in patients who undergo TAVR.

Methods

Patients who underwent TAVR at the University Hospital Schleswig-Holstein (USKH) Campus Kiel between March 2009 and February 2018 have been enrolled. Echocardiography determined the degree of MR before and within 7 days after TAVR. Patients were divided into two groups according to their MR at baseline: MR-grade ≤ 2 (non-relevant MR, nr-MR) and baseline MR-grade > 2 (relevant MR, r-MR). Primary endpoint was a composite of MR baseline influence on mortality and MR reduction and its' impact on mortality.

Results

A total of 820 patients (642 nr-MR and 178 in r-MR) were included in this study. Of these, 167 patients showed an improvement in MR-grade. Thereof 106 (63.5 %) referred to r-MR with a significant decrease in mean MR-grade (p < 0.01). Systolic pulmonary artery pressure (sPAP) (p < 0.01) and NT-proBNP (p = 0.03) decreased in patients who had an improvement. There was no significant difference in 5-year mortality for MR at baseline (p = 0.35) or reduction in mortality for r-MR patients with an MR improvement compared to patients with worsening or equal MR status (p = 0.80).

Conclusion

In patients undergoing TAVR, 63.5 % of patients with MR-grade ≥ 2 at baseline showed an improvement of grade of MR after TAVR with reduction of their sPAP and NT-proBNP values but there was no significant difference in mortality.

Personalised preinterventional risk stratification of mortality, length of stay and hospitalisation costs in transcatheter aortic valve implantation using a machine learning algorithm: a pilot trial

INTRODUCTION

Risk stratification based on Euroscore II (ESII) is used in some centres to assist decisions to perform transcatheter aortic valve implant (TAVI) procedures. ESII is a generic, non-TAVI-specific metric, and its performance fades for mortality at follow-up longer than 30 days. We investigated if a TAVI-specific predictive model could achieve improved predictive preinterventional accuracy of 1-year mortality compared with ESII.

PATIENTS AND METHODS

In this prospective pilot study, 284 participants with severe symptomatic aortic valve stenosis who underwent TAVI were enrolled. Standard clinical metrics (American Society of Anesthesiology (ASA), New York Heart Association and ESII) and patient-reported outcome measures (EuroQol-5 Dimension-Visual Analogue Scale, Kansas City Cardiomyopathy Questionnaire and Clinical Frailty Scale (CFS)) were assessed 1 day before TAVI. Using these data, we tested predictive models (logistic regression and decision tree algorithm (DTA)) with 1-year mortality as the dependent variable.

RESULTS

Logistic regression yielded the best prediction, with ASA and CFS as the strongest predictors of 1-year mortality. Our logistic regression model score showed significantly better prediction accuracy than ESII (area under the curve=0.659 vs 0.800; p=0.002). By translating our results to a DTA, cut-off score values regarding 1-year mortality risk emerged for low, intermediate and high risk. Treatment costs and length of stay (LoS) significantly increased in high-risk patients.

CONCLUSIONS AND SIGNIFICANCE

A novel TAVI-specific model predicts 1-year mortality, LoS and costs after TAVI using simple, established, transparent and inexpensive metrics before implantation. Based on this preliminary evidence, TAVI team members and patients can make informed decisions based on a few key metrics. Validation of this score in larger patient cohorts is needed.

Association of CT-Derived Extracardiac Features and Aortic Annulus Size in Patients Planned for TAVI

INTRODUCTION

Transcatheter aortic valve implantation (TAVI) is commonly used to treat patients with stenosed aortic valves. CT is one of the crucial steps in planning TAVI to obtain measurements of the aortic annulus to choose an appropriately sized prosthesis. Incorrect measurements can lead to patient-prosthesis mismatch and other complications. However, some patients cannot undergo ECG-gated CT with radiocontrast because of the presence of radiopaque objects in the thorax, arrhythmia, renal failure, etc. Aim: To explore supplementary methods to improve aortic annulus sizing for TAVI by extracardiac measurements.

METHODS

We included all patients who underwent CT as part of TAVI planning. Measurements of femoral and iliac arteries and the femoral head cross-sectional area were performed.

RESULTS

CT scans of 139 patients were included in this study. Sixty-three patients (45%) were males. Mean age of the female patients was 79.6 ± 7.1 years and of the male patients was 81.3 ± 6.1 years. Mean aortic annulus perimeter among female patients was 74.3 ± 6 mm (range 61.9-88.2) and 83 ± 7.9 mm among male patients (range 70.1-74.3 mm). Mean diameters of common iliac, external iliac, and common femoral arteries were 9.2 ± 1.8, 7.6 ± 1, 7.6 ± 1 mm, respectively, for females and 10.2 ± 1.8, 8.5 ± 1.3, and 8.6 ± 1.4 mm for males. Mean perimeter of the femoral head (average value of right and left femoral heads) among the female patients was 137.8 ± 6.3 mm, and among male patients was 155 ± 9.6 mm. A significant correlation was observed between the perimeter of the aortic annulus and the perimeter of the femoral head (Pearson's R² = 0.224). The correlation between the aortic annulus perimeter and the femoral head perimeter was stronger among men than among women (Pearson's R² = 0.66 and 0.19, respectively).

CONCLUSION

Femoral head diameter is associated with annulus size. This may help size the appropriate prosthesis in cases where the measurements by CT are in the border zone if corroborated by clinically driven data.

Influence of Left Ventricular Function on the "Aortic Regurgitation Index" Proposed for the Hemodynamic Assessment of Postprocedural Aortic Regurgitation

The aortic regurgitation (AR) index, proposed as an objective indicator of postprocedural AR, decreases in proportion to AR severity, besides reportedly providing additional prognostic information. Meanwhile, left ventricular (LV) function has also been considered an essential prognostic factor. This study aimed to clarify whether LV function affected the AR index using cardiac catheterization data.A retrospective study was performed in patients whose LV function was evaluated using a micromanometer-tipped catheter. Patients with grade 2 or higher AR were excluded to explore non-AR factors affecting the AR index value. The AR index was calculated as a ratio of the gradient between the aortic diastolic blood pressure (DBP) and the LV end-diastolic pressure (EDP) to the aortic systolic blood pressure (SBP): AR Index = [ (DBP - LVEDP) / SBP] × 100.A total of 64 patients [age, 62 (interquartile range: 48-70) years; LV ejection fraction, 19% (16%-26%) ] were examined. AR index values ranged from 18.3 to 68.6. Despite having no AR, two patients displayed an AR index < 25, indicating significant AR. Multiple-regression analysis revealed that LV diastolic stiffness (β = -0.750, P < 0.001), LV max dP/dt (β = -0.296, P = 0.006), and heart rate (β = 0.284, P = 0.011) were independent determinants of the AR index value.Patients with impaired LV diastolic function and preserved systolic function had low AR index values. The additional prognostic information of the AR index may be related to LV diastolic function.

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.

The Use of Biological Heart Valves

BACKGROUND

Biological heart-valve prostheses have undergone continuous devel- opment up to the present, and technological advances have been made in catheter- assisted valve systems (transcatheter aortic valve implantation, TAVI) and minimally invasive routes of application. These parallel trends have led to major changes in therapeutic strategies, widening the spectrum of patients who are candidates for biological aortic valve implantation.

METHODS

This review is based on pertinent publications retrieved by a systematic search in PubMed employing the search terms "conventional biological aortic pros- thesis," "rapid deployment prosthesis," and "transcatheter aortic valve implantation/ replacement."

RESULTS

Among biological heart-valve prostheses, a distinction is drawn between stented (conventional, rapid-deployment, and catheter-assisted) and non-stented types. The long-term durability of conventional, surgically implantable biological valve protheses is by far the best documented: the reported 5-year reoperation rates range from 13.4% to 36.6%, and the pacemaker implantation rate is ca. 4%. Rapid-deployment prostheses combine the advantages of conventional and ca- theter-assisted techniques and facilitate minimally invasive approaches. The TAVI method is currently recommended for high- and intermediate-risk patients, while conventional valve replacement remains the method of choice for those at low risk. Rapid-deployment and TAVI prostheses is associated with a higher pacemaker im- plantation rate than conventional prostheses: these rates are 8.5-15.3% for TAVI and 6.0-8.8% for rapid-deployment valves. The intermediate-term durability of catheter-assisted and rapid-deployment prostheses appears promising, but their long-term durability is still unclear.

CONCLUSION

The further development of biological heart-valve prostheses in the form of improved conventional, transcatheter, and rapid-deployment prostheses now enables individualized treatment. Before any such procedure is performed, the car- diac team must assess the patient's risk profile and the advantages and disadvan- tages of each type of prosthesis to determine which is best.

Three-Year Survival Comparison between Transcatheter and Surgical Aortic Valve Replacement for Intermediate- and Low-Risk Patients

Transcatheter aortic valve implantation is a suitable therapeutic intervention for patients deemed inoperable or high risk for surgical aortic valve replacement. Current investigations question whether it is a suitable alternative to surgery for intermediate- and low-risk patients. The following meta-analysis presents a comparison between transcatheter versus surgical aortic valve replacement in patients that are intermediate and low risk for surgery. Articles were collected via an electronic search using Google Scholar and PubMed. Articles of interest included studies comparing the survival of intermediate- and low-risk patients undergoing transcatheter aortic valve implantation to those undergoing surgical aortic valve replacement. Primary end points included 1-, 2-, and 3-year survival. Secondary end points included postintervention thromboembolic events, stroke, transient ischemic attacks, major vascular complications, permanent pacemaker implantation, life-threatening bleeding, acute kidney injury, atrial fibrillation, and moderate-to-severe aortic regurgitation. Six studies met the criteria for the meta-analysis. One- and two-year survival comparisons showed no difference between the two interventions. Surgical aortic valve replacement, however, presented with favorable 3-year survival compared with the transcatheter approach. Transcatheter aortic valve implantation had more major vascular complications, permanent pacemaker implantation, and moderate-to-severe aortic regurgitation rates compared with surgery. Surgical aortic valve replacement presented more life-threatening bleeding, acute kidney injury, and atrial fibrillation compared with a transcatheter approach. There was no statistical difference between the two approaches in terms of thromboembolic events, strokes, or transient ischemic attack rates. Surgical aortic valve replacement presents favorable 3-year survival rates compared with transcatheter aortic valve implantation.

How TAVI registries report clinical outcomes-A systematic review of endpoints based on VARC-2 definitions

Introduction

Transcatheter aortic valve implantation (TAVI) has been demonstrated to be an alternative treatment for severe aortic stenosis in patients considered as high surgical risk. Since its first human implantation by Cribier et al., TAVI has been shown to increase survival rate and quality of life for high surgical risks patients. The objective of this study is to provide an overview of TAVI registries and the reporting clinical outcomes based on the VARC-2 definitions. In addition, the comparability and adherence of VARC-2 reporting within the identified TAVI registries was reviewed.

Materials and methods

A systematic review of TAVI registries reporting VARC-2 definitions has been performed in line with PRISMA guidelines in PubMed, ScienceDirect, Scopus databases and EMBASE. Based on VARC-2, patients’ characteristics and procedure characteristics, 30-day clinical outcomes, 1-year mortality and composited endpoints were extracted from each registry’s publications.

Results

This review identified 466 studies that were potentially relevant, and 20 TAVI registries reported VARC-2 definitions involved in our present review. Of all 20 registries, an overall sample size of 12,583 patients was involved. The 30-day all-cause mortality ranged from 0 to 12.7%. From 20 registries, 14 registries reported the cardiovascular mortality at 30 days. 9 registries reported myocardial infarction (MI) rate based on VARC-2 definitions, and 7 registries reported peri-procedural MI rate (<72h). In our review, most of registries presented MI rates ranging from 0.5% to 2%. The majority of registries have reported complications such as bleeding, vascular complications and new pacemaker implantation.

Conclusion

Since the introduction of VARC definitions from 2011, VARC and VARC-2 definitions are still not systematically used by all TAVI studies. These endpoint definitions warrant a concise and systemic analysis of outcome measures. Reporting TAVI-outcome uniformly makes study result comparison feasible. This definitely will increase patient safety, additionally to provide sufficient evidence to support decision makers like regulatory bodies, HTA agencies, payers.

Evolut R Implantation to Treat Severe Pure Aortic Regurgitation in a Patient With Mitral Bioprosthesis

Transcatheter aortic valves have been designed to treat high-risk surgical candidates affected by severe aortic stenosis, but little is known about the use of transcatheter valves in patients with severe pure aortic regurgitation. We describe the implantation of Medtronic CoreValve Evolut R (Medtronic, Minneapolis, MN) to treat an 82-year-old patient affected by severe pure aortic regurgitation who underwent prior mitral valve replacement with a biological valve protruding into the left ventricular outflow tract.

Direct Flow Implantation in a Patient With Mechanical Mitral Prostheses

We describe a case of Direct Flow (Direct Flow Medical Inc, Santa Rosa, CA) transcatheter aortic valve implantation in a patient with a mechanical valve in a mitral position.

Recent advances in transcatheter aortic valve replacement for high-risk patients

Aortic stenosis is the most common valvular heart disease of old age. Patients with severe aortic stenosis who develop symptoms have a very poor prognosis without valve intervention. Surgical aortic valve replacement has historically been the only treatment option for these patients. However a significant minority are considered inoperable or at high surgical risk and therefore are refused or decline surgery. In recent years, transcatheter aortic valve replacement has emerged as an alternative treatment option in these high-risk patients. The aim of this review is to summarize the current role of transcatheter aortic valve replacement in contemporary clinical practice including recent advances in technological and procedural aspects and then discuss future directions.

Prediction of paravalvular leakage after transcatheter aortic valve implantation

Significant paravalvular leakage (PVL) after transcatheter aortic valve implantation (TAVI) is related to patient mortality. Predicting the development of PVL has focused on computed tomography (CT) derived variables but literature targeting CoreValve devices is limited, controversial, and did not make use of standardized echocardiographic methods. The study included 164 consecutive patients with severe aortic stenosis that underwent TAVI with a Medtronic CoreValve system©, with available pre-TAVI CT and pre-discharge transthoracic echocardiography. The predictive value for significant PVL of the CT-derived Agatston score, aortic annulus size and eccentricity, and “cover index” was assessed, according to both echocardiographic Valve Academic Research Consortium (VARC) criteria and angiographic Sellers criteria. Univariate predictors for more than mild PVL were the maximal diameter of the aortic annulus size (for both angiographic and echocardiographic assessment of PVL), cover index (for echocardiographic assessment of PVL only), and Agatston score (for both angiographic and echocardiographic assessment of PVL). The aortic annulus eccentricity index was not predicting PVL. At multivariate analysis, Agatston score was the only independent predictor for both angiographic and echocardiographic assessment of PVL. Agatston score is the only independent predictor of PVL regardless of the used imaging technique for the definition of PVL.

Current status of transcatheter aortic valve replacement

The advent of transcatheter aortic valve replacement (TAVR) has modified the treatment of severe aortic stenosis (AS). Large randomized trials and multicenter registries have endorsed the efficacy of TAVR in improving outcomes in patients with severe AS who are inoperable or high surgical risk. There has been a noticeable shift in using TAVR in patients with AS who are not at a high surgical risk. Appropriate diagnosis, patient selection, and referral remain cornerstones to achieving optimal outcomes after TAVR or SAVR (surgical aortic valve replacement).

Trans-subclavian versus transapical access for transcatheter aortic valve implantation: A multicenter study

OBJECTIVES

To compare the outcomes of trans-subclavian (TS) and transapical (TA) access for transcatheter aortic valve implantation (TAVI).

BACKGROUND

A considerable proportion of patients undergoing TAVI are not eligible for transfemoral approach. To date, there are few data to guide the choice between alternative vascular access routes.

METHODS

Among 874 consecutive patients who underwent TAVI, 202 procedures were performed through TA (n = 142, 70.3%) or TS (n = 60, 29.7%) access. Medtronic Corevalve (CV, Medtronic, Minneapolis, MN) was implanted in 17.3% of the patients, the Edwards-Sapien (ES, Edwards Lifesciences Inc., Irvine, CA) in 81.2% and other prostheses in 0.1%. In-hospital and long-term outcome were assessed using the Valve Academic Research Consortium (VARC)-2 definitions.

RESULTS

Mean age was 82 ± 6 years, STS score 9.3 ± 7.9%. The 2 groups showed a relevant imbalance in baseline characteristics. In hospital mortality was 6.4% (1.7% TS vs. 8.4% TA, P = 0.06), stroke 2.0%, acute myocardial infarction 1.0%, acute kidney injury 39.4%, sepsis 4.0% with no significant differences between groups, while bleeding was more frequent in TA patients (53.5% vs. 11.7% TS, P < 0.001). One- and 2-year survival was 85.2% and 73.2% in TS patients, and 83.9% and 74.9% in TA patients (P = ns for both). Access site was not an independent predictor of mortality at multivariable analysis.

CONCLUSION

Transapical compared with trans-subclavian access for TAVI was associated with a nonsignificant trend to increased periprocedural events. However, 1- and 2-year survival appears similar.

Transcatheter aortic valve implantation in patients with pre-existing chronic kidney disease

BACKGROUND

We investigated the effect of chronic kidney disease (CKD) on morbidity and mortality following transcatheter aortic valve implantation (TAVI) including patients on haemodialysis, often excluded from randomised trials.

METHODS AND RESULTS

We performed a retrospective post hoc analysis of all patients undergoing TAVI at our centre between 2008 and 2012. 118 consecutive patients underwent TAVI; 63 were considered as having (CKD) and 55 not having (No-CKD) significant pre-existing CKD, (defined as estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m²). Chronic haemodialysis patients (n = 4) were excluded from acute kidney injury (AKI) analysis. Following TAVI, in CKD and No-CKD patients respectively, AKI occurred in 23.7% and 14.5% (p = 0.455) and renal replacement therapy (RRT) was necessary in 8.5% and 3.6% (relative risk (RR) [95% CI] = 2.33 [0.47-11.5], p = 0.440); 30-day mortality rates were 6.3% and 1.8% (p = 0.370); and 1-year mortality rates were 17.5% and 18.2% (p = 0.919). Patients who developed AKI had a significantly increased risk of 30-day (12.5% vs. 1.1%, p = 0.029) mortality. We found the presence of diabetes (odds ratio (OR) [95% CI] = 4.58 [1.58-13.3], p = 0.005) and elevated baseline serum creatinine (OR [95% CI] = 1.02 [1.00-1.03], p = 0.026) to independently predict AKI to statistical significance by multivariate analysis.

CONCLUSION

TAVI is a safe, acceptable treatment for patients with pre-existing CKD, however caution must be exercised, particularly in patients with pre-existing diabetes mellitus and elevated pre-operative serum creatinine levels as this confers a greater risk of AKI development, which is associated with increased short-term post-operative mortality.

Effect of gender after transcatheter aortic valve implantation: a meta-analysis

BACKGROUND

The effect of gender on patients with aortic stenosis undergoing transcatheter aortic valve implantation (TAVI) remains to be defined.

METHODS

MEDLINE, Cochrane Library, and Scopus databases were searched for articles describing sex differences in baseline characteristics, procedures, and outcomes. All-cause death at follow-up of at least 1 year was the primary end point, and the independent effect of female gender was evaluated with pooled analysis using a random-effect model and with meta-regression.

RESULTS

Six studies with 6,645 patients were included, half of them being women presenting with lower European System for Cardiac Operative Risk Evaluation (EuroSCORE) compared with men. At 30 days, more frequent major vascular complications and major and life-threatening bleeding occurred in women, with lower rates of moderate to severe aortic regurgitation, whereas 30-day mortality was similar. After a median follow-up of 365 days (range, 365 to 730 days) all-cause mortality was 24.0% in women and 34.0% in men. A pooled analysis of the multivariable approach found female gender was significantly related to a lower risk of death (odds ratio, 0.82; 95% CI, confidence interval, 0.73 to 0.93; I(2) = 0%). A meta-regression analysis showed age, ejection fraction, previous cardiovascular accident, renal insufficiency, and access site did not influence these data.

CONCLUSIONS

Female patients undergoing TAVI present with a lower burden of comorbidities. The counterbalance between higher rates of vascular complications but lower of valve regurgitation may explain the reduced risk for women after TAVI, independently from baseline features and access site.