Transcatheter aortic valve implantation in low ejection fraction/low transvalvular gradient patients

Surgical vs Transcatheter Aortic Valve Replacement in Patients With a Low Ejection Fraction

Currently, there is no preference for surgical (SAVR) vs transcatheter (TAVR) aortic valve replacement in patients with low ejection fraction (EF). The present study retrospectively compared the outcomes of SAVR vs TAVR in patients with EF ≤40% (70 SAVR and 117 TAVR patients). Study outcomes were survival and the composite endpoint of stroke, aortic valve reintervention, and heart failure readmission. The patients who had TAVR were older (median: 75 (25-75th percentiles: 69-81) vs 51 (39-66) years old; P < .001) with higher EuroSCORE II (4.95 (2.99-9.85) vs 2 (1.5-3.25); P < .001). Postoperative renal impairment was more common with SAVR (8 (12.5%) vs 4 (3.42%); P = .03), and they had longer hospital stay [9 (7-15) vs 4 (2-8) days; P < .001). There was no difference between groups in stroke, reintervention, and readmission (Sub-distributional Hazard ratio: .95 (.37-2.45); P = .92). Survival at 1 and 5 years was 95% and 91% with SAVR and 89% and 63% with TAVR. Adjusted survival was comparable between groups. EF improved significantly (β: .28 (.23-.33); P < 0.001) with no difference between groups ( P = .85). In conclusion, TAVR could be as safe as SAVR in patients with low EF.

Identifying Patients without a Survival Benefit following Transfemoral and Transapical Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) offers a novel treatment option for patients with severe symptomatic aortic valve stenosis, particularly for patients who are unsuitable candidates for surgical intervention. However, high therapeutical costs, socio-economic considerations, and numerous comorbidities make it necessary to target and allocate available resources efficiently. In the present study, we aimed to identify risk factors associated with futile treatment following transfemoral (TF) and transapical (TA) TAVR. Five hundred and thirty-two consecutive patients (82 ± 9 years, female 63%) who underwent TAVR between June 2009 and December 2016 at the Vienna Heart Center Hietzing were retrospectively analyzed to identify predictors of futility, defined as all-cause mortality at one year following the procedure for the overall patient cohort, as well as the TF and TA cohort. Out of 532 patients, 91 (17%) did not survive the first year after TAVR. A multivariate logistic model identified cerebrovascular disease, home oxygen dependency, wheelchair dependency, periinterventional myocardial infarction, and postinterventional renal replacement therapy as the factors independently associated with an increased one-year mortality. Our findings underscore the significance of a precise preinterventional evaluation, as well as illustrating the subtle differences in baseline characteristics in the TF and TA cohort and their impact on one-year mortality.

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.

Is oral anticoagulation effective in preventing transcatheter aortic valve implantation failure? A propensity matched analysis of the Italian Transcatheter balloon-Expandable valve Registry study

BACKGROUND

Early hypo-attenuated leaflet thickening after transcatheter aortic valve implantation (TAVI) has been recently described presumably reflecting thrombus apposition. Although its clinical relevance is still unknown, oral anticoagulant therapy (OAT) led to almost complete resolution.

METHODS

The retrospecitve Italian Transcatheter balloon-Expandable valve registry that included all patients undergoing balloon-expandable TAVI in 33 Italian centers. Patients discharged after TAVI with aspirin alone were compared with those assuming aspirin and OAT before and after propensity score with matching. Prosthetic heart valve dysfunction at follow-up was the primary end point. All-cause death, cardiovascular death, bleeding, vascular complications and cerebrovascular accidents at 30 days and at follow-up were the secondary ones.

RESULTS

Among the 1904 patients enrolled in the Italian Transcatheter balloon-Expandable valve registry, 716 patients on OAT and aspirin or aspirin alone were identified and analyzed: 555 were on aspirin alone and 161 on OAT and aspirin. The median follow-up was 44.0 ± 12 months. After matching, risk of prosthetic valve dysfunction at follow-up did not differ between the two groups: 3.1% in patients treated with aspirin alone vs. 1.9% in those treated with OAT and aspirin, (P = 0.72). Nevertheless patients treated with aspirin alone at follow-up had a significantly lower risk of death (21 vs. 33%, P = 0.03) and major bleeding (4 vs. 14%, P = 0.04) with a similar rate of stroke/transient ischemic attack (TIA) (1.2 vs. 3.1%, P = 0.45). At 30 days rates of Valve Academic Research Consortium death were similar in both groups (0.6 vs. 3.7%, P = 0.12) with higher risk of life threatening bleeding and minor vascular complications in patients on OAT and aspirin.

CONCLUSION

After TAVI with Edwards Sapien valve OAT did not reduce the incidence of valve dysfunction and stroke but was responsible for mortality and bleeding increases.

Meta-Analysis of Outcomes of Transcatheter Aortic Valve Implantation Among Patients With Low Gradient Severe Aortic Stenosis

Transcatheter aortic valve implantation (TAVI) has emerged as an effective therapy for patients with severe aortic stenosis (AS). However, data on TAVI outcomes in patients with low gradient (LG) AS are limited. We performed a meta-analysis of studies comparing TAVI outcomes between patients with classic high gradient (HG) and LG AS through November 2018. The 30-day mortality, mid-term all-cause, and cardiovascular mortality at maximum follow-up were compared between patients with HG and LG AS (Pairwise meta-analysis), and between the three distinct groups of AS including HG, paradoxical low-flow low-gradient and low gradient with reduced ejection fraction (rEF-LG) (Network meta-analysis). Nineteen studies (n = 27,204 patients) met the inclusion criteria. The HG group had less 30-day, mid-term all-cause and cardiovascular mortality compared with the low-gradient AS group overall, (6% vs 7.5%, OR 0.76, 95% CI 0.66 to 0.87, I² = 18%), (21% vs 29%, OR 0.59, 95% CI 0.52 to 0.67, I² = 62%), and (12.6% vs 18.7%, OR 0.61, 95% CI 0.49 to 0.76, I² = 62%), respectively, p <0.0001. These outcomes were confirmed in a trial sequential analysis in which the cumulative Z-curve crossed the conventional test boundary as well as the trial sequential monitoring boundary for all outcomes. The network meta-analysis revealed that patients with rEF-LG had similar outcomes to those with pLFLG, and both had worse outcomes than patients with classic HG AS. In conclusion patients with classic HG have better 30-day mortality, mid-term all-cause and cardiovascular mortality compared with LG patients following TAVI. Among patients with LG severe AS, TAVI outcomes were similar in patients with rEF-LG and pLFLG.

Impact of baseline left ventricular ejection fraction on outcome after transfemoral transcatheter aortic valve implantation in patients with and without low-gradient aortic stenosis

OBJECTIVES

To evaluate the impact of baseline left ventricular ejection fraction (LVEF) and its interaction with low-gradient aortic stenosis (LGAS) on all-cause mortality after transfemoral aortic valve implantation (TF-TAVI).

METHODS

We reviewed mortality data of 624 consecutive single center TF-TAVI patients and categorized LVEF according to current ASE/EACVI recommendations (normal, mildly-, moderately-, and severely abnormal).

RESULTS

Baseline LVEF was normal in 336 (53.8%), mildly abnormal in 160 (25.6%), moderately abnormal in 91 (14.6%), and severely abnormal in 37 (5.9%) patients, and 1-year mortality was 19%, 17%, 23%, and 43% (P = 0.002), respectively. Patients with LGAS had a similar 1-year mortality compared to those without LGAS in groups with normal (19% vs 19%, P = 0.899) and mildly abnormal LVEF (16% vs 17%, P = 0.898). One-year mortality of patients with LGAS was significantly greater than in those without LGAS in presence of moderately abnormal LVEF (31% vs 11%, P = 0.022), and it was numerically greater than in those without LGAS in presence of severely abnormal LVEF (48% vs 25%, P = 0.219). In multivariate analysis, only the combination of moderately/severely abnormal LVEF and LGAS predicted increased 1-year mortality (HR: 2.12, 95% CI: 1.4-3.2, P < 0.001). Other variables, including EuroSCORE I did not affect this result.

CONCLUSIONS

Moderately/severely abnormal LVEF (≤40%) at baseline is associated with increased mortality after TF-TAVI, especially when the mean transvalvular aortic gradient is <40 mm Hg (LGAS), while outcomes in patients with normal and mildly abnormal LVEF are comparable regardless of the pressure gradient across the native aortic valve. (DRKS00013729).

Carotid Doppler sonography: additional tool to assess hemodynamic improvement after transcatheter aortic valve implantation

PURPOSE

The aim of our study was to assess the arterial cerebral blood flow variations in patients with aortic valve stenosis, immediately after the transcatheter aortic valve implantation (TAVI).

METHODS

The study population includes 62 consecutive patients who underwent TAVI for aortic valve stenosis (95%) and sugical bioprosthesis degeneration (5%). Carotid Doppler examination was performed recording blood flow, systolic peak velocity, time average mean velocity and mean acceleration time at baseline, after balloon aortic valvuloplasty, and within 10 min after the device release.

RESULTS

A significant improvement of blood flow was recorded at the end of the procedure (from 315.05 ± 141.72 to 538.67 ± 277.46 ml/min; P < 0.00001). The systolic peak velocity and the time average mean velocity increased from 52.27 ± 14.29 to 78.89 ± 20.48 cm/s (P < 0.00001) and from 12.24 ± 4.74 to 21.21 ± 9 cm/s (P < 0.00001), respectively. Consensually, the mean acceleration time decreased from 0.22 ± 0.02 to 0.03 ± 0.02 s (P < 0.00001) after the procedure.

CONCLUSION

Monitoring of Doppler measurements may be a useful and noninvasive method to assess acutely the improvement of hemodynamic flow after TAVI, specifically for the cerebral district.