Coronary access following ACURATE neo implantation for transcatheter aortic valve-in-valve implantation: Ex vivo analysis in patient-specific anatomies

Redo-TAVI with the ACURATE neo2 and Prime XL for balloon-expandable transcatheter heart valve failure

BACKGROUND

There are limited data regarding treatment for failed balloon-expandable transcatheter heart valves (THVs) in redo-transcatheter aortic valve implantation (TAVI).

AIMS

We aimed to assess THV performance, neoskirt height and expansion when performing redo-TAVI with the ACURATE platform inside a SAPIEN 3 (S3) compared to redo-TAVI with an S3 in an S3.

METHODS

Redo-TAVI was performed on the bench using each available size of the S3, the ACURATE neo2 (ACn2) and the next-generation ACURATE Prime XL (AC XL) implanted at 2 different depths within 20 mm/23 mm/26 mm/29 mm S3s serving as the "failed" index THV. Hydrodynamic testing was performed to assess THV function. Multimodality assessment was performed using photography, X-ray, microcomputed tomography (micro-CT), and high-speed videos.

RESULTS

The ACURATE in S3 combinations had favourable hydrodynamic performance compared to the S3 in S3 for all size combinations. In the 20 mm S3, redo-TAVI with the ACn2 had lower gradients compared to the S3 (mean gradient 16.3 mmHg for the ACn2 vs 24.7 mmHg for the 20 mm S3 in 20 mm S3). Pinwheeling was less marked for the ACURATE THVs than for the S3s. On micro-CT, the S3s used for redo-TAVI were underexpanded across all sizes. This was also observed for the ACURATE platform, but to a lesser extent.

CONCLUSIONS

Redo-TAVI with an ACn2/AC XL within an S3 has favourable hydrodynamic performance and less pinwheeling compared to an S3 in S3. This comes at the price of a taller neoskirt.

Comparison of Mid-Term Prognosis in Intermediate-to-Low-Risk Contemporary Population with Guidelines-Oriented Age Cutoff

BACKGROUND

Current European guidelines support transcatheter aortic valve implantation (TAVI) in intermediate-to-low-risk patients ≥75 years-old, but its prognostic relevance is unknown.

METHODS

Intermediate-to-low-risk (The Society of Thoracic Surgeons score <8%) patients enrolled in the HORSE registry were included. We compared the populations aged under 75 with those over 75. The primary endpoint was all-cause mortality.

RESULTS

A total of 2685 patients were included: 280 (8.6%) < 75 and 2405 ≥ 75 years. Through a mean follow-up of 437 ± 381 days, 198 (8.2%) and 23 (8.2%) patients died in the two arms without statistically significant differences (log-rank p = 0.925). At Cox regression analysis, age did not predict the occurrence of all-cause death, neither as a continuous variable (HR 1.01, 95% CI 0.99-1.04, p = 0.294) nor dichotomizing according to the prespecified cutoff of 75 years (HR 0.97, 95% CI 0.63-1.51, p = 0.924). Time-to-event ROC curves showed low accuracy of age to predict all-cause mortality (area under the curve of 0.54 for both 1-year and 2-year outcomes).

CONCLUSIONS

TAVI has comparable benefits across age strata for intermediate-to-low-risk patients. The age cutoff suggested by the current guidelines is not predictive of the risk of adverse events during hospital stays or of all-cause mortality through a mid-term follow-up.

Shaping the Future of Cardiovascular Disease by 3D Printing Applications in Stent Technology and its Clinical Outcomes

Cardiovascular disease (CVD) is a leading cause of death worldwide. In recent years, 3D printing technology has ushered in a new era of innovation in cardiovascular medicine. 3D printing in CVD management encompasses various aspects, from patient-specific models and preoperative planning to customized medical devices and novel therapeutic approaches. In-stent technology, 3D printing has revolutionized the design and fabrication of intravascular stents, offering tailored solutions for complex anatomies and individualized patient needs. The advantages of 3D-printed stents, such as improved biocompatibility, enhanced mechanical properties, and reduced risk of in-stent restenosis. Moreover, the clinical trials and case studies that shed light on the potential of 3D printing technology to improve patient outcomes and revolutionize the field has been comprehensively discussed. Furthermore, regulatory considerations, and challenges in implementing 3D-printed stents in clinical practice are also addressed, underscoring the need for standardization and quality assurance to ensure patient safety and device reliability. This review highlights a comprehensive resource for clinicians, researchers, and policymakers seeking to harness the full potential of 3D printing technology in the fight against CVD.

Coronary Reaccess After Modified Chimney Stenting in a Self-Expanding Transcatheter Valve-in-Valve

We demonstrate a modified technique of heterotopic chimney stenting for coronary obstruction during valve-in-valve transcatheter aortic valve replacement With successful end-on cannulation via the stent ostium. Our technique was reproducible on the bench with successful reaccess and without any interaction between the deployed coronary stent and the prosthetic leaflets.

TAVR Interventions and Coronary Access: How to Prevent Coronary Occlusion

Due to technological advancements during the past 20 years, transcatheter aortic valve replacements (TAVRs) have significantly improved the treatment of symptomatic and severe aortic stenosis, significantly improving patient outcomes. The continuous evolution of transcatheter valve models, refined imaging planning for enhanced accuracy, and the growing expertise of technicians have collectively contributed to increased safety and procedural success over time. These notable advancements have expanded the scope of TAVR to include patients with lower risk profiles as it has consistently demonstrated more favorable outcomes than surgical aortic valve replacement (SAVR). As the field progresses, coronary angiography is anticipated to become increasingly prevalent among patients who have previously undergone TAVR, particularly in younger cohorts. It is worth noting that aortic stenosis is often associated with coronary artery disease. While the task of re-accessing coronary artery access following TAVR is challenging, it is generally feasible. In the context of valve-in-valve procedures, several crucial factors must be carefully considered to optimize coronary re-access. To obtain successful coronary re-access, it is essential to align the prosthesis with the native coronary ostia. As part of preventive measures, strategies have been developed to safeguard against coronary obstruction during TAVR. One such approach involves placing wires and non-deployed coronary balloons or scaffolds inside an at-risk coronary artery, a procedure known as chimney stenting. Additionally, the bioprosthetic or native aortic scallops intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA) procedure offers an effective and safer alternative to prevent coronary artery obstructions. The key objective of our study was to evaluate the techniques and procedures employed to achieve commissural alignment in TAVR, as well as to assess the efficacy and measure the impact on coronary re-access in valve-in-valve procedures.

BASILICA Procedure Prior to Valve-in-Valve TAVR in a Supra-Annular TAV Prosthesis

An 80-year-old man with a supra-annular transcatheter aortic valve (TAV) prosthesis presented with severe transvalvular aortic regurgitation 18 months after the TAV replacement procedure. The authors report the first ever valve-in-valve procedure using BASILICA (bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction) in such a supra-annular TAV prosthesis. Minimal paravalvular leakage, normal coronary artery flow, and easy coronary access were seen postimplantation. (Level of Difficulty: Advanced.).

Impact of Evolution of Self-Expandable Aortic Valve Design: Peri-Operative and Short-Term Outcomes

A few data exist on the differences of implantable aortic valve bio-prostheses. We investigate three generations of self-expandable aortic valves in terms of the outcomes. Patients undergoing transcatheter aortic valve implantation (TAVI) were allocated into three groups according to the valve type: group A (CoreValve^TM), group B (Evolut^TMR) and group C (Evolut^TMPRO). The implantation depth, device success, electrocardiographic parameters, need for permanent pacemaker (PPM), and paravalvular leak (PVL) were assessed. In the study, 129 patients were included. The final implantation depth did not differ among the groups (p = 0.07). CoreValve^TM presented greater upward jump of the valve at release (2.88 ± 2.33 mm vs. 1.48 ± 1.09 mm and 1.71 ± 1.35 mm, for groups A, B, and C, respectively, p = 0.011). The device success (at least 98% for all groups, p = 1.00) and PVL rates (67% vs. 58%, vs. 60% for groups A, B, and C, respectively, p = 0.64) did not differ. PPM implantation within 24 h (33% vs. 19% vs. 7% for groups A, B, and C, respectively, p = 0.006) and until discharge (group A: 38% vs. group B: 19% and group C: 9%, p = 0.005) was lower in the newer generation valves. Newer generation valves present better device positioning, more predictable deployment, and fewer rates of PPM implantation. No significant difference in PVL was observed.