A 20-year journey in transcatheter aortic valve implantation: Evolution to current eminence

Transcatheter aortic valve replacement in heavily calcified aortic valve stenosis: a multicenter comparison

BACKGROUND

Heavy calcifications in severe aortic stenosis (AS) pose a major challenge in patients undergoing transcatheter aortic valve replacement (TAVR). Only a few studies have addressed the performance of different transcatheter heart valves (THV) in this subgroup of patients.

OBJECTIVES

We aimed to investigate the outcomes of the self-expanding Medtronic CoreValve Evolut valve frame and the balloon-expandable Edwards SAPIEN-3/3 Ultra THV in this challenging patient population.

MATERIALS AND METHODS

This was a multicenter registry including a total of 1513 patients with heavily calcified AS undergoing TAVR. The primary endpoint was the incidence and degree of paravalvular leak (PVL) after TAVR. Secondary endpoints were post-implant hemodynamics as well as clinical endpoints according to the VARC-3 definitions.

RESULTS

The CoreValve Evolut R but not the Evolut PRO showed significantly higher rates of PVL compared to the SAPIEN-3/3 Ultra (44.8% vs. 29.5% for mild PVL, p < 0.001), while there was no significant difference in ≥ moderate PVL between both groups (p = 0.399). The CoreValve Evolut R and Evolut PRO showed superior THV hemodynamics compared to the SAPIEN-3/3 Ultra group. These findings were confirmed in a propensity score-matched analysis. There were no significant differences regarding short-term outcomes including permanent pacemaker implantation and all-cause mortality between the three groups.

CONCLUSION

In patients with severely calcified AS, both CoreValve Evolut PRO and SAPIEN-3/3 Ultra THV showed lower rates of PVL than the CoreValve Evolut R. The self-expanding CoreValve platform had superior post-implant hemodynamics than the SAPIEN-3/3 Ultra system.

Comparison of the effects of perioperative fentanyl and morphine use on the short-term prognosis of patients with cardiac surgery in the ICU

Aim

This study aimed to analyze the effects of perioperative morphine and fentanyl use on delirium, length of ICU stay, and in-hospital mortality after cardiac surgery.

Methods

This cohort study retrieved the data of 4,596 patients admitted to ICU after cardiac surgery in MIMIC-IV database from 2008 to 2019. The primary outcome was postoperative delirium. The secondary outcomes were length of ICU stay, and in-hospital mortality. To compare the effects of perioperative fentanyl and morphine use on postoperative delirium, length of ICU stay, and in-hospital mortality, univariate, two-way stepwise, as well as multivariable Logistic regression, linear regression, and Cox proportional hazards models was respectively used. Odd ratio (OR), β coefficient, hazard ratio (HR), and respective confidence interval (CI) were calculated. Subgroup analysis was conducted in terms of age, use of extracorporeal circulation, midazolam, dexmedetomidine or surgery type.

Results

In total, the data of 4,596 patients were analyzed including 2,589 morphine user and 2007 fentanyl user. We found that the risk of postoperative delirium was reduced in patients with cardiac surgery undergoing perioperative morphine relative to perioperative fentanyl (OR = 0.62, 95%CI: 0.40-0.96). Perioperative morphine use was negatively correlated with the length of ICU stay in patients with cardiac surgery in comparison to patients with perioperative fentanyl use (β = -0.72, 95%CI: -1.06, -0.39). Relative to patients who had perioperative fentanyl, patients who had perioperative morphine were associated with reduced risk of in-hospital mortality in patients with cardiac surgery after adjusting for respective confounding factors (HR = 0.35, 95%CI: 0.13-0.91).

Conclusion

Perioperative morphine use was related to lower risk of delirium and in-hospital mortality as well as shortened length of ICU stay in these patients. The findings might offer a reference for perioperative anesthesia management in patients receiving cardiac surgery.

Assessment of bystander coronary artery disease in transcatheter aortic valve replacement (TAVR) patients using noncoronary-dedicated planning computed tomography angiography (CTA): diagnostic accuracy in a retrospective real-world cohort

AIM

To assess the diagnostic potential of a noncoronary-dedicated pre-TAVR CT angiography (CTA) conducted as a prospective ECG-gated scan without premedication and standard cardiac reconstructions in evaluating bystander coronary artery disease (CAD) against invasive coronary angiography (ICA) as the gold standard.

MATERIALS AND METHODS

This retrospective study included 232 patients who underwent both CTA and ICA as part of their pre-TAVR evaluation. Exclusion criteria included prior stent, pacemaker, coronary artery bypass, or valve surgery. Coronary arteries were analysed solely through thin-slice axial reconstructions, with observers blinded to ICA results. Stenosis was categorised as mild (< 50%), moderate (50%-69%), or severe (≥70%). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy were calculated for 50% and 70% diameter stenosis (DS) thresholds.

RESULTS

At the 50% DS threshold, CTA demonstrated 71% sensitivity, 74% specificity, 92% NPV, and 38% PPV. At the 70% DS threshold, results included 46% sensitivity, 91% specificity, 93% NPV, and 41% PPV. The highest vessel-specific NPV at 50% DS was for the left main (98%) and left anterior descending (LAD) (91%); at 70% DS, left main (LM) (98%) and left circumflex (LCX) (94%) showed the highest NPV. Image quality impacted NPV, with excellent or very good image quality linked to higher diagnostic performance.

CONCLUSION

Noncoronary-dedicated pre-TAVR CTA shows promise for ruling out significant CAD effectively and may act as a gatekeeper for ICA, aligning with typical coronary CT angiography (CCTA) outcomes.

The Impact of Transcatheter Aortic Valve Implantation on Health Care Costs and Clinical Outcomes Based on Frailty Risk: A Nationwide Cohort Analysis

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is preferred for treating severe aortic stenosis in older, frail populations, yet the impact of frailty on economic and clinical outcomes of TAVI is not well studied.

METHODS

This retrospective cohort study included 2175 TAVI patients from 2015 to 2019, using Korea's National Health Insurance Service database, stratifying patients into low, intermediate, and high-frailty groups, using the Hospital Frailty Risk Score (HFRS). Health care costs, admissions, and total length of hospitalization were analyzed using Wilcoxon-rank test 12 months pre- and post-TAVI. Composite endpoint of death, stroke, and major bleeding, with individual outcomes, were compared using χ2 tests and Kaplan-Meier analysis.

RESULTS

Mean age was 80.2 years, and 47.3% were male; 747 (34.3%) were low frailty, 1159 (53.3%) were moderate frailty, and 269 (12.4%) were high frailty. After TAVI, medical costs decreased in the intermediate- (pre-TAVI: 2,269,000 KRW [$1668 USD], post-TAVI: 1,607,000 KRW [$1181 USD]; P < 0.001) and high-frailty groups (pre-TAVI: 3,949,000 KRW [$2904 USD], post-TAVI: 2,188,000 KRW [$1609 USD]; P < 0.001). All frailty groups had shorter length of hospital stay post-TAVI (26 to 21 days in the low-frailty, 44 to 31 days in the intermediate-frailty, and 65 to 41 days in the high-frailty group; all P <0.001). The composite outcome was higher in the frailer groups (27.8% in the low-frailty vs 31.5% in the intermediate-frailty vs 37.9% in the high-frailty group; P = 0.008). All groups showed comparable rates of cardiovascular death, stroke, or bleeding.

CONCLUSIONS

TAVI is clinically viable and cost-saving treatment option for frail patients with severe aortic stenosis.

An Updated Comprehensive Review of Existing Transcatheter Aortic Valve Replacement Access

For the past 20 years, transcatheter aortic valve replacement (TAVR) has been the treatment of choice for symptomatic aortic stenosis. The transfemoral (TF) access is considered the gold standard approach for TAVR. However, TF-TAVR cannot be performed in some patients; thus, alternative accesses are required. Our review paper generalises the TAVR accesses currently available, including the transapical, transaortic, trans-subclavian/axillary, transcarotid, transcaval, and suprasternal approaches. Their advantages and disadvantages have been analysed. Since there is no standard recommendation for an alternative approach, access selection depends on the expertise of the local cardiac team, patient characteristics, and access properties. Each TAVR centre is recommended to master a minimum of one non-TF access alternative. Of note, more evidence is required to delve into the clinical outcomes of each approach, at both early and long-term (Figure 1).

Periprocedural Assessment of Paravalvular Regurgitation After Transcatheter Aortic Valve Replacement Using Diastolic Delta and Videodensitometry

BACKGROUND

Paravalvular regurgitation (PVR) is a common complication after transcatheter aortic valve replacement, posing an increased risk of heart failure and mortality. Accurate intraprocedural quantification of PVR is challenging. Both hemodynamic indices and videodensitometry can be used for intraprocedural assessment of PVR. We compared the predictive value of the isolated versus combined use of the hemodynamic index diastolic delta (DD) and videodensitometry for the incidence of relevant PVR 1 month after transcatheter aortic valve replacement.

METHODS AND RESULTS

In this prospective cohort study, patients underwent periprocedural PVR assessment by DD and videodensitometry (using left ventricular outflow tract-aortic regurgitation [LVOT-AR]). Cardiac magnetic resonance served as reference modality for PVR assessment. Relevant PVR was defined as cardiac magnetic resonance-regurgitant fraction >20%. Fifty-one patients were enrolled in this study. Mean age was 80.6±5.2 years and 45.1% of patients were men. Mean LVOT-AR and cardiac magnetic resonance-regurgitant fraction were 8.2%±7.8% and 11.7%±9.6%, respectively. The correlation between DD and LVOT-AR was weak (r=-0.36). DD and LVOT-AR showed a comparable accuracy to predict relevant PVR (area under the curve 0.82, 95% CI: 0.69-0.95 versus area area under the time-density curve 0.80, 95% CI: 0.62-0.99). The combination of DD and LVOT-AR improved the prediction of relevant PVR (area under the time-density curve, 0.90, 95% CI: 0.81-0.99), and resulted in an increased concordance (86.3%) and positive predictive value (75%) compared with DD alone (76.5% and 40%, respectively), or LVOT-AR alone (82.3% and 50%, respectively).

CONCLUSIONS

DD and videodensitometry are both accurate and feasible modalities for the assessment of PVR after transcatheter aortic valve replacement. The synergistic use of both techniques increases the predictive value for relevant PVR after transcatheter aortic valve replacement.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT04281771.

Interprofessional education in cardiothoracic surgery: a narrative review

Interprofessional education, an approach where healthcare professionals from various disciplines learn with, from, and about each other, is widely recognized as an important strategy for improving collaborative practice and patient outcomes. This narrative review explores the current state and future directions of interprofessional education in cardiothoracic surgery. We conducted a literature search using the PubMed, Scopus, and Web of Science databases, focusing on English-language articles published after 2000. Our qualitative synthesis identified key themes related to interprofessional education interventions, outcomes, and challenges. The integration of interprofessional education in cardiothoracic surgery training programs varies across regions, with a common focus on teamwork and interpersonal communication. Simulation-based training has emerged as a leading modality for cultivating these skills in multidisciplinary settings, with studies showing improvements in team performance, crisis management, and patient safety. However, significant hurdles remain, including professional socialization, hierarchies, stereotypes, resistance to role expansion, and logistical constraints. Future efforts in this field should prioritize deeper curricular integration, continuous faculty development, strong leadership support, robust outcome evaluation, and sustained political and financial commitment. The integration of interprofessional education in cardiothoracic surgery offers considerable potential for enhancing patient care quality, but realizing this vision requires a multifaceted approach. This approach must address individual, organizational, and systemic factors to build an evidence-based framework for implementation.

Emerging Transcatheter Therapies for Valvular Heart Disease: Focus on Mitral and Tricuspid Valve Procedures

The emergence of percutaneous treatment options provides novel therapeutic alternatives for older and feeble patients who are at high risk for any surgical procedure. The purpose of our review was to offer an up-to-date analysis of the rapidly expanding field of percutaneous technologies for mitral, tricuspid, and pulmonary procedures. Edge-to-edge repair is an established treatment for secondary mitral regurgitation (MR), while transcatheter mitral valve replacement is a potential and expanding option for managing both secondary and primary MR. However, additional advancements are necessary to enhance the safety and feasibility of this procedure. Transcatheter tricuspid intervention is an emerging option that was conceived after the success of transcatheter procedures in aortic and mitral valves, and it is currently still in the early stages of advancement. This can be attributed, at least in part, to the previously overlooked effect of tricuspid regurgitation on patient outcomes. The development of edge-to-edge repair represents the forefront of innovations in transcatheter procedures. There is a scarcity of data about tricuspid annuloplasty and replacement, and further study is necessary. Transcatheter mitral, tricuspid, and pulmonary procedures show prospects for the future, while their role in clinical practice has not been definitively established.

Long-Term Outcomes of Transcatheter vs Surgical Aortic Valve Replacement: Meta-analysis of Randomized Trials

Background

We aimed to perform a meta-analysis of randomized trials comparing long-term outcomes of patients undergoing transcatheter aortic valve replacement (TAVR) vs surgical aortic valve replacement (SAVR) for severe aortic stenosis. The short-term efficacy and safety of TAVR are proven, but long-term outcomes are unclear.

Methods

We included randomized controlled trials comparing TAVR vs SAVR at the longest available follow-up. The primary end point was death or disabling stroke. Secondary end points were all-cause mortality, cardiac mortality, stroke, pacemaker implantation, valve thrombosis, valve gradients, and moderate-to-severe paravalvular leaks. The study is registered with PROSPERO (CRD42023481856).

Results

Seven trials (N = 7785 patients) were included. Weighted mean trial follow-up was 5.76 ± 0.073 years. Overall, no significant difference in death or disabling stroke was observed with TAVR vs SAVR (HR, 1.02; 95% CI, 0.93-1.11; P = .70). Mortality risks were similar. TAVR resulted in higher pacemaker implantation and moderate-to-severe paravalvular leaks compared to SAVR. Results were consistent across different surgical risk profiles. As compared to SAVR, self-expanding TAVR had lower death or stroke risk (P interaction = .06), valve thrombosis (P interaction = .06), and valve gradients (P interaction < .01) but higher pacemaker implantation rates than balloon-expandable TAVR (P interaction < .01).

Conclusions

In severe aortic stenosis, the long-term mortality or disabling stroke risk of TAVR is similar to SAVR, but with higher risk of pacemaker implantation, especially with self-expanding valves. As compared with SAVR, the relative reduction in death or stroke risk and valve thrombosis was greater with self-expanding than with balloon-expandable valves.

Assessment of paravalvular regurgitation after transcatheter aortic valve replacement using 2D multi-velocity encoding and 4D flow cardiac magnetic resonance

AIMS

To compare the novel 2D multi-velocity encoding (venc) and 4D flow acquisitions with the standard 2D flow acquisition for the assessment of paravalvular regurgitation (PVR) after transcatheter aortic valve replacement (TAVR) using cardiac magnetic resonance (CMR)-derived regurgitant fraction (RF).

METHODS AND RESULTS

In this prospective study, patients underwent CMR 1 month after TAVR for the assessment of PVR, for which 2D multi-venc and 4D flow were used, in addition to standard 2D flow. Scatterplots and Bland-Altman plots were used to assess correlation and visualize agreement between techniques. Reproducibility of measurements was assessed with intraclass correlation coefficients. The study included 21 patients (mean age ± SD 80 ± 5 years, 9 men). The mean RF was 11.7 ± 10.0% when standard 2D flow was used, 10.6 ± 7.0% when 2D multi-venc flow was used, and 9.6 ± 7.3% when 4D flow was used. There was a very strong correlation between the RFs assessed with 2D multi-venc and standard 2D flow (r = 0.88, P < 0.001), and a strong correlation between the RFs assessed with 4D flow and standard 2D flow (r = 0.74, P < 0.001). Bland-Altman plots revealed no substantial bias between the RFs (2D multi-venc: 1.3%; 4D flow: 0.3%). Intra-observer and inter-observer reproducibility for 2D multi-venc flow were 0.98 and 0.97, respectively, and 0.92 and 0.90 for 4D flow, respectively.

CONCLUSION

Two-dimensional multi-venc and 4D flow produce an accurate quantification of PVR after TAVR. The fast acquisition of the 2D multi-venc sequence and the free-breathing acquisition with retrospective plane selection of the 4D flow sequence provide useful advantages in clinical practice, especially in the frail TAVR population.

LANDMARK comparison of early outcomes of newer-generation Myval transcatheter heart valve series with contemporary valves (Sapien and Evolut) in real-world individuals with severe symptomatic native aortic stenosis: a randomised non-inferiority trial

BACKGROUND

Transcatheter aortic valve implantation is an established, guideline-endorsed treatment for severe aortic stenosis. Precise sizing of the balloon-expandable Myval transcatheter heart valve (THV) series with the aortic annulus is facilitated by increasing its diameter in 1·5 mm increments, compared with the usual 3 mm increments in valve size. The LANDMARK trial aimed to show non-inferiority of the Myval THV series compared with the contemporary THVs Sapien Series (Edwards Lifesciences, Irvine, CA, USA) or Evolut Series (Medtronic, Minneapolis, MN, USA).

METHODS

In this prospective, multinational, randomised, open-label, non-inferiority trial across 31 hospitals in 16 countries (Germany, France, Sweden, the Netherlands, Italy, Spain, New Zealand, Portugal, Greece, Hungary, Poland, Slovakia, Slovenia, Croatia, Estonia, and Brazil), 768 participants with severe symptomatic native aortic stenosis were randomly assigned (1:1) to the Myval THV or a contemporary THV. Eligibility was primarily decided by the heart team in accordance with 2021 European Society of Cardiology guidelines. As per the criteria of the third Valve Academic Research Consortium, the primary endpoint at 30 days was a composite of all-cause mortality, all stroke, bleeding (types 3 and 4), acute kidney injury (stages 2-4), major vascular complications, moderate or severe prosthetic valve regurgitation, and conduction system disturbances resulting in a permanent pacemaker implantation. Non-inferiority of the study device was tested in the intention-to-treat population using a non-inferiority margin of 10·44% and assuming an event rate of 26·10%. This trial is registered with ClinicalTrials.gov, NCT04275726, and EudraCT, 2020-000137-40, and is closed to new participants.

FINDINGS

Between Jan 6, 2021, and Dec 5, 2023, 768 participants with severe symptomatic native aortic stenosis were randomly assigned, 384 to the Myval THV and 384 to a contemporary THV. 369 (48%) participants had their sex recorded as female, and 399 (52%) as male. The mean age of participants was 80·0 years (SD 5·7) for those treated with the Myval THV and 80·4 years (5·4) for those treated with a contemporary THV. Median Society of Thoracic Surgeons scores were the same in both groups (Myval 2·6% [IQR 1·7-4·0] vs contemporary 2·6% [1·7-4·0]). The primary endpoint showed non-inferiority of the Myval (25%) compared with contemporary THV (27%), with a risk difference of -2·3% (one-sided upper 95% CI 3·8, pnon-inferiority<0·0001). No significant difference was seen in individual components of the primary composite endpoint.

INTERPRETATION

In individuals with severe symptomatic native aortic stenosis, the Myval THV met its primary endpoint at 30 days.

FUNDING

Meril Life Sciences.

Antithrombotic Therapy in Patients Undergoing Transcatheter Aortic Valve Implantation

Transcatheter aortic valve implantation (TAVI) now represents the mainstay of treatment for severe aortic stenosis. Owing to its exceptional procedural efficacy and safety, TAVI has been extended to include patients at lower surgical risk, thus now encompassing a diverse patient population receiving this treatment. Yet, long-term outcomes also depend on optimal medical therapy for secondary vascular prevention, with antithrombotic therapy serving as the cornerstone. Leveraging data from multiple randomized controlled trials, the current guidelines generally recommend single antithrombotic therapy, with either single antiplatelet therapy (SAPT) or oral anticoagulation (OAC) alone in those patients without or with atrial fibrillation, respectively. Yet, individualization of this pattern, as well as specific case uses, may be needed based on individual patient characteristics and concurrent procedures. This review aims to discuss the evidence supporting antithrombotic treatments in patients treated with TAVI, indications for a standardized treatment, as well as specific considerations for an individualized approach to treatment.

Safety and effectiveness of the novel Myval Octacor transcatheter heart valve in severe, symptomatic aortic valve stenosis - A real-world Indian experience (The OCTACOR India Study)

PURPOSE

To evaluate the safety and effectiveness of the novel, next-generation Myval Octacor - Transcatheter Heart Valve (THV) in patients with severe, symptomatic, native aortic stenosis (AS).

METHODS

This multicenter, real-world observational registry included 123 patients with severe symptomatic AS, across 16 Indian centers who underwent treatment with the novel Myval Octacor THV. Study endpoints included all-cause mortality, all stroke, acute kidney injury (AKI), major vascular complications, moderate or severe paravalvular leakage (PVL) and new permanent pacemaker implantation (PPI) until 30 days follow-up.

RESULTS

Of the 123 patients (average age 70.07 ± 8.33 years), 37.4 % (n = 46) were female and 39.84 % presented with bicuspid valves. The technical success rate of the procedure was 100 % and the device success rate at 30 days was 98.4 %. At 30 days (n = 123) after the procedure, the overall mortality was 1.6 %. AKI occurred in 1.6 % of patients and there was no incidence of stroke, bleeding (types 3 and 4), and major vascular complications. In an analysis of 31 patients whose echocardiographic parameters were available across all timepoints, there were significant improvements in the mean pressure gradient (54.31 ± 18.19 mmHg vs. 10.42 ± 4.24 mmHg; p < 0.0001) and effective orifice area (0.66 ± 0.21 cm2 vs. 1.80 ± 0.44 cm2; p < 0.0001) from baseline to the 30-day follow-up. None of the patients experienced severe PVL, while moderate PVL was observed in two patients (1.6 %).

CONCLUSIONS

Early outcomes of the next-generation, novel Myval Octacor THV proved its safety and effectiveness in the treatment of severe AS.

Comparison of ultrasound- versus fluoroscopy-guidEd femorAl access In tranS-catheter aortic valve replacement In the Era of contempoRary devices: The EASIER registry

BACKGROUND

Vascular complications (VCs) still represent one of the principal concerns of trans-femoral trans-catheter aortic valve replacement (TF-TAVR). New-generation devices can minimize such complications but the arterial access management is left to the operator's choice. This study aims to describe the rate of VCs in a contemporary cohort of patients undergoing TAVR with new-generation devices and to determine whether an ultrasound-guided (USG) vs. a fluoroscopy-guided (FG) femoral access management has an impact on their prevention.

METHODS

This is a prospective, observational, multicenter study. Consecutive patients undergoing TAVR with new-generation devices were analyzed from January 2022 to October 2022 in five tertiary care centers. Femoral accesses were managed according to the operator's preferences. All the patients underwent a pre-discharge peripheral ultrasound control. VCs and bleedings were the main endpoints of interest.

RESULTS

A total of 458 consecutive patients were enrolled (274 in the USG group and 184 in the FG group). VCs occurred in 6.5 % of the patients (5.2 % minor and 1.3 % major). There was no difference between the USG and the FG groups in terms of any VCs (7.3 % vs. 5.4 %; p = 0.4), or any VARC-3 bleedings (6.9 % vs 6 %, p = 0.9). At logistic regression analysis, the two guidance strategies did not result as predictors of VCs (odds Ratio 0.8, 95 % Confidence Interval 0.46-1.4; P = 0.4).

CONCLUSIONS

In a contemporary cohort of patients undergoing TAVR with new-generation devices, the occurrence of VCs is low and mostly represented by minor VCs. USG and FG modalities did not affect the rate of VCs.

Patient-specific computer simulation of transcatheter aortic valve replacement in patients with previous mechanical mitral prosthesis: A case series

Transcatheter aortic valve replacement performed in patients with previously implanted mechanical mitral prosthesis represents a high risk procedure with several potential complications. We report a systematic use of a prediction model based on artificial intelligence to plan the interventional strategy in this challenging scenario.

Utility of Coronary Computed Tomography Angiography in Patients Undergoing Transcatheter Aortic Valve Implantation: A Meta-Analysis and Meta-Regression Based on Published Data from 7458 Patients

BACKGROUND

Coronary CT angiography (CCTA) may detect coronary artery disease (CAD) in transcatheter aortic valve implantation (TAVI) patients and may obviate invasive coronary angiography (ICA) in selected patients. We assessed the diagnostic accuracy of CCTA for detecting CAD in TAVI patients based on published data.

METHODS

Meta-analysis and meta-regression were performed based on a comprehensive electronic search, including relevant studies assessing the diagnostic accuracy of CCTA in the setting of TAVI patients compared to ICA. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), were calculated on a patient and per segment level.

RESULTS

Overall, 27 studies (total of 7458 patients) were included. On the patient level, the CCTA's pooled sensitivity and NPV were 95% (95% CI: 93-97%) and 97% (95% CI: 95-98%), respectively, while the specificity and PPV were at 73% (95% CI: 62-82%) and 64% (95% CI: 57-71%), respectively. On the segmental coronary vessel level, the sensitivity and NPV were 90% (95% CI: 79-96%) and 98% (95% CI: 97-99%).

CONCLUSIONS

This meta-analysis highlights CCTA's potential as a first-line diagnostic tool although its limited PPV and specificity may pose challenges when interpreting heavily calcified arteries. This study underscores the need for further research and protocol standardization in this area.

Treatment of severe symptomatic aortic valve stenosis using non-invasive ultrasound therapy: a cohort study

BACKGROUND

Calcific aortic stenosis is commonly treated using surgical or transcatheter aortic valve replacement; however, many patients are not considered suitable candidates for these interventions due to severe comorbidities and limited life expectancy. As such, non-invasive therapies might offer alternative therapeutic possibilities in these patients. This study aimed to assess the safety of non-invasive ultrasound therapy and its ability to improve valvular function by softening calcified valve tissue.

METHODS

This prospective, multicentre, single-arm series enrolled 40 adult patients with severe symptomatic aortic valve stenosis at three hospitals in France, the Netherlands, and Serbia between March 13, 2019, and May 8, 2022. Patients were treated with transthoracically delivered non-invasive ultrasound therapy. Follow-ups were scheduled at 1, 3, 6, 12, and 24 months. The primary endpoints were procedure-related deaths within 30 days and improved valve function. We report the 6-month data. This study is registered at ClinicalTrials.gov, NCT03779620 and NCT04665596.

FINDINGS

40 high-risk patients with a mean Society of Thoracic Surgeons score of 5·6% (SD 4·4) and multiple severe comorbidities were included. The primary endpoint, procedure-related mortality, did not occur; furthermore, no life-threatening or cerebrovascular events were reported. Improved valve function was confirmed up to 6 months, reflected by a 10% increase in mean aortic valve area from 0·58 cm2 (SD 0·19) at baseline to 0·64 cm2 (0·21) at follow-up (p=0·0088), and a 7% decrease in mean pressure gradient from 41·9 mm Hg (20·1) to 38·8 mm Hg (17·8; p=0·024). At 6 months, the New York Heart Association score had improved or stabilised in 24 (96%) of 25 patients, and the mean Kansas City Cardiomyopathy Questionnaire score had improved by 33%, from 48·5 (SD 22·6) to 64·5 (21·0). One serious procedure-related adverse event occurred in a patient who presented with a transient decrease in peripheral oxygen saturation. Non-serious adverse events included pain, discomfort during treatment, and transient arrhythmias.

INTERPRETATION

This novel, non-invasive ultrasound therapy for calcified aortic stenosis proved to be safe and feasible.

FUNDING

Cardiawave.

Early Safety and Performance of the Premounted Dry-Pericardium Vienna Self-Expandable Transcatheter Aortic Valve System: 30-Day Outcomes of the First-in-Human VIVA Feasibility Study

The purpose of this first-in-human (FIH) study was to determine the safety and feasibility of the transfemoral premounted dry-pericardium Vienna Self-Expandable Supra-Annular Aortic Valve System. This novel system is repositionable and retrievable and comes already premounted on the delivery system, eliminating the need for assembly and crimping of the device before valve implantation. This is a prospective, nonrandomized, single-arm, single-center, first-stage FIH feasibility study, which will be followed by a second-stage pivotal, multicenter, multinational study in symptomatic patients with severe aortic stenosis. The first-stage FIH study evaluated the safety and feasibility of the device in 10 patients with severe aortic stenosis based on recommendations by the Valve Academic Research Consortium-2 for transcatheter aortic valve implantations. The mean patient age was 79 ± 5 years, 60% were male, and all patients were in New York Heart Association functional class II to III. The primary safety end point was successful when all patients were alive at 30-day follow-up. Device and technical success were observed in all patients. Two patients had a stroke, 1 of which occurred 5 days after the procedure. New permanent pacemakers were implanted in 2 patients (22.2%), of which only 1 was because of complete heart block. Only 1 patient (10%) had moderate paravalvular leak at 30 days. After the procedure, the mean aortic valve gradient decreased from 48.7 ± 10.8 mm Hg to 8.8 ± 4.3 mm Hg. In conclusion, this FIH feasibility study demonstrates successful procedural feasibility, with no 30-day mortality and favorable valve hemodynamic performance, leading to an improvement in quality of life. ClinicalTrials.gov identifier NCT04861805.

Transcatheter Aortic Valve Replacement in Bicuspid Versus Tricuspid Aortic Valve Stenosis: Meta-Analysis and Systemic Review

Because of its anatomic and procedural complexities, bicuspid aortic valve (BAV) has been excluded from previous trials investigating transcatheter aortic valve replacement (TAVR). We aimed to compare the clinical outcomes of TAVR in BAV and tricuspid aortic valve patients. We searched the databases systematically from inception until March 2023 for studies that reported the outcomes of TAVR in BAV and tricuspid aortic valve patients. The primary focus was all-cause mortality at 1 year. Additional outcomes included outcomes at 30-day follow-up. Secondary and subgroup analyses were performed on propensity-matched patients, patients at low surgical risk, and based on the type of transcatheter valve type. We included 30 studies with a total of 193,274 patients who underwent TAVR, of which 14,353 patients had BAV stenosis. The rate of 1-year mortality was lower in the BAV group compared with the tricuspid group with the results reaching statistical significance (odds ratio [OR] 0.86, 95% confidence interval [CI] 0.75 to 0.98, p = 0.02). The rate of 30-day stroke, however, was higher in patients with BAV who underwent TAVR (OR 1.24, 95% CI 1.08 to 1.43, p <0.05). Other 30-day clinical outcomes were similar between the 2 groups. Similar outcomes were observed in secondary analysis of matched populations with less mortality and higher rate of stroke in patients with BAV (OR 0.84, 95% CI 0.72 to 0.96, p = 0.01, and OR 1.38, 95% CI 1.09 to 1.75, p <0.05, respectively). Comparing the outcomes for self-expandable and balloon-expandable valves resulted in similar results. Subgroup analysis of low-surgical-risk patients similarly showed lower 1-year mortality in patients with BAV (OR 0.67, 95% CI 0.50 to 0.91, p = 0.01), without difference in 30-day stroke between the 2 groups (OR 1.24, 95% CI 0.83 to 1.88, p = 0.30). In conclusion, this report indicates that TAVR is safe and feasible in patients with BAV, including patients at low surgical risk. The higher rate of 30-day stroke, however, warrants caution when pursuing TAVR in this population. More studies, specifically randomized trials, are still warranted to further assess the safety and the long-term outcomes in this group.

Comparison of middle-term valve durability between transcatheter aortic valve implantation and surgical aortic valve replacement: an updated systematic review and meta-analysis of RCTs

Background

This study aims to compare valve durability between transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR).

Methods

We conducted a systematic review and meta-analysis using data from randomized controlled trials (RCTs). The primary outcome was structural valve deterioration (SVD). Secondary outcomes were bioprosthetic valve failure, reintervention, effective orifice area (EOA), mean pressure gradient, and moderate-severe aortic regurgitation (AR, transvalvular and/or paravalvular).

Results

Twenty-five publications from seven RCTs consisting of 7,970 patients were included in the analysis with follow-up ranges of 2-8 years. No significant difference was found between the two groups with regard to SVD [odds ratio (OR) 0.72; 95% CI: 0.25-2.12]. The TAVI group was reported to exhibit a statistically significant higher risk of reintervention (OR 2.03; 95% CI: 1.34-3.05) and a moderate-severe AR (OR 6.54; 95% CI: 3.92-10.91) compared with the SAVR group. A trend toward lower mean pressure gradient in the TAVI group [(mean difference (MD) -1.61; 95% CI: -3.5 to 0.28)] and significant higher EOA (MD 0.20; 95% CI: 0.08-0.31) was noted.

Conclusion

The present data indicate that TAVI provides a comparable risk of SVD with favorable hemodynamic profile compared with SAVR. However, the higher risk of significant AR and reintervention was demonstrated.

Systematic Review Registration

PROSPERO (CRD42022363060).

TAVI after More Than 20 Years

It has been more than 20 years since the first in man transcatheter aortic valve intervention (TAVI), and during this period we have witnessed an impressive evolution of this technique, with an extension of its use from non-operable patients to high-, intermediate- and even low-risk patients with aortic stenosis, and with a decrease in the incidence of complications. In this review, we discuss the evaluation of patients before TAVI, the procedure and the changes it has seen over time, and we present the current main complications and challenges of TAVI.

Prognostic Impact of Modified H2FPEF Score in Patients Receiving Trans-Catheter Aortic Valve Replacement

BACKGROUND

H2FPEF is a recently introduced score for the diagnosis of heart failure with preserved ejection fraction (HFpEF). Many patients with severe aortic stenosis have clinical/subclinical HFpEF and have worsening heart failure even after trans-catheter aortic valve replacement (TAVR). We investigated the prognostic impact of the H2FPEF score in TAVR candidates.

METHODS

Patients undergoing TAVR procedures at a single academic center between 2015 and 2022 were included. The H2FPEF score was calculated using baseline characteristics before TAVR. The prognostic impact of the score on the post-TAVR composite endpoint, consisting of all-cause death and heart failure readmissions during the 2-year observation period, was evaluated.

RESULTS

A total of 244 patients (median age 86 years, 70 males) were included. The median value of H2FPEF score was 3 (2, 4). The score was significantly associated with the primary outcome with a hazard ratio of 1.33 (95% confidence interval 1.02-1.74, p = 0.036). We constructed a modified H2FPEF score by adjusting cutoffs of several items for better prognostic stratification (i.e., age and body mass index). A modified score had a higher area under the curve than the original one (0.65 vs. 0.59, p = 0.028) and was independently associated with the primary outcome with an adjusted hazard ratio of 1.22 (95% confidence interval 1.01-1.49, p = 0.047).

CONCLUSIONS

A modified H2FPEF score, which was originally developed to diagnose the presence of HFpEF, could be used to risk-stratify elderly patients receiving TAVR. The clinical utility of this score should be validated in future studies.

Transcatheter Aortic Valve Implantation: Addressing the Subsequent Risk of Permanent Pacemaker Implantation

Transcatheter aortic valve implantation (TAVI) is now a commonly used therapy in patients with severe aortic stenosis, even in those patients at low surgical risk. The indications for TAVI have broadened as the therapy has proven to be safe and effective. Most challenges associated with TAVI after its initial introduction have been impressively reduced; however, the possible need for post-TAVI permanent pacemaker implantation (PPI) secondary to conduction disturbances continues to be on the radar. Conduction abnormalities post-TAVI are always of concern given that the aortic valve lies in close proximity to critical components of the cardiac conduction system. This review will present a summary of noteworthy pre-and post-procedural conduction blocks, the best use of telemetry and ambulatory device monitoring to avoid unnecessary PPI or to recognize the need for late PPI due to delayed high-grade conduction blocks, predictors to identify those patients at greatest risk of requiring PPI, important CT measurements and considerations to optimize TAVI planning, and the utility of the MInimizing Depth According to the membranous Septum (MIDAS) technique and the cusp-overlap technique. It is stressed that careful membranous septal (MS) length measurement by MDCT during pre-TAVI planning is necessary to establish the optimal implantation depth before the procedure to reduce the risk of compression of the MS and consequent damage to the cardiac conduction system.

Transcatheter Aortic Valve Implantation Two Decades of Evolution - TAVI From Current Perspective

Background

In the treatment of valvular heart diseases, transcatheter therapies have changed the rules of the game, especially in the case of aortic stenosis and mitral regurgitation. Since the first in man transcatheter aortic valve intervention (TAVI) performed by Dr. Alain Cribier in 2002 in a non-operable aortic stenosis (AS) patient, TAVI has changed the lives of so many patients for whom medical treatment was, up to then, the only option.

Objective

This article outlines patient selection and pre-procedure evaluation, current perspectives, recent advances, current and future devices, current guidelines informing the use of TAVI, expanding indications for TAVI, ongoing challenges and the future of TAVI.

Methods

The use of these percutaneous techniques has also increased significantly in the past few years with its first application in 2002, transcatheter aortic valve implantation (TAVI) has revolutionized the management of aortic stenosis and has become the standard of care for patients with AS at prohibitively high surgical risks, as well as a preferred treatment for elderly patients with intermediate and high-risk AS.

Results

Since the first pioneering procedure was performed 22 years ago, transcatheter aortic valve implantation (TAVI) has evolved into a routine procedure increasingly performed under conscious sedation via transfemoral access. On a global market worth $2 billion per year, over 300 000 patients have received a transcatheter aortic valve, demonstrating its clinical and market impact. TAVI may be used in lower risk, younger, asymptomatic populations with ongoing studies using an expanding portfolio of devices. Also, for patients deemed unsuitable for cardiac surgery, mitral transcatheter therapies represent the treatment of choice. Percutaneous repair techniques have had the most clinical experience to date.

Conclusion

During this 20-year period, the increased knowledge on pre-procedural planning, the important technological improvements in transcatheter valves, the increased experience and the numerous studies that have been carried out have permitted an expansion of the indications for TAVI, from inoperable patients to high- and intermediate-risk patients. This article outlines patient selection and pre-procedure evaluation, current perspectives, recent advances, current and future devices, current guidelines informing the use of TAVI, expanding indications for TAVI, ongoing challenges and the future of TAVI.