Safety of transoesophageal echocardiography during structural heart disease interventions under procedural sedation: a single-centre study

AIMS

The aim of this study was to determine the incidence of transoesophageal echocardiography (TOE)-related adverse events (AEs) during structural heart disease (SHD) interventions and to identify potential risk factors.

METHODS AND RESULTS

We retrospectively analysed 898 consecutive patients undergoing TOE-guided SHD interventions under procedural sedation. TOE-related AEs were classified as bleeding complications, mechanical lesions, conversion to general anaesthesia with intubation, and the occurrence of pneumonia. A follow-up was conducted up to 3 months after the intervention. TOE-related AEs were observed in 5.3% of the patients (n = 48). The highest rate of AEs was observed in the percutaneous mitral valve repair (PMVR) group with 8.2% (n = 32), whereas 4.8% (n = 11) of the patients in the left atrial appendage group and 1.8% (n = 5) in the patent foramen ovale/atrial septal defect group developed a TOE-related AE (P = 0.001). The most frequent AE was pneumonia with an incidence of 2.6% (n = 26) in the total cohort. Bleeding events occurred in 1.8% (n = 16) of the patients, mostly in the PMVR group with 2.1% (n = 8). In the multivariate regression analysis, we found a lower haemoglobin {odds ratio (OR) [95% confidence interval (CI)]: 8.82 (0.68-0.98) P = 0.025} and an obstructive sleep apnoea syndrome (OSAS) [OR (95% CI): 2.51 (1.08-5.84) P = 0.033] to be associated with AE. Furthermore, AEs were related to procedural time [OR (95% CI): 1.01 (1.0-1.01) P = 0.056] and oral anticoagulation [OR (95% CI): 1.97 (0.9-4.3) P = 0.076] with borderline significance in the multivariate regression analysis. No persistent damages were observed.

CONCLUSION

TOE-related AEs during SHD interventions are clinically relevant. It was highest in patients undergoing PMVR. A lower baseline haemoglobin level and an OSAS were found to be associated with the occurrence of a TOE-related AE.

Safety of transesophageal echocardiography during transcatheter edge-to-edge tricuspid valve repair: A single-center experience

Objectives

We aimed to determine transesophageal echocardiography (TEE) related complications during Transcatheter edge-to-edge tricuspid valve repair (TTVR).

Background

Transesophageal echocardiography is essential to guide structural heart disease (SHD) interventions. TTVR has become an evolving procedure for high-risk patients not suitable for surgery. Whether this complex procedure is associated with TEE related complications is not known so far.

Methods

We retrospectively analyzed 64 consecutive patients undergoing TTVR between 2019 and 2021 with the TriClip system (Abbott, Chicago, IL, USA) at our center. All procedures were performed under general anesthesia (GA). TEE related complications were classified as major and minor complications.

Results

Transesophageal echocardiography related complications were observed in two patients (3.1%) with one major complication (1.6%) and one minor complication (1.6%). In one patient perforation of the esophageal mucosa requiring red blood cell transfusion was observed, the other patient had hematemesis due to minor esophageal and gastric lesions without the need for blood transfusion. Both patients recovered during hospital stay with no persistent symptoms at discharge.

Conclusions

Transesophageal echocardiography related complications during TTVR are clinically relevant occurring in 3.1% of the patients. Further investigations are needed to identify potential risk factors and patients at high risk to develop a TEE related complication in the course of TTVR.

Multi-Slice Computed Tomography Analysis in Patients Undergoing Transcatheter Aortic Valve Replacement – Impact of Workflows on Measurement of Virtual Aortic Annulus and Valve Size

Exact and reliable measurements of anatomical dimensions in pre-procedural multi-slice computed tomography (MSCT) scans are crucial for optimal valve sizing and clinical results of transcatheter aortic valve replacement (TAVR). This study aimed to investigate interrater reliability between routinely used workflows for pre-procedural analysis. MSCT scans of 329 patients scheduled for TAVR were analyzed using both a 3mensio and SECTRA IDS7 platform. The results were retrospectively compared using the intraclass correlation coefficient, revealing excellent correlation in the analysis of simple diameters and poor correlation in the assessment of more complex structures with impact on calculated valve size.

Iatrogenic atrial septal defect persistence after percutaneous mitral valve repair: a meta-analysis

BACKGROUND

Percutaneous mitral valve repair (PMVR) requires a puncture of the atrial septum, resulting in iatrogenic atrial septal defect (iASD), which usually causes a transient left-to-right shunt. However, the influencing risk factors for iASD persistence and functional consequences are not fully understood. This meta-analysis aimed to summarise available data on the persistence of iASD following PMVR.

METHODS

The authors conducted a literature search in PubMed/MEDLINE and EMBASE databases to identify studies investigating iASD persistence in PMVR patients.

RESULTS

Six observational studies (n = 361) met inclusion criteria for the final analysis. Prevalence of persistent iASD was documented with 28% after 12 months follow-up. iASD size increased over time with a diameter of 5.3 ± 0.76 mm after one month and 6.5 ± 0.21 mm after 12 months. Possible predictors of iASD persistence after PMVR appeared to be pre-existing AF (RR 1.24; p = .03), residual mitral regurgitation > II° (RR 2.06; p = .03) and prolonged fluoroscopic time (RR 8.27; p = .01). Patients with iASD persistence had a higher risk for development of right heart overload regarding the increased area of the right atrium (MD 5.24; p = .004) and enlarged diameter of the right ventricle (MD 3.33; p < .0001). Rehospitalization was more frequently reported in iASD patients (RR 9.52; p = .004).

CONCLUSIONS

This meta-analysis proved iASD persistence in 28% of PMVR after 12 months follow-up with a higher risk for right heart volume overload and more frequent rehospitalization compared to patients without iASD persistence. Since percutaneous catheter-based treatments with transseptal approaches are rising, further evidence about the hemodynamic impact of persistent iASD is warranted.

Real-time echocardiography-fluoroscopy fusion imaging for left atrial appendage closure: prime time for fusion imaging?

BACKGROUND

Real-time echocardiography-fluoroscopy fusion imaging (FI) merges real-time echocardiographic imaging with fluoroscopic images allowing intuitive anatomical spatial orientation during structural heart disease interventions. We aimed to assess the safety and efficacy of FI during percutaneous left atrial appendage closure (LAAC).

METHODS

34 consecutive patients before (-FI) and 121 patients after (+FI) the introduction of FI for LAAC were included in a single-centre study. In-hospital safety parameters were analysed according to adverse event (AE) definition of the Munich consensus document and procedure-related parameters were assessed for efficacy. An ANCOVA was performed to investigate the influence of a learning curve.

RESULTS

Time until successful transseptal puncture was significantly reduced as well as total procedure time and the amount of contrast agent used (+FI/-FI:17 ± 6.35 min vs. 22 ± 8.33 min, p = 0.001; +FI/-FI: 50 min IQR 43 min - 60 min vs. 57 min IQR 45 min -70 min; p = 0.013; +FI/-FI: 70 mL, IQR 55 ml-90 mL vs. 152 mL, IQR 107 mL - 205 mL; p < 0.001). However, fluoroscopy time and dose-area product did not differ between both groups. There was no significant difference in the occurrence of in-hospital adverse events (+FI/-FI: 2.5% vs. 0%; p = 0.596). The ANCOVA revealed that the learning curve does not affect procedural efficacy parameters such as procedure time, time to transseptal puncture, amount of contrast agent and dose-area product.

CONCLUSIONS

FI for LAAC reduces the total procedure time, the time to successful transseptal puncture and periprocedural amount of contrast agent.

Short- and Mid-Term Outcomes in Patients Deemed Inoperable Undergoing Transapical and Transfemoral TAVR with an STS-PROM below Four Percent

Transapical (TA) TAVR is known to be associated with increased mortality and vascular complications compared with transfemoral (TF) TAVR in high-risk and inoperable patients. However, safe alternative access methods remain crucial. We aimed to (1) evaluate the 30-day and 1-year outcomes comparing TA and TF TAVR in patients with an STS-PROM of <4% deemed inoperable and (2) determine dependent and independent predictors for all-cause one-year mortality. Data were collected from a single-center registry consisting of 340 eligible patients. One-to-one propensity score matching was performed (n = 50 TA, n = 50 TF). Primary endpoints were all-cause mortality, stroke, and major bleeding. Predictors for all-cause one-year mortality were evaluated. Thirty-day mortality (TF vs. TA: 0.0% vs. 4.0%; p = 0.153) was comparable in both cohorts. One-year all-cause mortality was twice as high in TA patients (TF vs. TA: 10.0% vs. 20.0%, p logrank = 0.165, HR 2.10). Cerebrovascular events and major bleeding during one-year follow-up were similar. The multivariate analysis identified hemoglobin <12 g/dL at admission and dual antiplatelet therapy as strong predictors for one-year mortality. Although femoral access is the primary access with favorable 30-day and 1-year results, transapical access was successful for patients unsuitable for TF TAVR, showing acceptable short- and mid-term results in inoperable patients with low-risk profiles.

Predictors of functional mitral regurgitation recurrence after percutaneous mitral valve repair

We aimed to identify predictors of mitral regurgitation recurrence (MR) after percutaneous mitral valve repair (PMVR) in patients with functional mitral regurgitation (FMR). Patients with FMR were enrolled who underwent PMVR using the MitraClip^® device. Procedural success was defined as reduction of MR of at least one grade to MR grade ≤ 2 + assessed at discharge. Recurrence of MR was defined as MR grade 3 + or worse at one year after initially successful PMVR. A total of 306 patients with FMR underwent PMVR procedure. In 279 out of 306 patients (91.2%), PMVR was successfully performed with MR grade ≤ 2 + at discharge. In 11.4% of these patients, MR recurrence of initial successful PMVR after 1 year was observed. Recurrence of MR was associated with a higher rate of heart failure rehospitalization during the 12 months follow-up (52.0% vs. 30.3%; p = 0.029), and less improvement in New York Heart Association (NYHA) functional class [68% vs. 19% of the patients presenting with NYHA functional class III or IV one year after PMVR when compared to patients without recurrence (p = 0.001)]. Patients with MR recurrence were characterized by a higher left ventricular sphericity index {0.69 [Interquartile range (IQR) 0.64, 0.74] vs. 0.65 (IQR 0.58, 0.70), p = 0.003}, a larger left atrium volume [118 (IQR 96, 143) ml vs. 102 (IQR 84, 123) ml, p = 0.019], a larger tenting height 10 (IQR 9, 13) mm vs. 8 (IQR 7, 11) mm (p = 0.047), and a larger mitral valve annulus [41 (IQR 38, 43) mm vs. 39 (IQR 36, 40) mm, p = 0.015] when compared to patients with durable optimal long-term results. In a multivariate regression model, the left ventricular sphericity index [Odds Ratio (OR) 1.120, 95% Confidence Interval (CI) 1.039–1.413, p = 0.003)], tenting height (OR 1.207, 95% CI 1.031–1.413, p = 0.019), and left atrium enlargement (OR 1.018, 95% CI 1.000–1.038, p = 0.047) were predictors for MR recurrence after 1 year. In patients with FMR, baseline parameters of advanced heart failure such as spherical ventricle, tenting height and a large left atrium might indicate risk of recurrent MR one year after PMVR.

Clinical outcomes of patients undergoing percutaneous left atrial appendage occlusion in general anaesthesia or conscious sedation: data from the prospective global Amplatzer Amulet Occluder Observational Study

OBJECTIVE

To evaluate the safety and efficacy of percutaneous left atrial appendage occlusion (LAAO) using conscious sedation (CS).

BACKGROUND

Several percutaneous structural heart disease interventions are safely and efficiently performed using CS instead of general anaesthesia (GA). This concept has not been evaluated in a large multicenter cohort of patients undergoing LAAO.

METHODS

Patients from the prospective, global Amplatzer Amulet Occluder Observational Study were divided into two groups (GA vs CS). Baseline information, periprocedural and postprocedural efficacy and complications, as well as outcomes through 7 days post implant were compared.

RESULTS

Patients undergoing transesophageal-guided implants were categorised by GA (n=607, 64%) or CS (n=342, 36%) usage. Mean age was 75 years in both groups. LAAO technical success was achieved in 99% of both groups. The procedure duration (GA: 35±22 min vs CS: 27±19 min, p<0.001), total amount of contrast medium (GA: 105±81 mL vs CS: 86±66 mL, p<0.001) and fluoroscopic time (GA: 13±9 min vs CS: 12±13 min, p<0.001) were less in CS cases. Procedure-related or device-related serious adverse events during the first 7 days were numerically higher in the CS group (GA: 4.9% vs CS: 7.6%, p=0.114). Peridevice residual flow was absent or ≤5 mm 1-3 months after the procedure in 99.7% of the GA and in 100% of the CS group (p=1.000).

CONCLUSIONS

In a large global study, LAAO with the Amplatzer Amulet occluder is safe and feasible using CS. Procedure duration and total amount of contrast were less with CS than GA cases.

TRIAL REGISTRATION NUMBER

NCT02447081; Results.

Contemporary use of balloon aortic valvuloplasty and evaluation of its success in different hemodynamic entities of severe aortic valve stenosis

OBJECTIVES

To evaluate outcome assessment of percutaneous balloon aortic valvuloplasty (BAV) in different flow and gradient patterns of severe aortic stenosis (AS).

BACKGROUND

The mean pressure gradient reduction after BAV is an often-used surrogate parameter to evaluate procedural success. The definition of a successful BAV has not been evaluated in different subgroups of severe AS, which were introduced in the latest guidelines on the management of patients with valvular heart disease.

METHODS

In this observational study, consecutive patients from July 2009 to March 2018 undergoing BAV were divided into normal-flow high-gradient (NFHG), low-flow low-gradient (LFLG), and paradoxical low-flow low-gradient (pLFLG) AS. Baseline characteristics, hemodynamic, and clinical information were collected and compared.

RESULTS

One-hundred-fifty-six patients were grouped into NFHG (n = 68, 43.5%), LFLG (n = 68, 43.5%), and pLFLG (n = 20, 12.8%) AS. Mean age of the study population was 81 years. Cardiogenic shock or refractory heart failure (46.8%) was the most common underlying reasons for BAV. Spearman correlation revealed that the mean pressure gradient reduction, determined by echocardiography, had a moderate correlation with the increase in the aortic valve area (AVA) in patients with NFHG AS (ρ: 0.529, p < .001) but showed no association in patients with LFLG (ρ: 0.017, p = .289) and pLFLG (ρ: 0.030, p = .889) AS. BAV as bridge to surgical or transcatheter aortic valve replacement was possible in 44.2% of patients, with no difference between groups (p = .070).

CONCLUSION

The mean pressure gradient reduction might be an adequate surrogate parameter for BAV success in patients with NFHG AS but is not suitable for patients with other hemodynamic entities.

Stroke after transcatheter aortic valve implantation: new insights into risk prediction

Background

Stroke is still a feared complication following transcatheter aortic valve implantation (TAVI), associated with increased mortality and severe impact on patients' daily living. Despite technological development and knowledge improvement, cerebrovascular events (CVE) are still not predictable so far and simple risk scores are lacking.

Purpose

This study aimed to evaluate different preprocedural factors that may favour stroke after TAVI, especially regarding severity of aortic calcification.

Methods

From May 2011 to January 2018 a total of 1365 patients underwent TAVI with a balloon-expandable (n=442, 32.4%) or self-expandable (n=923, 67.6%) device at our institution. All patients underwent multi-slice computed tomography (MSCT) before TAVI. To obtain the significant factors for stroke risk prediction we performed multivariate regression analysis and selected the optimal cut-off values according to the maximum Youden index for dichotomization of the risk score items. Finally, we used receiver operating characteristics (ROC) analysis and areas under the ROC curves (AUC) to validate our risk score in comparison to other existing models.

Results

60 of 1365 patients (4.4%) had new neurological impairment after TAVI during hospital stay (mean 11.2±6.7 days). We performed propensity score matching (1:10) to balance baseline characteristics between patients with and without stroke following TAVI, resulting in 56 patients with in-hospital stroke and 521 patients without. Preprocedural factors associated with stroke turned out to be history of prior stroke (OR 1.94; 95% CI 0.85–4.43; p=0.114), aortic valve area ≥0.545 cm2 (OR 3.11; 95% CI 1.16–8.34; p=0.024), atrioventricular angle ≥48.5° (OR 2.32; 95% CI 1.20–4.49; p=0.013), RCC Agatston Score ≥447.2 AU (OR 1.8; 95% CI 0.94–3.44; p=0.077), LVOT Agatston Score ≥262.4 AU (OR 2.01; 95% CI 1.08–3.75; p=0.028) and ascending thoracic aorta Agatston Score ≥116.4 AU (OR 2.21; 95% CI 1.17–4.17; p=0.015). ROC analysis showed that our risk model had an AUC of 0.73 (95% CI 0.66–0.80; p&lt;0.001), a sensitivity of 70.6%, a specificity of 69.0%, a positive predictive value of 19.5% and a high negative predictive value of 95.7%. Our risk model appeared to be the best for stroke prediction after TAVI compared to other risk scores used in literature before like EuroSCORE II (AUC 0.50; 95% CI 0.43–0.58; p=0.950) or CHA2DS2-VASc Score (AUC 0.62; 95% CI 0.55–0.70; p=0.004).

Conclusion

Especially aortic root calcium volume assessed by MSCT predicts CVE after TAVI and could be integrated into a six items risk model for preprocedural prediction of stroke after TAVI. This model could guide us in identifying those patients who are most likely to benefit from transcatheter cerebral embolic protection devices.

Funding Acknowledgement

Type of funding source: None

Use and success evaluation of percutaneous aortic balloon valvuloplasty in different hemodynamic entities of severe aortic stenosis in the TAVR era

Background

In the era of transcatheter aortic valve replacement (TAVR), there is renewed interest in percutaneous balloon aortic valvuloplasty (BAV), which may qualify as the primary treatment option of choice in special clinical situations. Success of BAV is commonly defined as a significant mean pressure gradient reduction after the procedure.

Purpose

To evaluate the correlation of the mean pressure gradient reduction and increase in the aortic valve area (AVA) in different flow and gradient patterns of severe aortic stenosis (AS).

Methods

Consecutive patients from 01/2010 to 03/2018 undergoing BAV were divided into normal-flow high-gradient (NFHG), low-flow low-gradient (LFLG) and paradoxical low-flow low-gradient (pLFLG) AS. Baseline characteristics, hemodynamic and clinical information were collected and compared. Additionally, the clinical pathway of patients (BAV as a stand-alone procedure or BAV as a bridge to aortic valve replacement) was followed-up.

Results

One-hundred-fifty-six patients were grouped into NFHG (n=68, 43.5%), LFLG (n=68, 43.5%) and pLFLG (n=20, 12.8%) AS. Underlying reasons for BAV and not TAVR/SAVR as the primary treatment option are displayed in Figure 1. Spearman correlation revealed that the mean pressure gradient reduction had a moderate correlation with the increase in the AVA in patients with NFHG AS (r: 0.529, p&lt;0.001) but showed no association in patients with LFLG (r: 0.145, p=0.239) and pLFLG (r: 0.030, p=0.889) AS. Underlying reasons for patients to undergo BAV and not TAVR/SAVR varied between groups, however cardiogenic shock or refractory heart failure (overall 46.8%) were the most common ones. After the procedure, independent of the hemodynamic AS entity, patients showed a functional improvement, represented by substantially lower NYHA class levels (p&lt;0.001), lower NT-pro BNP levels (p=0.003) and a numerical but non-significant improvement in other echocardiographic parameters like the left ventricular ejection fraction (p=0.163) and tricuspid annular plane systolic excursion (TAPSE, p=0.066). An unplanned cardiac re-admission due to heart failure was necessary in 23.7% patients. Less than half of the patients (44.2%) received BAV as a bridge to TAVR/SAVR (median time to bridge 64 days). Survival was significantly increased in patients having BAV as a staged procedure (log-rank p&lt;0.001).

Conclusion

In daily clinical practice, the mean pressure gradient reduction might be an adequate surrogate of BAV success in patients with NFHG AS but is not suitable for patients with other hemodynamic entities of AS. In those patients, TTE should be directly performed in the catheter laboratory to correctly assess the increase of the AVA. BAV as a staged procedure in selected clinical scenarios increases survival and is a considerable option in all flow states of severe AS. (NCT04053192)

Figure 1

Funding Acknowledgement

Type of funding source: None

Performance of the Corevalve Evolut R and PRO in severely calcified anatomies: a propensity-score matched analysis

Background

The Corevalve Evolut R and PRO belong to the newer generation of self-expandable valves and are increasingly used to treat patients with severe aortic stenosis. Over the years, technical advancements and increasing experience with the procedure itself are responsible for excellent clinical and hemodynamic results. Patients with severely calcified native aortic valve anatomies still pose a special task to the implanting team since the risk for intraprocedural complications might be increased.

Purpose

To evaluate the hemodynamic and clinical performance of the CoreValve Evolut R and PRO in patients with severely calcified native aortic valve anatomies.

Methods

Baseline characteristics, imaging data and procedural outcome of patients undergoing transfemoral transcatheter aortic valve implantation with the CoreValve Evolut R and PRO from 09/2015 to 03/2018 were prospectively collected. Patients underwent high-resolution multisclice computed tomography (MSCT). A pre-specific threshold of 600 Hounsfield units was set to account for the hyperdensity of the applied contrast medium and to enable comparability with MSCT thresholds, derived by non-contrast enhanced MSCT scans. Patients were divided by the extent of calcification into a severely calcified anatomy group (men &gt;2062AU, woman &gt;1377AU) or a not severely calcified anatomy group (men &lt;2062AU, woman &lt;1377AU). Propensity score matching with the variables log EuroSCORE, LVOT calcium load and the cover index in a 1:2 fashion was performed and clinical and hemodynamic results in accordance with VARC II were collected.

Results

Ninety-eight patients with severely calcified anatomies (SC) could be identified and were matched with 196 patients with lower calcified (LC) anatomies. Patients with severely calcified anatomies were older (SC: 83.1 years vs. LC: 80.3 years, p&lt;0.001) and had a smaller aortic valve area (SC: 0.63cm2 vs. LC: 0.70cm2, p=0.028). The mean implantation depth did not differ (SC 5.4mm±2.4 vs. LC: 5.1±2.2, p=0.554). Pre-dilatation was more often performed in the SC group (SC: 30.6% vs. LC: 15.8%, p=0.003) and the stroke/TIA rate did not differ (SC: 5.1% vs. LC: 3.5%, p=0.532). In SC patients, a permanent pacemaker implantation was significantly more often needed (SC: 28.5% vs. LC:7.6%, p&lt;0.001). The mean pressure gradient after the procedure was effectively reduced (SC: 7.1mmHg±3.9 vs. LC: 7.8±3.7mmHg, p=0.477). No aortic regurgitation (AR) was more often present in patients with SC anatomies (SC: 72.5% vs. LC: 85.2%, p=0.011). The aortic regurgitation index numerically differed between groups without reaching statistical significance (SC: 24.1±7.1 vs. LC: 27.3±6.7, p=0.067).

Conclusion

The CoreValve Evolut R and PRO show a good clinical safety profile and excellent hemodynamic results even in patients with severely calcified anatomies. In those patients, a permanent pacemaker implantation was more often necessary.

Funding Acknowledgement

Type of funding source: None

Iron status, anemia and functional capacity in adults with congenital heart disease: a single center analysis

Background

Iron is essential to the mitochondrial energy production in cardiomyocytes and its depletion is negatively associated with symptoms, functional capacity, quality of life and outcomes in patients with heart failure – independent of anemia. The relevance of iron deficiency in adults with congenital heart disease however has not been evaluated to date, and we thus aimed to evaluate it in an all-comer cohort of patients with congenital heart disease in correlation with symptoms and functional capacity.

Methods and results

527 patient cases from one referral center over 2 years were evaluated concerning their iron status, anemia, functional capacity and ejection fraction of their systemic ventricle. 264 were female, 94 had a shunt lesion, 96 had left-sided obstructive lesions, 181 right-sided lesions, while 108 were considered to have complex lesions and 28 were cyanotic. The median age was 34 years, the mean BMI was 25.2±5 kg/m2, 429 patients had a normal ejection fraction and 34 moderately and severely depressed. 35 patients were classified as NYHA III, and 56 as NYHA II, while their functional capacity was evaluated via cardiopulmonary testing with a mean VO2max/kg of 22.6±6.5 and mean 69±17% of the expected. The mean serum iron concentration was 99.4±42.3 mcg/dL, their mean transferrin saturation was 27.36±13%, the mean ferritin concentration was 130.8±185 ng/mL, the mean soluble transfer factor was 1.3±0.66 mg/l and their mean Hemoglobin 14.8±2 mg/dL, while the mean MCV was 88±5.3 and the mean MCHC 33.7±1.4.

40 patients were anemic according to the WHO definition for anemia, in 28 of those patients that was already known. Iron deficiency according to stratified according to ferritin was present in 53 patients. However, when stratified according to the heart failure guidelines definition for iron deficiency 299 patients were found affected. Using the soluble transferrin receptor (sTfR) and sTfR-ferritin index iron deficiency was suspected in 10 additional individuals. Iron deficiency was associated with the ejection fraction (p=0.0001) - patients with moderately or severely depressed systemic ventricular function more often were diagnosed with iron deficiency (p=0.007)-, while it did not correlate with functional NYHA classification (p=0.622) or functional capacity (p=0.1 and 0.057). Iron deficiency was also not found significantly different amongst congenital defects but did correlate with all laboratory iron studies.

Conclusions

In this ambulatory population of adults with congenital heart disease we found an association of ejection fraction with iron deficiency, however no association of iron deficiency with functional capacity. The question arising is if a new definition of iron deficiency anemia in congenital heart disease similar to heart failure would be of clinical value.

Funding Acknowledgement

Type of funding source: None

TAVR-related echocardiographic assessment - status quo, challenges and perspectives

Transcatheter aortic valve replacement (TAVR) is an emerging and a well-established procedure for high-risk and inoperable patients worldwide. Recent studies revealed furthermore that TAVR is equal or even superior to surgical valve replacement in intermediate risk patients. Therefore, a successful procedure is not only dependent on precise preprocedural patient selection but also on careful intraprocedural multimodal imaging guidance and adequate postprocedural follow-up. Up to date, 2D/3D transthoracic and/or transoesophageal echocardiography is an easy and goal-oriented tool for periprocedural TAVR-assessment regarding annulus measurements, cardiac function and concomitant valve diseases. Further procedural success is directly related to prevention of severe early and late complications. Thus, a careful intra- and postprocedural echocardiographic guidance is crucial to evaluate prosthetic function, position and its haemodynamic implication and changes in the integrity of the left ventricle during intra- and postprocedural management. We explored the role of echocardiography for pre-, intra- and postprocedural TAVR-assessment, illustrated by cases and possible algorithms, in a comprehensive literature review. Furthermore, we describe the role of fusion imaging, that is, real-time fusion of transoesophageal echocardiography and fluoroscopy (EchoNavigator Release System^® I and II) during TAVR.

Performance of the CoreValve Evolut R and PRO in Severely Calcified Anatomy: A Propensity Score Matched Analysis

BACKGROUND

The CoreValve Evolut R and PRO (Medtronic, Minneapolis, MN, USA) are among the newest-generation of self-expandable transcatheter aortic valve replacement (TAVR) devices and show excellent results. Treating patients with severely calcified (SC) native aortic valve anatomy may be challenging because of the increased risk of periprocedural complications. This study investigated the performance of Evolut R and PRO in this special patient subset.

METHODS

Patients who underwent TAVR with the CoreValve Evolut R or PRO (n=381) from September 2015 to March 2018 were divided by aortic valve calcification extent. Patients with SC aortic valve anatomy (n=98; men, >2,062 and women, >1,377 Agatston units) were compared with those with non-severely calcified (NCS) aortic valve anatomy after 1:2 propensity score matching. Outcomes were evaluated according to the updated valve academic research consortium criteria.

RESULTS

Patients with SC anatomy were older (83 years vs 80 years, p<0.001) and had a smaller aortic valve area (0.63 cm² vs 0.70 cm², p=0.028). Pre-dilatation was more often performed (30.6% vs 15.8%, p=0.003) and a permanent pacemaker implantation was more often necessary (32.9% vs 8.8%, p<0.001) in the SC group. None/mild aortic regurgitation (AR) was evenly distributed (SC, 96.9% vs NCS, 99.5%, p=0.109); moderate AR was present in 3.1% of SC patients and in 0.5% of NSC patients. Severe AR was not observed.

CONCLUSION

The CoreValve Evolut R and PRO showed good clinical safety profiles and excellent haemodynamic results in patients with SC anatomy and who more often required permanent pacemaker implantation.

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.

Micro-dislodgement during transcatheter aortic valve implantation with a contemporary self-expandable prosthesis

Objectives

To evaluate the incidence, risk factors and the clinical outcome of micro-dislodgement (MD) with a contemporary self-expandable prosthesis during transcatheter aortic valve implantation.

Methods

MD was defined as movement of the prosthesis of at least 1.5 mm upwards or downwards from its position directly before release compared to its final position. Patients were grouped according to the occurrence (+MD) or absence (-MD) of MD. Baseline characteristics, imaging data and outcome parameters were retrospectively analyzed.

Results

We identified 258 eligible patients. MD occurred in 31.8% (n = 82) of cases with a mean magnitude of 2.8 mm ± 2.2 in relation to the left coronary cusp and 3.0 mm ± 2.1 to the non-coronary cusp. Clinical and hemodynamic outcomes were similar in both groups with consistency over a follow-up period of three months. A larger aortic valve area (AVA) (-MD vs. +MD: 0.6 cm² ± 0.3 vs. 0.7cm² ± 0.2; p = 0.014), was the only independent risk factor for the occurrence of MD in a multivariate regression analysis (OR 5.3; 95% CI: 1.1–24.9; p = 0.036).

Conclusions

MD occurred in nearly one third of patients and did not affect clinical and hemodynamic outcome. A larger AVA seems to be a potential risk factor for MD.

Prediction of One-Year Mortality Based upon A New Staged Mortality Risk Model in Patients with Aortic Stenosis Undergoing Transcatheter Valve Replacement

Background: In-depth knowledge about potential predictors of mortality in transcatheter aortic valve replacement (TAVR) is still warranted. Currently used risk stratification models for TAVR often fail to reach a holistic approach. We, therefore, aimed to create a new staged risk model for 1-year mortality including several new categories including (a) AS-entities (b) cardiopulmonary hemodynamics (c) comorbidities, and (d) different access routes. Methods: 737 transfemoral (TF) TAVR (84.3%) and 137 transapical (TA) TAVR (15.7%) patients were included. Predictors of 1-year mortality were assessed according to the aforementioned categories. Results: Over-all 1-year mortality (n = 100, 11.4%) was significantly higher in the TA TAVR group (TF vs. TA TAVR: 10.0% vs. 18.9 %; p = 0.0050*). By multivariate cox-regression analysis, a three-staged model was created in patients with fulfilled categories (TF TAVR: n = 655, 88,9%; TA TAVR: n = 117, 85.4%). Patients in “stage 2” showed 1.7-fold (HR 1.67; CI 1.07–2.60; p = 0.024*) and patients in “stage 3” 3.5-fold (HR 3.45; CI 1.97–6.05; p < 0.0001*) enhanced risk to die within 1 year. Mortality increased with every stage and reached the highest rates of 42.5% in “stage 3” (p_logrank < 0.0001*), even when old- and new-generation devices (p_logrank = n.s) were sub-specified. Conclusions: This new staged mortality risk model had incremental value for prediction of 1-year mortality after TAVR independently from the TAVR-era.

P4714Individual patient data meta-analysis comparing general anesthesia and deep sedation on safety and length of intensive care unit stay in patients undergoing percutaneous mitral valve repair

Background

Percutaneous edge-to-edge mitral valve repair (PMVR) has emerged as a treatment option for patients with severe mitral regurgitation not considered suitable candidates for surgery. The procedure can be performed in general anesthesia (GA) or deep sedation (DS) without mechanical ventilation. However, debate remains about the optimal approach.

Purpose

To compare the impact of the anesthetic method on efficacy, safety, and length of intensive care stay.

Methods

We identified studies comparing GA versus DS in patients undergoing PMVR by searching PubMed and CENTRAL. We included studies for which investigators agreed to provide individual patient data. Analyzed outcomes were a composite safety endpoint comprising all-cause death, stroke, pneumonia, and major to life-threating bleeding as well as length of intensive care unit stay. We performed an one-stage and two-stage meta-analysis on each outcome after multiple imputation of missing data. For two-stage meta-analysis, between-study heterogeneity was estimated according to Paule-Mandel and confidence intervals were derived using the method proposed by Hartung and Knapp.

Results

We included five observational studies (n=647 patients). Procedural success was achieved in 618 of 647 (95.5%) patients. The composite safety endpoint occurred in 92 of 647 (14.2%) patients with no difference between patients treated with GA or DS. In this regard, risk ratio was 0.78 (95% confidence interval, 0.53 to 1.14; P=0.20) following the one-stage approach and 0.73 (95% confidence interval, 0.30 to 1.80; P=0.39) following the two-stage approach. Length of intensive care stay was longer after GA as compared to DS (adjusted mixed linear regression model, 1.94 days, 95% confidence interval, 1.29 to 2.59 days, P<0.001; random effects model pooling study-specific estimates from adjusted linear models 1.40 days, 95% confidence interval, 0.54 to 2.22 days, P=0.0104).

Conclusion

Both, DS and GA offer good procedural success rates and a similar safety profile. However, length of intensive care stay is shorter after DS.

P3742Transcatheter aortic valve implantation in large annuli: incidence and predictors of specific adverse events with the largest self-expanding device

Background

The recently released largest self-expanding transcatheter aortic valve device (STHV-34) is characterized by good results but nevertheless demands an experienced team for the implantation in large annuli.

Purpose

Looking at multi slice computed tomography (MSCT) and procedural data, we tried to identify characteristics that could explain intraprocedural VARC-2 and valve specific non-VARC-2 events.

Methods

We performed a single center retrospective analysis in 80 patients treated with STHV-34. STHV-34 patients were separated into subjects without events (NE, n=43, 54%) and the following adverse events: resheathing/-capture processes (RS/C, n=19, 24%), valve dislodgments (VD, n=21; 26%), infolding (IF, n=6, 8%) and complete dislocation with bail-out valve-in-valve implantation (ViV, n=3, 4%). Events were further categorized in non-VARC-2 and VARC-2. The analysis sought for underlying anatomical conditions and defined risk factors by multivariate analysis.

Results

Primary device success was reached in 96% and immediate postprocedural absence of moderate-to-severe aortic regurgitation was 100%. We identified specific anatomical conditions predisposing for non-VARC-2 and VARC-2 events: RS/C: annular calcium load<1600 AU (OR 47 [CI 1.4–216], p=0.0004). IF: peripheral kinking (RR 5.0 [CI 1.0–24], p=0.0478) and previous RS/C maneuvers (83%). ViV: annular ellipticity index (NS 1.2±0.1 vs. ViV 1.4±0.1, p=0.0049), aortic angulation (AA) angle (NS 54.0±7.0° vs. ViV 61.7±1.5°, p=0.0240) and LVOT-AO angle (NS 149.1±18.9° vs. ViV 130.3±3.5°, p=0.0470).

Conclusion

We confirm high procedural success for the largest currently available STHV-34. The incidence of intraprocedural non-VARC-2 and VARC-2 events are associated with anatomical characteristics that may influence valve selection and implantation strategy.

P3859Stroke after transcatheter aortic valve implantation: an unpredictable risk?

Background

Transcatheter aortic valve implantation (TAVI) has become the preferred alternative to surgical valve replacement in high risk patients with severe symptomatic aortic stenosis. Stroke is still a feared complication following TAVI, associated with increased mortality and severe impact on patients' daily living. Despite technological development and knowledge improvement, cerebrovascular events (CVE) are still not predictable so far and simple risk scores are lacking. The expansion of TAVI therapy towards younger and lower risk populations will force us to discover the mechanisms determining stroke after TAVI.

Purpose

This study aimed to evaluate different patient and procedure related factors for prediction of stroke after TAVI, especially regarding severity of aortic calcification.

Methods

From May 2011 to January 2018 a total of 1365 patients underwent TAVI with a balloon-expandable (32.4%) or self-expandable (67.6%) valve at our institution. 60 patients (4.4%) suffered from new neurological impairment in terms of CVE after TAVI during hospital stay (mean 11.2±6.7 days). We performed propensity score matching (1:10) to balance baseline characteristics between patients with and without stroke following TAVI, resulting in 56 patients with in-hospital stroke and 521 patients without neurological disorder. Stroke was defined according to the Valve Academic Research Consortium recommendations (VARC-2).

Results

Body surface area (stroke vs. control: 2.73±0.27 vs. 2.81±0.29 m2; p=0.0451) and prior stroke (stroke vs. control: 17.86% vs. 8.64%; p=0.0256) were patient related predictors of stroke after TAVI during in-hospital stay. While aortic valve Agatston score (stroke vs. control: 2475±1593 vs. 2060±1344 AU; p=0.0383) and ascending thoracic aorta Agatston score (stroke vs. control: 986.5±1989 vs. 505.2±1018 AU; p=0.0045) showed to be good predictors, peripheral vascular diseases were not associated with stroke (stroke vs. control: 35.7% vs. 31.3%; p=0.4986). A procedural predictor of acute CVE was extended procedure time (stroke vs. control: 101.8±39.6 vs. 90.0±31.3 hours; p=0.0105). Finally, stroke after TAVI resulted in clearly prolonged hospital stay (stroke vs. control: 16.1±9.0 vs. 10.7±6.2 days; p<0.0001).

Conclusion

The severity of aortic valve and ascending thoracic aorta calcification predicts stroke after TAVI as well as extended procedure time, possibly due to increased mechanical intravascular manipulation by prolonged catheterisation. These correlations could guide us in identifying those patients who are most likely to benefit from transcatheter cerebral embolic protection devices.

P5583Micro-movement during transcatheter aortic valve implantation with a contemporary self-expandable prosthesis

Background

Precise positioning of the prosthesis is a crucial step during transcatheter aortic valve implantation. In some cases, contemporary self-expandable prostheses show micro-movement (MM) during the final phase of release.

Purpose

We aimed to establish a definition for MM, evaluated the incidence of MM using the CoreValve Evolut RTM, investigated potential risk factors for MM and the associated clinical outcomes.

Methods

MM was defined as movement of the prosthesis of at least 1.5 mm from its position directly before release compared to its final position. Patients were grouped according to the occurrence (+MM) or absence (-MM) of MM. Baseline characteristics, imaging data and outcome parameters in accordance with the updated valve academic research consortium (VARC-2) criteria were retrospectively analyzed.

Results

We identified 258 eligible patients. MM occurred in 31.8% (n=82) of cases with a mean magnitude of 2.8±2.2 mm in relation to the left coronary cusp and 3.0±2.1 mm to the non-coronary cusp. Clinical and hemodynamic outcomes were similar in both groups. The mean pressure gradient was effectively reduced after TAVI (-MM vs. +MM: 7±3.4 mmHg vs. 8±3.9 mmHg, p=0.326) with consistency over a follow-up period of at least three months (-MM vs. +MM: 6.7±3.7 mmHg vs. 7.9±8.4 mmHg, p=0.168). At three months follow-up most of the patients presented with no aortic regurgitation (-MM vs. +MM: 64% vs. 67.9%, p=0.569). Mild aortic regurgitation was observed in 34.2% of the -MM group and in 29.5% of the +MD group (p=0.414). Moderate aortic regurgitation occurred in 1.9% of all patients with no differences between groups (-MM vs. +MM: 1.9% vs. 2.6%, p=0.662). Patients with MM presented with a more symmetric calcification pattern (-MM vs. +MM: 27.3% vs. 40.2%; p=0.037) and a larger aortic valve area (-MM vs. +MM: 0.6 cm2 ± 0.3 vs. 0.7 cm2 ± 0.2; p=0.014), which was found to be a potential risk factor for the occurrence of MM in a multivariate regression analysis (OR 3.5; 95% CI: 1.1–10.9; p=0.032)

Conclusion

MM occurred in nearly one third of patients and did not affect clinical and hemodynamic outcome. A larger aortic valve area was the only independent risk factor for the occurrence of MM.

P2467Fusion imaging (Anatomical Intelligence) enables automated left atrial appendage sizing in real-time a single center pilot study

Background and purpose

Percutaneous left atrial appendage occlusion (LAAO) depicts an alternative treatment for patients with atrial fibrillation who are deemed for long-term oral anticoagulation therapy. In order to perform a successful LAAO accurate sizing of left atrial appendage (ostium, landing zone and depth) for device selection is essential. Echo-Fluoro fusion imaging in real-time offers with its latest prototype a patient-specific segmented automated 3D heart model and sizing of left atrial appendage (LAA). We therefore aimed to evaluate the automated segmented LAA sizing by comparing to 2D transesophageal (TOE) and MSCT measurements as gold standard.

Methods

We studied prospectively data of 8 consecutive patients who were admitted to our clinic for left atrial appendage closure. MSCT was performed preprocedural and analyzed with commercially available 3mensio software (Pie medical imaging). 2D TOE measurements and automated segmentation of the LAA and sizing were performed during the procedure by a highly experienced team of periinterventional cardiac imaging specialist and structural heart disease interventionalist who were blinded to the prior MSCT analysis. Dimension of ostium, landing zone (10 mm into the LAA parallel to the ostial plane at the level of the left circumflex for Amplatzer device) and depth (perpendicular to the ostial plane) were obtained in different TOE views according to instructions for use of Amulet Occluder. In order to generate an automated 3 D heart model, a high-quality 3D TOE image of the LAA volume and surrounding structures was acquired. After successful ECG-gated segmentation a 3 D heart model was generated. Automated LAA sizing followed in real-time. All measurements were taken into consideration before device selection. A Kruskal Wallis test was used to compare mean ranks of independent samples. A concordance analysis according to Kendall W was carried out to investigate reliability.

Results

The mean age of the patients was 82,6±4.15 years and half of the patients were female. All procedures were conducted successfully. The mean values of ostium and landing zone were comparable in TOE, automated sizing and MSCT sizing (ostium: 23,78±2,15 mm vs 25,71±5,25 mm vs 27,35±3,3 mm; (p=0,175); landing zone 22,13±3,18 mm vs 23,57±3,31 mm vs 24,00±3,51 mm; (p=0,377)). Furthermore, a significant concordance between the measurements was shown (ostium W= 0,991; p=0.045, landing zone W=0,835, p=0.014).

Conclusion

Automated LAA sizing acquired by fusion imaging may be an elegant real-time alternative for precise LAA Occluder device selection and needs to be investigated further.

P2274Single-center experience with different regimes of antiplatelet therapy and oral anticoagulation in transcatheter aortic valve replacement

Background

Antithrombotic therapy in transcatheter aortic valve replacement (TAVR) is highly controversial. Dual antiplatelet therapy (DAPT) for 3–6 months with aspirin and clopidogrel is the current recommendation. Whereas in patients with indication for OAC several regimes were described, ranging from OAC monotherapy to dual and even triple therapy. Besides vitamin K antagonists (VKA), non-Vitamin K oral anticoagulants (NOAC) are frequently used in TAVR patients with indication for permanent OAC.

Purpose

We therefore aimed to evaluated different antithrombotic regimes and their impact on outcome.

Methods

We performed a single center retrospective analysis in 1160 patients treated by transfemoral approach (TF TAVR). Primary endpoints were 30-day mortality, stroke and bleeding according to VARC-2 criteria. Secondary endpoint was all-cause mortality at 1 year.

Results

In 1160 patients with TF TAVR, a broad range of regimes occurred in clinical practice. The majority of patients were on DAPT (637 patients, 55.0%), followed by VKA + clopidogrel (186 patients, 16%). Other patients received OAC mono (98 patients; 9%), triple therapy (93 patients; 8%), NOAC mono (31 patients; 3%), single antiplatelet therapy (SAPT, 40 patients; 4%) or NOAC + clopidogrel (31 patients, 3%).

All-cause mortality 30 days after TF TAVR differed between the regimens. (SAPT/OAC+SAPT/N-OAC+DAPT 0.0% vs DAPT 3.6% vs OAC 10.2% vs. NOAC 1.3% vs NOAC+SAPT 0.3%; pANOVA<0.0001). Severe bleeding events were comparable (SAPT 5.0% vs DAPT 2.4% vs OAC 7.1% vs NOAC 1.3% vs OAC+SAPT 3.2% vs NOAC+SAPT 0.0% vs. N-OAC+SDPT 4.3%; pANOVA=0.15). Stroke rates were comparable in all subcohorts as well (SAPT 5.0% vs DAPT 3.0% vs OAC 7.1% vs NOAC 2.7% vs OAC+SAPT 1.6% vs NOAC+SAPT 0.0% vs. N-OAC+DAPT 1.1%; pANOVA=0.13). Only 2 hemorrhagic strokes (5.6%) appeared under DAPT and OAC mono respectively, whereas all others were of thromboembolic origin (94.4%). Surprisingly, all-cause mortality at one-year after TF TAVR was higher in OAC patients compared to all other used regimes (logrankoverallp=0.0012).

Conclusion

Data from our retrospective analysis indicate that a variety of different antithrombotic regimes occur even in a single centre analysis. All-cause mortality was enhanced in patients with oral anticoagulation. Therefore, clinical trials need to investigate if this is only explained by additional atrial fibrillation.

P1857Risk calculator for prediction of iatrogenic atrial septal defect persistence following percutaneous mitral valve repair

Background

The rising number of new percutaneous interventions for left-sided heart disease leads to increased occurrence of iatrogenic atrial septal defect (iASD). The percutaneous mitral valve repair (PMVR) for severe, symptomatic mitral regurgitation (MR) also requires intraprocedural puncture of the interatrial septum. In some cases iASD is persisting and becomes haemodynamically relevant with enhanced right heart overload due to significant left-to-right-shunting.

Purpose

This study aimed to evaluate pre- and periprocedural factors that may favour persistence and haemodynamic relevance of iASD in patients after PMVR.

Methods

In 2015, 75 consecutive patients with severe MR (age 74.8±10.5y) and following PMVR were enrolled. After 12 months, 57 patients completed their follow up (FU) including clinical conditions, transthoracic echocardiography (TTE), and cardiovascular magnetic resonance (CMR) whenever feasible. We evaluated the impact of comorbidities as well as intraprocedural, haemodynamic and functional characteristics that may favour persistence of iASD by multivariate analysis. Haemodynamic relevance of iASD was defined as right heart overload with predominantly significant enlargement of the right atrium (RA), impairment of right heart function as defined by fractional area shortening (FAC), and ratio of pulmonary to systemic blood flow (Qp/Qs>1) when available.

Results

18 out of 57 patients (32%) showed a persistent iASD (+iASD), being associated with a specific combination of comorbidities as well as pre-procedural and periprocedural factors that can be summarised by a multifactorial iASD risk calculator (+iASD vs. -iASD: 6.3±2.9 vs. 3.9±2.7; p=0.0058). 11 iASD (61%) became haemodynamically relevant (+hd iASD) with a significant right heart overload (RA area +hd iASD vs. -hd iASD: baseline 23.1±4.1 vs. 23.2±4.3; FU 30.7±6.3 vs. 20.1±4.6; p<0.0001), reduced RV function (FAC +hd iASD vs. -hd iASD: baseline 41.0±10.3 vs. 29.9±7.2; FU 25.3±7.2 vs. 29.1±13.2; p<0.0156) and left-to-right shunting (Qp/Qs -iASD vs. +hd iASD vs. -hd iASD: 1.0±0.3 vs. 1.7±0.4 vs. 0.8±0.1 L/min; p=0.0011).

Conclusion

This study shows for the first time, that persistence of iASD can be predicted by pre- and periprocedural factors using a risk calculator that may additionally guide careful follow up imaging and therapeutic action after PMVR to avoid development of progressive heart failure.

More than numbers: preprocedural multislice computed tomography analysis in a patient undergoing transcatheter aortic valve implantation

Multislice computed tomography (MSCT) has emerged as an integral part of patient evaluation in transcatheter aortic valve implantation (TAVI). Beyond sizing, it offers valuable information especially in challenging anatomies and helps to provide accurate dimensions and highlight potential pitfalls. We present the case of a 94-year-old woman with a coronary anomaly who was initially scheduled for TAVI. Based on MSCT scan and clinical evaluation we decided to perform a less invasive approach. In this setting MSCT evaluation allowed an appropriate benefit-risk assessment and substantially influenced the interventional strategy.

Valvuloplasty balloon entrapment in a self-expanding aortic valve stent frame after inadvertent wire passage through the outflow struts

Transcatheter aortic valve replacement (TAVR) is a leading-edge therapy option for patients with severe aortic stenosis (AS) and high surgical risk. However, this minimally invasive procedure is associated with specific complications that may be life-threatening. Valvuloplasty balloon entrapment during postdilatation in transcatheter self-expanding aortic valve stent frames has not yet been a focus of interest in this context. Although it is a rare event, it may critically influence outcome, and different management strategies can be considered. Hereafter, we present the case of a 67-year-old male who underwent transfemoral TAVR and subsequent postdilatation. The valvuloplasty balloon was entrapped in the self-expanding aortic valve stent frame after inadvertent wire passage through the outflow struts. Since surgical risk was high, we preferred a percutaneous approach and extracted the entrapped balloon with high traction force under rapid pacing after valve stabilization with another balloon, which was placed in the annular position.

Balloon Valvuloplasty Followed by Transcatheter Aortic Valve Implantation as a Staged Procedure in Patients With Low-Flow Low-Gradient Aortic Stenosis

OBJECTIVE

Balloon aortic valvuloplasty (BAV) as a bridge to transcatheter aortic valve implantation (TAVI) is a well-established treatment option in patients who are in a critical state or who suffer from underlying comorbidities that disguise the severity of aortic stenosis (AS). If convalescence is achieved, TAVI can be performed with good results in high-gradient aortic stenosis (HG-AS) patients. Whether this approach is safe and effective in low-flow low-gradient aortic stenosis (LFLG-AS) has not been analyzed; therefore, we investigated whether BAV followed by TAVI as a staged procedure is an effective treatment option in patients with LFLG-AS.

METHODS

Patients with severe AS who received BAV followed by staged TAVI were identified. Baseline data, periprocedural and postprocedural information, echocardiographic data, and follow-up data were collected. The patient population was divided into LFLG-AS and HG-AS groups.

RESULTS

From July 2009 until September 2017, we identified 38 eligible patients (16 LFLG-AS and 22 HG-AS). Log EuroScore I (51.8 ± 20.9% LFLG-AS vs 33.7 ± 19.1% HG-AS; P<.01) differed significantly between groups, as did baseline echocardiographic data that were used to categorize groups. BAV and staged TAVI were carried out 100% successfully with comparable results. Instant symptom relief and pressure gradient reduction were accomplished after both procedures. Thirty-day mortality rates (0% LFLG-AS vs 9% HG-AS; P=.21) and 1-year mortality rates (18.8% LFLG-AS vs 27.2% HG-AS; P=.54) did not differ between groups.

CONCLUSION

BAV followed by staged TAVI is a safe and effective treatment option in sick or questionable candidates, irrespective whether LFLG-AS or HG-AS is present.

Dynamic coronary roadmapping during percutaneous coronary intervention: a feasibility study

BACKGROUND

A novel software ("Dynamic Coronary Roadmap") was developed, which offers a real-time, dynamic overlay of the coronary tree on fluoroscopy. Once the roadmap has been automatically generated during angiography it can be used for navigation during percutaneous coronary interventions (PCI). As a feasibility study, we aimed to investigate the feasibility of real-time dynamic coronary roadmapping and consecutive coronary overlay during elective PCI.

METHODS AND RESULTS

We studied 936 overlay runs, created following the same amount of angiographies, which were generated during 36 PCIs. Feasibility of dynamic coronary roadmapping was analyzed using a dedicated software tool. Roadmap quality (correct dynamic imaging of the vessels without relevant artefacts or missing parts) was distinguished from overlay quality (congruence of dynamic coronary roadmapping and coronary anatomy). Additionally, we assessed procedural success and the occurrence of major cardiac and cerebrovascular events (MACCE). Roadmap quality was defined as "fit for use" in 99.5%. In 97.4% of runs overlay quality was deemed "fit for use". Overall, we observed low inter and intra observer variability (ICC R = 0.84 for roadmap quality and R = 0.75 for overlay quality). Procedural success rate was 100%. MACCE occurred in two (5.6%) patients during post-interventional in-hospital stay and were not software-related.

CONCLUSIONS

Dynamic coronary roadmapping provides in > 98% of cases sufficient roadmap quality with an anatomically correct overlay of the coronary vessels with good inter and intra observer variability. Future randomized studies are warranted to test possible advantages like procedure time reduction and less consumption of contrast medium.

Sealing capacity of the ventricular muscle band after iatrogenic left ventricular perforation during transcatheter aortic valve implantation

Left ventricular (LV) perforation accompanied by acute cardiac tamponade is a rare but one of the most feared complication during transcatheter aortic valve implantation. Few cases with the need of emergent surgical repair are described in literature. Handling of this uncommon but possible life-threatening event requires well-considered action by the implanting team and is associated with substantially increased intrahospital mortality. We present a unique case of LV perforation management with percutaneous pericardiocentesis only. As a possible underlying physiological mechanism, we identified the movement of the ventricular muscle band which possibly sealed the perforation side due to transverse and circumferential muscle contractions.

Stent fractures after common femoral artery bail-out stenting due to suture device failure in TAVR

BACKGROUND

Vascular access site-related complications are frequent in the context of transfemoral transcatheter aortic valve replacement (TAVR). The implantation of a covered stent graft is an effective treatment option for bleeding control. However, the external iliac and common femoral arteries are exposed to flexion of the hip joint. Therefore, stent compression and stent/strut fractures may occur, facilitating stent occlusion.

PATIENTS AND METHODS

In all 389 patients who received transfemoral TAVR from 2013-2015 at the Düsseldorf Heart Centre, we monitored the management of vascular access site-related complications. Our analyses focused on immediate technical success and bleeding control, primary patency, and the occurrence of stent/strut fractures after six to 12 months of follow-up.

RESULTS

Vascular access site-related complications occurred in 13 % (n = 51), whereof in 10 patients, the bleeding was successfully managed by prolonged compression. In 40 out of 51 patients, a covered stent graft was implanted in the common femoral artery, leading to 100 % immediate bleeding control. After a mean follow-up of 334 ± 188 days, 28 stents out of 29 patients with completed follow-up (excluding e. g. death) were without flow-limiting stenosis (primary patency 97 %) or relevant stent compression (diameter pre/post 8.6/8.1 mm, p = 0.048, late lumen loss 1.1 ± 0.2 mm, mean flow velocity 92 ± 34 cm/s). In four asymptomatic patients, stent/strut fractures were detected (14 %) without flow-limiting stenosis.

CONCLUSIONS

The implantation of a covered stent graft is highly effective and safe to control vascular access site-related complications after TAVR. Stent/strut fractures in the flexible segment of the common femoral artery may occur, as consequently verified by X-ray visualization, but show no impairment on flow or clinical parameters after six to 12 months.

High body mass index is a risk factor for difficult deep sedation in percutaneous mitral valve repair

Background

The safety and efficacy of deep sedation (DS) in MitraClip^® procedures have been shown previously. However, clinical experience demonstrates that in some patients DS is difficult to achieve. We hypothesize that some patient characteristics can predict difficult DS.

Methods

We prospectively analysed 69 patients undergoing MitraClip^® procedures using DS. Application of DS was graded as simple (group 1) or difficult (group 2) depending on a cumulative score based on one point for each of the following criteria: decrease in oxygen saturation, retention of carbon dioxide, disruptive body movements, and the need for catecholamines. Patients with one point or less were classified as group 1, and patients with two or more points were classified as group 2.

Results

In 58 of 69 patients (84.1%), the performance of DS was simple, while in 11 patients (15.9%), DS was difficult to achieve. Patients with difficult DS were characterized by a higher body mass index (33.7 ± 6.0 kg/m² vs. 26.1 ± 4.1; p = 0.001), younger age (67 ± 13 years vs. 75 ± 13 years; p = 0.044), and reduced left ventricular ejection fraction (36% ± 10 vs. 45% ± 14; p = 0.051) and presented more often with an obstructive sleep apnoea syndrome (6.9% vs. 45.5%; p = 0.003). In the multivariate analysis, body mass index was an independent predictor of difficult DS. Using a body mass index of 31 kg/m² as a cut-off value, the sensitivity of predicting difficult DS was 73%, and the specificity was 88%. Using a body mass index of 35 kg/m² as a cut-off value, the specificity increased to 97%, with a sensitivity of 36%.

Conclusion

In patients with a higher body mass index who undergo MitraClip^® procedures, DS might be difficult to perform.

Acute reverse annular remodeling during MitraClip® therapy predicts improved clinical outcome in heart failure patients: a 3D echocardiography study

Background

Transcatheter mitral valve repair (TMVR) has been shown to have acute effects on mitral valve geometry in patients with functional mitral regurgitation (FMR). This study investigates the impact of MitraClip^® therapy-induced annular remodeling on clinical outcome and mitral regurgitation in heart failure patients.

Methods

TMVR was performed successfully in 45 patients with FMR. In this study, mitral valve datasets were obtained before and directly after MitraClip^® implantation using three-dimensional (3D) transesophageal echocardiography, and were analyzed offline retrospectively using dedicated 3D reconstruction software. Patients underwent clinical and echocardiographic evaluation at baseline and after 6 months. At follow-up, the patients were allocated into two groups according to their improvement in New York Heart Association (NYHA) functional class: a Low Responder group with ΔNYHA <1.5 (n = 25); and a High Responder group with ΔNYHA ≥1.5 (n = 20).

Results

At 6-month follow-up, data analysis revealed that while mitral regurgitation was reduced significantly in both groups, only the High Responder group had experienced significant downsizing of the 3D circumference (137 ± 14 mm to 126 ± 13 mm; p < 0.01) and the anterior-to-posterior diameter (33 ± 5 mm to 29 ± 4 mm; p < 0.01) of the mitral annulus during the intervention. Furthermore, only the High Responder group with reverse annular remodeling as shown had substantial advances in quality of life (Minnesota living with heart failure questionnaire: 55 ± 10 to 34 ± 14 points; p < 0.01) and functional status (6-min walk distance: 290 ± 104 m to 462 ± 111 m; p = 0.07).

Conclusion

Our study demonstrates that instantaneous left ventricular annular remodeling during MitraClip^® implantation is associated with improved clinical outcome of heart failure patients with functional mitral regurgitation.

Trial registration The study was approved by the local ethics committee (Study Number 4497R, Registration ID: 2013121585). Trial registration: NCT02033811 Retrospectively registered January 9, 2014.

Safety and efficacy of transseptal puncture guided by real-time fusion of echocardiography and fluoroscopy

Aims

Visual guidance through echocardiography and fluoroscopy is crucial for a successful transseptal puncture (TSP) in a prespecified region of the fossa ovalis. The novel EchoNavigator system Release II (EchoNav II, Philips Healthcare, Andover, Massachusetts, USA) enables the real-time fusion of fluoroscopic and echocardiographic images. We evaluated this new imaging method in respect to safety and efficacy of TSP during MitraClip implantation and left atrial appendage closure.

Methods

Forty-four patients before (−EchoNav) and 44 patients after (+EchoNav) the introduction of real-time fusion were included in our retrospective, single-centre study. The primary endpoint was the occurrence of adverse events due to TSP. Secondary endpoints were successful puncture at the prespecified region and time until TSP (min).

Results

In both groups TSP was performed successfully in the prespecified region and no adverse events occurred during or due to the accomplishment of TSP. Time until TSP was significantly reduced in the +EchoNav group in comparison with the EchoNav group (18.48 ± 5.62 min vs. 23.20 ± 9.61 min, p = 0.006).

Conclusions

Real-time fusion of echocardiography and fluoroscopy proved to be as safe and successful as standard best practice for TSP. Moreover, efficacy was improved through significant reduction of time until TSP.

Optimal C-arm angulation during transcatheter aortic valve replacement: Accuracy of a rotational C-arm computed tomography based three dimensional heart model

AIM

To investigate the accuracy of a rotational C-arm CT-based 3D heart model to predict an optimal C-arm configuration during transcatheter aortic valve replacement (TAVR).

METHODS

Rotational C-arm CT (RCT) under rapid ventricular pacing was performed in 57 consecutive patients with severe aortic stenosis as part of the pre-procedural cardiac catheterization. With prototype software each RCT data set was segmented using a 3D heart model. From that the line of perpendicularity curve was obtained that generates a perpendicular view of the aortic annulus according to the right-cusp rule. To evaluate the accuracy of a model-based overlay we compared model- and expert-derived aortic root diameters.

RESULTS

For all 57 patients in the RCT cohort diameter measurements were obtained from two independent operators and were compared to the model-based measurements. The inter-observer variability was measured to be in the range of 0°-12.96° of angular C-arm displacement for two independent operators. The model-to-operator agreement was 0°-13.82°. The model-based and expert measurements of aortic root diameters evaluated at the aortic annulus (r = 0.79, P < 0.01), the aortic sinus (r = 0.93, P < 0.01) and the sino-tubular junction (r = 0.92, P < 0.01) correlated on a high level and the Bland-Altman analysis showed good agreement. The interobserver measurements did not show a significant bias.

CONCLUSION

Automatic segmentation of the aortic root using an anatomical model can accurately predict an optimal C-arm configuration, potentially simplifying current clinical workflows before and during TAVR.

Left Atrial and Left Ventricular Function and Remodeling Following Percutaneous Mitral Valve Repair

BACKGROUND

Mitral regurgitation causes left atrial (LA) and left ventricular (LV) dysfunction, dilatation, and remodeling. Following percutaneous mitral valve repair (PMVR) using the MitraClip® approach, reverse cardiac remodeling is desirable. To date, the influence of PMVR on LA and segmental LV function and remodeling has not been investigated in detail.

METHODS

Twenty-six patients who received the MitraClip device were enrolled in an open-label, single-center observational study. Patients underwent clinical assessment, conventional echocardiography and global and segmental longitudinal strain analysis of the left atrium and left ventricle by speckle tracking echocardiography at baseline and at a three-month follow up.

RESULTS

PMVR improved both LV systolic function (from 40.5 ± 2.5% to 45.0 ± 2.5%, p = 0.04) and LV global longitudinal strain (from -8.9 ± 0.7% to -10.7 ± 0.9%, p = 0.004). Segmental analysis revealed improved myocardial deformation mainly in the basal (basalseptal -8.9 ± 0.8% to -12.9 ± 0.8%, p = 0.0002; basallateral -7.9 ± 1.1% to -13.9 ± 1.4%, p = 0.0005) and midventricular segments (mid-septal -12.7 ± 0.9% to -14.5 ± 1.1%, p = 0.02; mid-lateral -7.5 ± 0.8% to -10.8 ± 1.2%, p = 0.006). In patients with pre-procedural preserved LA function with sinus rhythm the impact of PMVR revealed an improvement in LA global conduit function (from 10.6 ± 1.2% to 13.9 ± 1.6%, p = 0.003) and global contractile function (from -2.1 ± 0.47% to -3.5 ± 0.5%, p = 0.03). The reversed remodeling was not associated with altered levels of the cardiac biomarkers matrix metalloproteinase 2 (MMP-2) and MMP-9, tissue-inhibitors of MMPs (TIMP-2 and ST-2).

CONCLUSIONS

PMVR improves global segmental LV and LA function and leads to a reverse remodeling.