Transcatheter Mitral Valve Implantation in Failed Transventricular Mitral Valve Repair

An 84-year-old man presented with dyspnea at rest due to severe mitral regurgitation. He first underwent transventricular mitral valve repair with the Harpoon system, which relapsed owing to rupture of neochords. He was definitively treated with transcatheter mitral valve implantation of the Tendyne system 8 months later.

Transthyretin cardiac amyloidosis in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement: experience of a single center

BACKGROUND

Even if prevalent among patients with severe aortic stenosis (AS), the clinical suspicion for transthyretin cardiac amyloidosis (ATTR-CA) remains difficult in this subset. We report our single center experience on ATTR-CA detection among TAVR candidates to provide insights on the prevalence and clinical features of dual pathology as compared to lone AS.

METHODS

Consecutive severe AS patients undergoing transcatheter aortic valve replacement (TAVR) evaluation at a single center were prospectively included. Those with suspected ATTR-CA based on clinical assessment underwent 99m Tc-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) bone scintigraphy. The RAISE score, a novel screening tool with high sensitivity for ATTR-CA in AS, was retrospectively calculated to rule-out ATTR-CA in the remaining patients. Patients were categorized as follow: "ATTR-CA+": patients with confirmed ATTR-CA at DPD bone scintigraphy; "ATTR-CA-": patients with negative DPD bone scintigraphy or a negative RAISE score; "ATTR-CA indeterminate": patients not undergoing ATTR-CA assessment with a positive RAISE score. The characteristics of ATTR-CA+ and ATTR-CA- patients were compared.

RESULTS

Of 107 included patients, ATTR-CA suspicion was posed in 13 patients and confirmed in six. Patients were categorized as follow: 6 (5.6%) ATTR-CA+, 79 (73.8%) ATTR-CA-, 22 (20.6%) ATTR-CA indeterminate. Excluding ATTR-CA indeterminate patients, the prevalence of ATTR-CA was 7.1% (95% CI 2.6-14.7%). As compared to ATTR-CA - patients, ATTR-CA + patients were older, had higher procedural risk and more extensive myocardial and renal damage. They had higher left ventricle mass index and lower ECG voltages, translating into a lower voltage to mass ratio. Moreover, we describe for the first time bifascicular block as an ECG feature highly specific of patients with dual pathology (50.0% vs. 2.7%, P<0.001). Of note, pericardial effusion was rarely found in patients with lone AS (16.7% vs. 1.2%, P=0.027). No difference in procedural outcomes was observed between groups.

CONCLUSIONS

Among severe AS patients, ATTR-CA is prevalent and presents with phenotypic features that may aid to differentiate it from lone AS. A clinical approach based on routine search of amyloidosis features might lead to selective DPD bone scintigraphy with a satisfactory positive predictive value.

Impact of Previous Cardiac Operations in Patients Undergoing Surgery for Type A Acute Aortic Dissection. Long-Term Follow Up

Aim of this multicenter study was to evaluate the impact of reoperative cardiac surgery for type A acute aortic dissection (TAAAD) on early and long-term outcomes. Patients with history of previous cardiac surgery were included in group R while those undergoing first operation where included in group F. Kaplan-Meier analysis was used to evaluate long-term survival in the 2 groups. A total of 1472 patients were included in the analysis. Of these, 85 (5.8%) and 1387 (94.2%) were included in group R and F, respectively. Thirty-day mortality was 24% (20 patients) and 18% (249 patients) in groups R and F, respectively(P = 0.8). Kaplan-Meier survival at 10 and at 20-year was 51.5% and 30.2% in group R and 48% and 32% in group F (P = 0.368). Patients with a history of previous cardiac operations who develop TAAAD can undergo surgery with similar early and long-term outcomes compared to those at their first operation.

Minimally Invasive Surgery: Standard of Care for Mitral Valve Endocarditis

Background. Minimally invasive surgery via right mini-thoracotomy has become the standard of care for the treatment of mitral valve disease worldwide, particularly at high-volume centers. In recent years, the spectrum of indications has progressively shifted and extended to fragile and higher-risk patients, also addressing more complex mitral valve disease and ultimately including patients with native or prosthetic infective endocarditis. The rationale for the adoption of the minimally invasive approach is to minimize surgical trauma, promote an earlier postoperative recovery, and reduce the incidence of surgical wound infection and other nosocomial infections. The aim of this retrospective observational study is to evaluate the effectiveness and the early and late outcome in patients undergoing minimally invasive surgery for mitral valve infective endocarditis. Methods. Prospectively collected data regarding minimally invasive surgery in patients with mitral valve infective endocarditis were entered into a dedicated database for the period between January 2007 and December 2022 and retrospectively analyzed. All comers during the study period underwent a preoperative evaluation based on their clinical history and anatomy for the allocation to the most appropriate surgical strategy. The selection of the mini-thoracotomy approach was primarily driven by a thorough transthoracic and especially transesophageal echocardiographic evaluation, coupled with total body and vascular imaging. Results. During the study period, 92 patients underwent right mini-thoracotomy to treat native (80/92, 87%) or prosthetic (12/92, 13%) mitral valve endocarditis at our institution, representing 5% of the patients undergoing minimally invasive mitral surgery. Twenty-six (28%) patients had undergone previous cardiac operations, whereas 18 (20%) presented preoperatively with complications related to endocarditis, most commonly systemic embolization. Sixty-nine and twenty-three patients, respectively, underwent early surgery (75%) or were operated on after the completion of the targeted antibiotic treatment (25%). A conservative procedure was feasible in 16/80 (20%) patients with native valve endocarditis. Conversion to standard sternotomy was necessary in a single case (1.1%). No cases of intraoperative iatrogenic aortic dissection were reported. Four patients died perioperatively, accounting for a thirty-day mortality of 4.4%. The causes of death were refractory heart or multiorgan failure and/or septic shock. A new onset stroke was observed postoperatively in one case (1.1%). Overall actuarial survival rate at 1 and 5 years after operation was 90.8% and 80.4%, whereas freedom from mitral valve reoperation at 1 and 5 years was 96.3% and 93.2%, respectively. Conclusions. This present study shows good early and long-term results in higher-risk patients undergoing minimally invasive surgery for mitral valve infective endocarditis. Total body, vascular, and echocardiographic screening represent the key points to select the optimal approach and allow for the extension of indications for minimally invasive surgery to sicker patients, including active endocarditis and sepsis.

Three-Dimensional Finger Test: A New Echocardiographic Method to Locate the Best Access Site During NeoChord Procedure

OBJECTIVE

Transventricular beating-heart mitral valve repair (TBMVR) with artificial chordae implantation is a technique to treat mitral valve prolapse. Two-dimensional (2D) echocardiography completed with simultaneous biplane view during surgeon finger pushing on the left ventricular (LV) wall (finger test [FT]) is currently used to localize the desired LV access, on the inferior-lateral wall, between the papillary muscles (PMs). We aimed to compare a new three-dimensional (3D) method with conventional FT in terms of safety and better localization of LV access.

METHODS

During TBMVR, conventional FT was completed using 3D transesophageal echocardiography by placing the sample box in the bicommissural view of the LV, including the PMs and the apex. The 3D volume was subsequently edited to visualize the LV from above (surgical view) to localize the bulge of the operator's finger pushing on the LV. We asked the first operator, the second operator, and the cardiac surgery fellow, separately, to evaluate the location of their finger pushing, both with the 2D method and the 3D method, to estimate the interoperator concordance.

RESULTS

From 2019 to 2021, 42 TBMVRs were performed without complications related to access using FT completed with the 3D method. Regarding the choice of the right and safe entry site, the operator's agreement was higher using 3D rendering compared with conventional FT (mean agreement 0.59 ± 0.29 for 2D vs 0.83 ± 0.20 for 3D), while full operator agreement was 10 of 42 for 2D and 23 of 42 for 3D (P = 0.004).

CONCLUSIONS

Three-dimensional FT is easy to perform and facilitates surgeons choosing the best access for TBMVR in term of anatomical localization and safety.

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

BACKGROUND

Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres.

METHODS

This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low-middle-income countries.

RESULTS

In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of 'single-use' consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low-middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia.

CONCLUSION

This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high- and low-middle-income countries.

Sex Differences in Epidemiology, Morphology, Mechanisms, and Treatment of Mitral Valve Regurgitation

Sex-related disparities have been recognized in incidence, pathological findings, pathophysiological mechanisms, and diagnostic pathways of non-rheumatic mitral regurgitation. Furthermore, access to treatments and outcomes for surgical and interventional therapies among women and men appears to be different. Despite this, current European and US guidelines have identified common diagnostic and therapeutic pathways that do not consider patient sex in decision-making. The aim of this review is to summarize the current evidence on sex-related differences in non-rheumatic mitral regurgitation, particularly regarding incidence, imaging modalities, surgical-derived evidence, and outcomes of transcatheter edge-to-edge repair, with the goal of informing clinicians about sex-specific challenges to consider when making treatment decisions for patients with mitral regurgitation.

Impact of Right Ventricular Pacing in Patients With TAVR Undergoing Permanent Pacemaker Implantation

BACKGROUND

Long-term right ventricular pacing (VP) has been related to negative left ventricular remodeling and heart failure (HF), but there is a lack of evidence regarding the prognostic impact on transcatheter aortic valve replacement (TAVR) patients.

OBJECTIVES

The aim of the PACE-TAVI registry is to evaluate the association of high percentage of VP with adverse outcomes in patients with pacemaker implantation after TAVR.

METHODS

PACE-TAVI is an international multicenter registry of all consecutive TAVR patients who underwent permanent pacemaker implantation for conduction disturbances in the first 30 days after the procedure. Patients were divided into 2 subgroups according to the percentage of VP (<40% vs ≥40%) at pacemaker interrogation. The primary endpoint was the composite of cardiovascular mortality or hospitalization for HF.

RESULTS

A total of 377 patients were enrolled, 158 with VP <40% and 219 with VP ≥40%. After multivariable adjustment, VP ≥40% was associated with a higher incidence of the primary endpoint (HR: 2.76; 95% CI: 1.39-5.51; P = 0.004), first HF hospitalization (HR: 3.37; 95% CI: 1.50-7.54; P = 0.003), and cardiovascular death (HR: 3.77; 95% CI: 1.02-13.88; P = 0.04), while the incidence of all-cause death was not significantly different (HR: 2.17; 95% CI: 0.80-5.90; P = 0.13). Patients with VP ≥ 40% showed a higher New York Heart Association functional class both at 1 year (P = 0.009) and at last available follow-up (P = 0.04) and a nonsignificant reduction of left ventricular ejection fraction (P = 0.18) on 1-year echocardiography, while patients with VP <40% showed significant improvement (P = 0.009).

CONCLUSIONS

In TAVR patients undergoing permanent pacemaker implantation, a high percentage of right VP at follow-up is associated with an increased risk for cardiovascular death and HF hospitalization. These findings suggest the opportunity to minimize right VP through dedicated algorithms in post-TAVR patients without complete atrioventricular block and to evaluate a more physiological VP modality in patients with persistent complete atrioventricular block.

Acute Modification of Hemodynamic Forces in Patients with Severe Aortic Stenosis after Transcatheter Aortic Valve Implantation

Transcatheter aortic valve implantation (TAVI) is the established first-line treatment for patient with severe aortic stenosis not suitable for surgery. Echocardiographic evaluation of hemodynamic forces (HDFs) is a growing field, holding the potential to early predict improvement in LV function. A prospective observational study was conducted. Transthoracic echocardiography was performed before and after TAVI. HDFs were analyzed along with traditional left ventricular (LV) function parameters. Twenty-five consecutive patients undergoing TAVI were enrolled: mean age 83 ± 5 years, 74.5% male, mean LV Ejection Fraction (LVEF) at baseline 57 ± 8%. Post-TAVI echocardiographic evaluation was performed 2.4 ± 1.06 days after the procedure. HDF amplitude parameters improved significantly after the procedure: LV Longitudinal Forces (LF) apex-base [mean difference (MD) 1.79%; 95% CI 1.07-2.5; p-value < 0.001]; LV systolic LF apex-base (MD 2.6%; 95% CI 1.57-3.7; p-value < 0.001); LV impulse (LVim) apex-base (MD 2.9%; 95% CI 1.48-4.3; p-value < 0.001). Similarly, HDFs orientation parameters improved: LVLF angle (MD 1.5°; 95% CI 0.07-2.9; p-value = 0.041); LVim angle (MD 2.16°; 95% CI 0.76-3.56; p-value = 0.004). Conversely, global longitudinal strain and LVEF did not show any significant difference before and after the procedure. Echocardiographic analysis of HDFs could help differentiate patients with LV function recovery after TAVI from patients with persistent hemodynamic dysfunction.

Single-Dose St. Thomas Versus Custodiol® Cardioplegia for Right Mini-thoracotomy Mitral Valve Surgery

OBJECTIVE

Custodiol® and St. Thomas cardioplegia are widely employed in mini-thoracotomy mitral valve (MV) operations. One-dose of the former provides 3 h of myocardial protection. Conversely, St. Thomas solution is usually reinfused every 30 min and safety of single delivery is unknown. We aimed to compare single-shot St. Thomas versus Custodiol® cardioplegia.

METHODS

Primary endpoint of the prospective observational study was cardiac troponin T level at different post-operative time-points. Propensity-weighted treatment served to adjust for confounding factors.

RESULTS

Thirty-nine patients receiving St. Thomas were compared with 25 patients receiving Custodiol® cardioplegia; cross-clamping always exceeded 45 min. No differences were found in postoperative markers of myocardial injury. Ventricular fibrillation at the resumption of electric activity was more frequent following Custodiol® cardioplegia (P = .01).

CONCLUSION

Effective myocardial protection exceeding 1 h of ischemic arrest can be achieved with a single-dose St. Thomas cardioplegia in selected patients undergoing right mini-thoracotomy MV surgery.

Real-World Multiple Comparison of Transcatheter Aortic Valves: Insights From the Multicenter OBSERVANT II Study

BACKGROUND

Head-to-head comparisons of devices for transcatheter aortic valve implantation (TAVI) are mostly limited to 2-arm studies so far. The aim of this study was to compare simultaneously outcomes of the most used, second- and third-generation transcatheter aortic valves in a real-world population.

METHODS

A total of 2728 patients undergoing TAVI with different second- and third-generation devices, and enrolled in the multicenter, prospective OBSERVANT II study (Observational Study of Effectiveness of TAVI With New Generation Devices for Severe Aortic Stenosis Treatment) from December 2016 to September 2018 were compared according to the transcatheter aortic valve received. Outcomes were adjudicated through a linkage with administrative databases, and adjusted using inverse propensity of treatment weighting. The primary end point was the composite of all-cause death, stroke and rehospitalization for heart failure at 1-year. Rates were reported consecutively for Evolut R, Evolut PRO, SAPIEN 3, ACURATE neo, and Portico groups.

RESULTS

The primary end point did not differ among groups (23.9% versus 24.7% versus 21.5% versus 23.7% versus 27.4%, respectively, P=0.56). Permanent pacemaker implantation was significantly lower for patients receiving SAPIEN 3 (19.9% versus 19.3% versus 12.5% versus 14.7% versus 22.1%, respectively, P<0.01) at 1 year. The SAPIEN 3 had lower rates of paravalvular regurgitation (moderate-to-severe grade 10.1% versus 5.0% versus 2.1% versus 13.1% versus 10.8%, respectively, P<0.01) but higher transprosthetic gradients (median mean gradients 7.0 versus 6.0 versus 10.0 versus 7.0 versus 8.0 mm Hg, respectively, P<0.01) after TAVI.

CONCLUSIONS

Data from real-world practice showed low and comparable rates of complications after TAVI considering all the available devices. Patients receiving SAPIEN 3 valve had lower rates of paravalvular regurgitation and permanent pacemaker implantation, but higher transprosthetic gradients.

Surgical management and outcomes in patients with acute type A aortic dissection and cerebral malperfusion

Objective

The study objective was to evaluate the surgical results in patients with acute type A aortic dissection and cerebral malperfusion.

Methods

From 2000 to 2019, 234 patients with type A aortic dissection and cerebral malperfusion were stratified into 3 groups: 50 (21%) with syncope (group 1), 152 (65%) with persistent loss of focal neurological function (group 2), and 32 (14%) with coma (group 3). Results were evaluated and compared by univariable and multivariable analyses.

Results

Median age was higher in group 1, and incidence of cardiogenic shock was higher in group 3. The femoral artery was the most common cannulation site, whereas the axillary artery was used in 18% of group 1, 30% of group 2, and 25% of group 3 patients (P = .337). Antegrade cerebral perfusion was performed in more than 80% of patients, and ascending aorta/arch replacement was performed in 40% of group 1, 27% of group 2, and 31% of group 3 (P = .21). In-hospital mortality was 18% in group 1, 27% in group 2, and 56% in group 3 (P = .001). Survival at 5 years is 57.0% in group 1, 57.7% in group 2, and 38.7% in group 3 (P = .0005). On multivariable analysis, age, cardiopulmonary bypass time, and group 3 versus group 2 were independent risk factors for mortality, whereas axillary cannulation was a protective factor.

Conclusions

Patients with aortic dissection and cerebral malperfusion without preoperative coma showed acceptable mortality, and those with coma had a high in-hospital mortality regardless of the type of brain protection. Overall axillary artery cannulation appeared to be a protective factor.

P102 NEW THREE–DIMENSIONAL ECHOCARDIOGRAPHIC PREDICTING PARAMETERS IN TRANS–VENTRICULAR HEART–BEATING MITRAL VALVE REPAIR WITH NEOCHORDAE: A MONOCENTRIC RETROSPECTIVE STUDY

Background

Trans–ventricular off pump mitral valve (MV) repair with neochordae implantation (Neochord procedure) is a minimally invasive surgical technique for correction of degenerative mitral regurgitation (MR) due to prolapse or flail. The aim of this study was to evaluate mid–term results of patients undergoing this procedure and find new three–dimensional pre–operative echocardiographic parameters to predict MR recurrence at follow–up.

Methods

We performed a retrospective analysis of 72 consecutive patients with severe MR due to prolapse or flail who underwent Neochord procedure at our hospital from March 2015 to February 2021. MV pre–operative anatomical parameters were assessed using 2D TEE, 3D TEE and dedicated three–dimensional (3D) post–processing analysis with dedicated software (QLAB, Philips). TTE follow–up and clinical evaluation were performed at 3 months, 6 months, 1 year and then annually.

Results

Twenty–seven patients were female (37.5%), mean age was 77±9 years. The average preoperative EuroSCORE II was 2.2%±1.5%. Twenty–three patients (32%) had an history of paroxysmal or persistent atrial fibrillation. Procedural success at discharge was achieved in sixty–eight patients (94.5%). Mean follow–up was 30±16 months. Three years follow–up was completed by fifty patients. At three years thirteen patients (26%) presented with recurrence of severe MR or underwent new surgical operation. Prevalence of mild or trace MR at three years follow–up visit was 70%. End–systolic annulus area (12.5±2.5 cm2 vs 14.1±2.6 cm2; p = 0.038), end–systolic annulus diameter (13.2±1.2 cm vs 14±1.3 cm; p = 0.042) and indexed left atrial volume (59±17 ml/m2 vs 76±37 ml/m2; p = 0.041) were lower in patients with residual MR less than moderate (MR &lt; 3+/4+). Three–dimensional indexes specifically focused on coaptation reserve and annular disfunction were the best predictors of MR &lt; 3+/4+ at follow–up, in particular diastolic sum of the leaflets/end–systolic annulus area ([AUC] 0.74; p = 0.029) and systo–diastolic annulus area fractional change ([AUC] 0.743; p = 0.035). Furthermore, each of these annular parameters, calculated using dedicated 3D software, were predictive of residual MR, whereas annular 2D dimensions were not (p = 0.347).

Conclusion

In patients with degenerative MR treated with Neochord procedure, 3D analysis focused on annular measures and coaptation indexes, that included 3D annular dimensions, predicts better MR relapse than conventional 2D parameters.

C40 THREE–DIMENSIONAL FINGER TEST: A NEW ECHOCARDIOGRAPHIC METHOD TO LOCATE THE BEST ACCESS SITE DURING NEOCHORD PROCEDURE

Background

The NeoChord procedure is a trans–ventricular, beating–heart chordal implantation for severe degenerative mitral valve regurgitation due to prolapse or flail leaflet and it is performed using a dedicated device (DS 1000 system, NeoChord, Inc. St. Louis Park, MN). The use of the transesophageal echocardiography (TEE) is crucial to guide the procedure. Bi–dimensional (2D) imaging completed with simultaneous biplane view during surgeon finger pushing on the LV wall (finger test) is currently used to choose the LV access, which is usually on the mid–distal infero–lateral wall (ILW), between the papillary muscles (PMs) at the inferior level of their insertion on LV wall. This simulation helps the operators to evaluate the safe distance to PMs to minimize the risk of damaging the sub–valvular apparatus during the insertion of the device. We aimed to compare a new 3D method with the conventional one in terms of safety and better localization of the desired entry site.

Methods

During the procedure finger test has been performed with conventional 2D imaging and simultaneous biplane method. It has been completed using the real time 3D TEE placing the sample box in the bi–commissural view of the LV including the PMs and the apex. The resulting 3D volume was subsequently edited to visualize the LV from above (surgical view) to localize the bulge of the operator finger pushing on the desired segment of the LV wall. We asked the first operator, the second operator and the cardiac surgery fellow, separately, to evaluate location of their finger pushing, in terms of desired position and safety of access, both with 2D method and the 3D method to estimate the inter–operator concordance.

Results

From March 2019 to September 2021 42 consecutive cases have been performed using finger test completed with 3D method without complications related to the trans–ventricular access. Regarding the choice of the right and safe entry site, the percentage of agreement between operators was higher using LV real time 3D rendering compared to the conventional finger test [82 + 21% Vs 59% + 29%, IC 95%, p: 0,04].

Conclusion

Three–dimensional finger test is easy to perform and decreases inter–operator variability of image interpretation facilitating the surgeons to choose the best entry site in term of anatomical localization and safety.

Valve-in-valve transcatheter aortic valve replacement or re-surgical aortic valve replacement in degenerated bioprostheses: A systematic review and meta-analysis of short and midterm results

INTRODUCTION

Despite limited to short and midterm outcomes, valve-in-valve (ViV) transcatheter aortic valve implantation (TAVI) has emerged as a valid alternative to re-surgical aortic valve replacement (re-SAVR) for high- and intermediate-risk patients with degenerated surgical bioprosthesis.

METHODS

All studies comparing multivariate adjustment between ViV TAVI and re-SAVR were screened. The primary end-points were all-cause and cardiovascular (CV) mortality at 30 days and at Midterm follow-up. Short-term complications were the secondary endpoints.

RESULTS

We obtained data from 11 studies, encompassing 8570 patients, 4224 undergoing ViV TAVI, and 4346 re-SAVR. Four studies included intermediate-risk patients and seven high-risk patients. 30-day all-cause and CV mortality were significantly lower in ViV (odds ratio [OR] 0.43, 95% confidence intervals [CIs] 0.29-0.64 and OR 0.44, 0.26-0.73 respectively), while after a mean follow-up of 717 (180-1825) days, there was no difference between the two groups (OR 1.04, 0.87-1.25 and OR 1.05, 0.78-1.43, respectively). The risk of stroke (OR 1.03, 0.59-1.82), MI (OR 0.70, 0.34-1.44), major vascular complications (OR 0.92, 0.50-1.67), and permanent pacemaker implantation (OR 0.67, 0.36-1.25) at 30 days did not differ, while major bleedings and new-onset atrial fibrillation were significantly lower in ViV patients (OR 0.41, 0.25-0.67 and OR 0.23, 0.12-0.42, respectively, all 95% CIs).

CONCLUSIONS

In high- and intermediate-risk patients with degenerated surgical bioprostheses, ViV TAVI is associated with reduced short-term mortality, compared with re-SAVR. Nevertheless, no differences were found in all-cause and CV mortality at midterm follow-up. PROSPERO CRD42021226488.

Aortic Valve Replacement Versus Conservative Treatment in Asymptomatic Severe Aortic Stenosis: The AVATAR Trial

BACKGROUND

Surgical aortic valve replacement (SAVR) represents a class I indication in symptomatic patients with severe aortic stenosis (AS). However, indications for early SAVR in asymptomatic patients with severe AS and normal left ventricular function remain debated.

METHODS

The AVATAR trial (Aortic Valve Replacement Versus Conservative Treatment in Asymptomatic Severe Aortic Stenosis) is an investigator-initiated international prospective randomized controlled trial that evaluated the safety and efficacy of early SAVR in the treatment of asymptomatic patients with severe AS, according to common criteria (valve area ≤1 cm² with aortic jet velocity >4 m/s or a mean transaortic gradient ≥40 mm Hg), and with normal left ventricular function. Negative exercise testing was mandatory for inclusion. The primary hypothesis was that early SAVR would reduce the primary composite end point of all-cause death, acute myocardial infarction, stroke, or unplanned hospitalization for heart failure compared with a conservative strategy according to guidelines. The trial was designed as event-driven to reach a minimum of 35 prespecified events. The study was performed in 9 centers in 7 European countries.

RESULTS

Between June 2015 and September 2020, 157 patients (mean age, 67 years; 57% men) were randomly allocated to early surgery (n=78) or conservative treatment (n=79). Follow-up was completed in May 2021. Overall median follow-up was 32 months: 28 months in the early surgery group and 35 months in the conservative treatment group. There was a total of 39 events, 13 in early surgery and 26 in the conservative treatment group. In the early surgery group, 72 patients (92.3%) underwent SAVR with operative mortality of 1.4%. In an intention-to-treat analysis, patients randomized to early surgery had a significantly lower incidence of primary composite end point than those in the conservative arm (hazard ratio, 0.46 [95% CI, 0.23-0.90]; P=0.02). There was no statistical difference in secondary end points, including all-cause mortality, first heart failure hospitalizations, major bleeding, or thromboembolic complications, but trends were consistent with the primary outcome.

CONCLUSIONS

In asymptomatic patients with severe AS, early surgery reduced a primary composite of all-cause death, acute myocardial infarction, stroke, or unplanned hospitalization for heart failure compared with conservative treatment. This randomized trial provides preliminary support for early SAVR once AS becomes severe, regardless of symptoms. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02436655.

Minimally Invasive Mitral Valve Surgery After Transcatheter Edge-to-Edge Repair

OBJECTIVE

Up to 28% of patients may need mitral valve (MV) surgery after transcatheter edge-to-edge repair (TEER). This study evaluates the outcomes of minimally invasive MV surgery after TEER. Methods: International multicenter registry of minimally invasive MV surgery after TEER between 2013 and 2020. Subgroups were stratified by the number of devices implanted (≤1 vs >1), as well as time interval from TEER to surgery (≤1 year vs >1 year). Results: A total of 56 patients across 13 centers were included with a mean age of 73 ± 11 years, and 50% were female. The median Society of Thoracic Surgeons Predicted Risk of Mortality (STS PROM) score for MV replacement was 8% (Q1-Q3 = 5% to 11%) and the ratio of observed to expected mortality was 0.9. The etiology of mitral regurgitation (MR) prior to TEER was primary MR in 75% of patients and secondary MR in 25%. There were 30 patients (54%) who had >1 device implanted. The median time between TEER and surgery was 252 days (33 to 636 days). Hemodynamics, including MR severity, MV area, and mean gradient, significantly improved after minimally invasive surgery and sustained to 1-year follow-up. In-hospital and 30-day mortality was 7.1%, and 1-year actuarial survival was 85.6% ± 6%. Conclusions: Minimally invasive MV surgery after TEER may be achieved as predicted by the STS PROM. Most patients underwent MV replacement instead of repair. As TEER is applied more widely, patients should be informed about the potential need for surgical intervention over time after TEER. These discussions will allow better informed consent and post-procedure planning.

Transcatheter Aortic Valve Implantation With or Without Predilation: A Meta-Analysis

AIMS

To evaluate the impact of systematic predilation with balloon aortic valvuloplasty (BAV) on transcatheter aortic valve implantation (TAVI).

METHODS AND RESULTS

We performed a systematic meta-analysis investigating patients undergoing TAVI with systematic BAV vs no BAV in RCT or in adjusted studies. Device success was the primary endpoint, while all-cause mortality, 30-day moderate/severe aortic regurgitation (AR), stroke, permanent pacemaker implantation (PPI) and acute kidney injury (AKI) were the secondary endpoints. Subanalysis according to design of the study (RCT and adjusted analysis) and to the type of valve (balloon-expandable [BE] vs self-expanding [SE]) were conducted. We obtained data from 15 studies, comprising 16,408 patients: 10,364 undergoing BAV prior to TAVI and 6,044 in which direct TAVI has been performed. At 30-day follow-up, BAV did not improve the rate of device success in the overall population (OR, 1.09; 95% CI, 0.90-1.31), both in SE (OR, 0.93; 95% CI, 0.60-1.45) and in BE (OR, 1.16; 95% CI, 0.88-1.52) valves. Between BAV and direct TAVI, no differences in secondary outcomes were observed neither in overall population nor according to valve type between BAV and direct TAVI strategies. All endpoints results were consistent between RCTs and adjusted studies except for postdilation rate that did not differ in observational studies (OR, 0.70; 95% CI, 0.47-1.04), while it was lower in BAV when only RCTs were included in the analysis (OR, 0.48; 95% CI, 0.24-0.97).

CONCLUSIONS

Direct TAVI is feasible and safe compared to predilation approach with similar device success rates and clinical outcomes. Direct TAVI could represent a first-choice approach in contemporary TAVI procedures.

Prognostic implications of impaired longitudinal left ventricular systolic function assessed by tissue Doppler imaging prior to transcatheter aortic valve implantation for severe aortic stenosis

Change in longitudinal left ventricular (LV) systolic function serves as an early marker of the deleterious effect of aortic stenosis (AS) and other cardiac comorbidities on cardiac function. We explored the prognostic value of tissue Doppler imaging (TDI)-derived longitudinal LV systolic function, defined by the peak systolic average of lateral and septal mitral annular velocities (average S') among symptomatic patients with severe AS undergoing transcatheter aortic valve implantation (TAVI). 297 consecutive patients with severe AS undergoing TAVI at three european centers with available average S' at preprocedural echocardiography were retrospectively included. The primary endpoint was the Kaplan Meier estimate of all-cause mortality. After a median 18 months (IQR 12-18) follow-up, 36 (12.1%) patients had died. Average S' was associated with all-cause mortality (per 1 cm/sec decrease: HR 1.29, 95%CI 1.03-1.60, p = 0.025), the cut-off of 6.5 cm/sec being the most accurate. Patients with average S' < 6.5 cm/sec (55.2%) presented characteristics of more advanced LV remodeling and functional impairment along with higher burden of cardiac comorbidities, and experienced higher all-cause mortality (17.6% vs. 7.5%, p = 0.007), also when adjusted for in-study outcome predictors (adj-HR: 2.69, 95%CI 1.22-5.93, p = 0.014). Results were consistent among patients with preserved ejection fraction, normal-flow AS, high-gradient AS and in those without LV hypertrophy. Longitudinal LV systolic function assessed by average S' is independently associated with long-term all-cause mortality among TAVI patients. An average S' below 6.5 cm/sec best defines clinically meaningful reduced longitudinal systolic function and may aid clinical risk stratification in these patients.

Post-operative Quality of Life after Full-sternotomy and Mini-sternotomy Aortic Valve Replacement

BACKGROUND

Few longitudinal data exist comparing quality of life (QoL) after full sternotomy aortic valve replacement (fsAVR) vs mini-sternotomy AVR (msAVR) METHODS: 1844 consecutive AVR prospectively enrolled in a European multicentre Registry were dichotomized according to surgical access. A non-parsimonious propensity-score matching selected 187 pairs of fsAVR or msAVR with comparable baseline characteristics. Hospital outcome was compared in the two groups. QoL was assessed with Short Form-36, further detailed in its Physical Component Score (PCS) and Mental Component Score (MCS). QoL was investigated at hospital admission, discharge, 1 month, 6 months and 1 year thereafter.

RESULTS

There were 1654 fsAVR and 190 msAVR in the entire population. fsAVR showed a worse preoperative risk-profile, a longer ICU length of stay (59.7 hours vs 38.8, p=0.002), and a higher life-threatening/disabling bleeding (4.1% vs. 0%; p=0.011); msAVR reported a higher early reintervention for failed index intervention (2.1% vs. 0.5%, p=0.001). QoL showed better PCS and MCS at 1 month after fsAVR, but no temporal-trend differences (PCS group-time p=0.202; MCS group-time p=0.141). Propensity-matched pairs showed comparable baseline characteristics and hospital outcome (p=NS for all endpoints), and comparable improvements of PCS and MCS over time, but no between-group differences over time (PCS group-time p=0.834; MCS group-time p=0.737).

CONCLUSIONS

Patients with similar baseline profiles report comparable hospital outcome and comparable improvement of physical and mental health, up to 1 year after surgery, with both fsAVR and msAVR. As for QoL, mini-sternotomy does not seem to offer any advantage compared to the traditional approach.

302 Impact of right ventricular pacing in patients with TAVI underwent permanent pacemaker implantation: the Pace-TAVI International Multicentre Study

Aims

Permanent pacemaker implantation after transcatheter aortic valve implantation (TAVI) has emerged as a relevant issue, being more frequent than after surgery and the progressive shift towards low-risk patients stressed the importance to reduce the risk of complications that could impact patient’s long-term prognosis. Long-term right ventricular pacing has been related to an increased risk of electromechanical asynchrony, negative left-ventricular remodelling, atrial fibrillation and heart failure, but there is a lack of evidence regarding the prognostic impact on TAVI patients. The aim of this international multicentre study is to assess the impact of right ventricular pacing on prognosis of TAVI patients undergone pacemaker implantation after the procedure due to conduction disorders.

Methods and results

All the consecutive patients with severe aortic stenosis treated with TAVI and subsequently underwent pacemaker implantation in each participating centre were enrolled. Patients were divided into two subgroups according to the percentage of ventricular pacing (VP cut-off: 40%) at pacemaker interrogation. The primary endpoint was the composite of cardiovascular mortality and hospitalization for heart failure in subgroups based on the percentage of ventricular stimulation. All cause and cardiovascular mortality in the subgroups according to the percentage of ventricular pacing were the secondary endpoints. In total, 427 patients were enrolled, 153 patients with VP &lt; 40% and 274 with a with VP ≥ 40%. Patients with VP ≥ 40% were older (81.16 ± 6.4 years vs. 80.51 ± 6.8 years), with higher NYHA class, a lower EF (55.26 ± 12.2 vs. 57.99 ± 11.3 P = 0.03), an increased end diastolic ventricular volume (112.11 ± 47.6 vs. 96.60 ± 40.4, P = 0.005) and diameter (48.89 ± 9.7 vs. 45.84 ± 7.5 P = 0.01). A higher incidence of moderate post-procedural paravalvular leak was observed in patients with VP ≥ 40% (37.5% vs. 26.85%, P = 0.03). Ventricular pacing ≥40% was associated with a higher incidence of the composite primary endpoint of CV mortality and HF hospitalization (p at log rank test = 0.006, adjusted HR: 2.41; 95% CI: 1.03–5.6; P = 0.04). Patients with ventricular pacing ≥ 40% had also a higher risk of all-cause (p at log rank test = 0.03, adjusted HR = 1.57; 95% CI: 1.03–2.38; P = 0.03) and cardiovascular (p at log ank test =0.008, adjusted HR: 3.77; CI: 1.32–10.78; P = 0.006) mortality compared to patients with a VP &lt; 40%.

Conclusions

TAVI Patients underwent permanent pacemaker implantation after the procedure due to conduction disorders and with a VP ≥ 40% at follow-up are at increased risk of cardiovascular death and HF hospitalizations and of all-cause mortality compared to patients with a VP &lt; 40%. It is mandatory to reduce the percentage of ventricular pacing at follow-up when possible or consider left ventricular branch pacing and biventricular pacing in TAVI patients.

Impact of computed-tomography defined sarcopenia on outcomes of older adults undergoing transcatheter aortic valve implantation

BACKGROUND

The adoption of Computed tomography (CT)-defined sarcopenia to risk stratify transcatheter aortic valve implantation (TAVI) candidates remains limited by a lack of both standardized definition and evidence of independent value over currently adopted mortality prediction tools.

METHODS

391 consecutive TAVI patients with pre-procedural CT scan were included (81 ​± ​6 years, 57.5% male, STS-PROM score 4.4 ​± ​3.6%) and abdominal muscle retrospectively quantified. The two definitions of radiologic sarcopenia previously adopted in TAVI studies were compared (psoas muscle area [PMA] at the L4 vertebra level: "PMA-sarcopenia"; indexed skeletal muscle area at the L3 vertebra level: "SMI-sarcopenia"). The primary endpoint was longer available-term all-cause mortality. Secondary endpoints were Valve Academic Research Consortium-2-defined in-hospital and 30-day outcomes.

RESULTS

SMI- and PMA-sarcopenia were present in 192 (49.1%) and 117 (29.9%) patients, respectively. After a median of 24 (12-30) months follow-up, 83 (21.2%) patients died. PMA-(adj-HR 1.81, 95%CI 1.12-2.93, p ​= ​0.015), but not SMI-sarcopenia (adj-HR 1.23, 95%CI 0.76-2.00, p ​= ​0.391), was associated with all-cause mortality independently of age, sex and in-study outcome predictors (atrial fibrillation, hemoglobin, history of peripheral artery disease, cancer and subcutaneous adipose tissue). PMA-defined sarcopenia provided additive prognostic value over current post-TAVI mortality risk estimators including STS-PROM (p ​= ​0.001), Euroscore II (p ​= ​0.025), Charlson index (p ​= ​0.025) and TAVI2-score (p ​= ​0.020). Device success, early safety, clinical efficacy and 30-day all-cause death were unaffected by sarcopenia status regardless of definition.

CONCLUSIONS

PMA-sarcopenia (but not SMI-sarcopenia) is predictive of 2 year mortality among TAVI patients. The prognostic information provided by PMA-sarcopenia is independent of the tools currently adopted to predict post-TAVI mortality in clinical practice.

Valve-in-valve transcatheter aortic valve replacement or re-surgical aortic valve replacement in degenerated bioprostheses: a systematic review and meta-analysis of short and mid-term results

Introduction

Despite limited to short and mid-term outcomes, Valve-in-valve (ViV) transcatheter aortic valve implantation (TAVI) has emerged as a less invasive alternative to redo surgery for high and intermediate-risk patients with good outcomes across different surgical risk profiles.

Purpose

The aim of the resent meta-analysis is to compare short and mid-term outcomes of VIV and surgical redo fo patients with a degenerative aortic bioprosthesis.

Methods

All studies comparing with multivariate adjustment between ViV TAVI and re-SAVR were screened. All-cause mortality at 30-day and at follow-up were the primary endpoints, while Valve Academy research Consortium (VARC) endpoints at 30 days including stroke, myocardial infarction (MI), major vascular complications, major bleeding, new onset atrial fibrillation (AF) and permanent pacemaker implantation (PPI) during the index hospitalization were the secondary endpoints. Subgroup analysis were performed according to the surgical risk. All the analyses were stratified according to the design of the study (observational vs propensity-matched study).

Results

We obtained data from 11 studies, encompassing 8570 patients, 4224 undergoing ViV TAVI and 4346 re-SAVR. Four studies included intermediate-risk patients and seven high-risk patients. Mean age was 76 and 71.5 years in the ViV and re-SAVR group respectively, with a 60.2% and 61.3% of male. For the ViV procedure, BE prostheses were used in the 49.6% of patients and SE prostheses in the 45.8%. The ViV group have higher prevalence of previous CAD (53.8% vs 41.1%) and CABG (35% vs 23.6%) and more history of HF (72.1% vs 65.6%), CKD (26.6% vs 14.8%) and COPD (25.4 vs 14.8%). 30-day all-cause and CV mortality were significantly lower in ViV (OR 0.43, 0.29–0.64 and OR 0.44, 0.26–0.73 respectively), while after a mean follow-up of 717 (180–1825) days, there were no difference between the two groups (OR 1.04, 0.87–1.25 and OR 1.05, 0.78–1.43 respectively). The result were consistent both in intermediate and high-risk classes. The risk of stroke (OR 1.03, 0.59–1.82), MI (OR 0.70, 0.34–1.44), major vascular complications (OR 0.92, 0.50–1.67) and permanent pacemaker implantation (OR 0.67, 0.36–1.25) at 30 days did not differ, while major bleedings and new onset atrial fibrillation were significantly lower in ViV patients (OR 0.41, 0.25–0.67 and OR 0.23, 0.12–0.42 respectively, all CI 95%).

Conclusions

In patients with a degenerated aortic bioprosthesis, ViV TAVI is associated with better short-term outcomes, including all-cause mortality, without any difference in all-cause and cardiovascular mortality at mid-term follow-up compared to surgical redo.

Funding Acknowledgement

Type of funding sources: None.

Percutaneous vs. surgical revascularization for patients with unprotected left main stenosis: a meta-analysis of 5-year follow-up randomized controlled trials

AIMS

A 5-year survival of patients with unprotected left main (ULM) stenosis according to the choice of revascularization (percutaneous vs. surgical) remains to be defined.

METHODS AND RESULTS

Randomized controlled trials (RCTs) comparing percutaneous coronary intervention (PCI) vs. coronary artery bypass graft (CABG) with a follow-up of at least 5 years were included. All-cause death was the primary endpoint. MACCE [a composite endpoint of all-cause mortality, myocardial infarction (MI), stroke, and repeat revascularization] along with its single components and cardiovascular (CV) death were the secondary ones. Analyses were stratified according to the use of first- vs. last-generation coronary stents. Subgroup comparisons were performed according to SYNTAX score (below or above 33) and to age (using cut-offs of each trial's subgroup analysis). Four RCTs with 4394 patients were identified: 2197 were treated with CABG, 657 with first generation, and 1540 with last-generation stents. At 5-year rates of all-cause death did not differ [odds ratio (OR) 0.93, 95% confidence interval (CI) 0.71-1.21], as those of CV death and stroke. Coronary artery bypass graft reduced rates of MACCE (OR 0.69, 95% CI 0.60-0.79), mainly driven by MI (OR 0.48, 95% CI 0.36-0.65) and revascularization (OR 0.53, 95% CI 0.45-0.64). Benefit of CABG for MACCE was consistent, although with different extent, across values of SYNTAX score (OR 0.76, 95% CI 0.59-0.97 for values < 32 and OR 0.63, 95% CI 0.47-0.84 for values ≥ 33) while was not evident for 'younger' patients (OR 0.83, 95% CI 0.65-1.07 vs. OR 0.65, 95% CI 0.51-0.84 for 'older' patients).

CONCLUSION

For patients with ULM disease followed-up for 5 years, no significant difference was observed in all-cause and cardiovascular death between PCI and CABG. Coronary artery bypass graft reduced risk of MI, revascularization, and MACCE especially in older patients and in those with complex coronary disease and a high SYNTAX score.

Aortic valve replacement vs. balloon-expandable and self-expandable transcatheter implantation: A network meta-analysis

INTRODUCTION

Recently, observational data have raised concerns about safety of selfexpandable (SE) compared to balloon-expandable (BE) valves in TAVI, although potentially limited by patient selection bias.

METHODS

All Randomized Controlled Trials (RCTs) comparing BE vs. SE TAVI or/and vs. aortic valve replacement (AVR) were included and compared through Network Meta Analysis (NMA). All-cause and cardiovascular (CV) mortality were the primary endpoints, stroke, rates of permanent pacemaker implantation (PPI), moderate/severe paravalvular leak (PVL) and reintervention were the secondary endpoints. Results We obtained data from 11 RCTs, encompassing 9752 patients. After one and two years, no significant differences for allcause and CV mortality were observed. Compared to surgical bioprostheses, both BE and SE TAVI reduced the risk of acute kidney injury (OR 0.42; CI 95% 0.30-0.60 and OR 0.44; CI 95% 0.32-0.60), new-onset atrial fibrillation (OR 0.24; CI 95% 0.14-0.42 and OR 0.21; CI 95% 0.13-0.34) and major bleedings (OR 0.32; CI 95% 0.16-0.65 and OR 0.47; CI 95% 0.25-0.89). The BE prostheses reduced the risk of moderate/severe PVL at 30-day (OR 0.31; CI 95% 0.17-0.55) and of PPI both at 30-day (OR 0.51; CI 95% 0.33-0.79) and 1 year (OR 0.40; CI 95% 0.30-0.55) as compared to SE TAVI. Conclusions A TAVI strategy, independently from BE or SE prostheses, offers a midterm survival comparable to AVR. The BE prostheses are associated with a reduction of PPI and PVL compared to SE prostheses without any differences in all-cause and CV mortality during two years of follow up. PROSPERO ID CRD42020182407.

Transcatheter Mitral Valve Replacement After Surgical Repair or Replacement

Background:

Mitral valve-in-valve (ViV) and valve-in-ring (ViR) are alternatives to surgical reoperation in patients with recurrent mitral valve failure after previous surgical valve repair or replacement. Our aim was to perform a large-scale analysis examining midterm outcomes after mitral ViV and ViR.

Methods:

Patients undergoing mitral ViV and ViR were enrolled in the Valve-in-Valve International Data Registry. Cases were performed between March 2006 and March 2020. Clinical endpoints are reported according to the Mitral Valve Academic Research Consortium (MVARC) definitions. Significant residual mitral stenosis (MS) was defined as mean gradient ≥10 mm Hg and significant residual mitral regurgitation (MR) as ≥ moderate.

Results:

A total of 1079 patients (857 ViV, 222 ViR; mean age 73.5±12.5 years; 40.8% male) from 90 centers were included. Median STS-PROM score 8.6%; median clinical follow-up 492 days (interquartile range, 76–996); median echocardiographic follow-up for patients that survived 1 year was 772.5 days (interquartile range, 510–1211.75). Four-year Kaplan-Meier survival rate was 62.5% in ViV versus 49.5% for ViR ( P <0.001). Mean gradient across the mitral valve postprocedure was 5.7±2.8 mm Hg (≥5 mm Hg; 61.4% of patients). Significant residual MS occurred in 8.2% of the ViV and 12.0% of the ViR patients ( P =0.09). Significant residual MR was more common in ViR patients (16.6% versus 3.1%; P <0.001) and was associated with lower survival at 4 years (35.1% versus 61.6%; P =0.02). The rates of Mitral Valve Academic Research Consortium–defined device success were low for both procedures (39.4% total; 32.0% ViR versus 41.3% ViV; P =0.01), mostly related to having postprocedural mean gradient ≥5 mm Hg. Correlates for residual MS were smaller true internal diameter, younger age, and larger body mass index. The only correlate for residual MR was ViR. Significant residual MS (subhazard ratio, 4.67; 95% CI, 1.74–12.56; P =0.002) and significant residual MR (subhazard ratio, 7.88; 95% CI, 2.88–21.53; P <0.001) were both independently associated with repeat mitral valve replacement.

Conclusions:

Significant residual MS and/or MR were not infrequent after mitral ViV and ViR procedures and were both associated with a need for repeat valve replacement. Strategies to improve postprocedural hemodynamics in mitral ViV and ViR should be further explored.

Predictors of pacemaker implantation after transcatheter aortic valve implantation according to kind of prosthesis and risk profile: a systematic review and contemporary meta-analysis

AIMS

Permanent pacemaker implantation (PPI) may be required after transcatheter aortic valve implantation (TAVI). Evidence on PPI prediction has largely been gathered from high-risk patients receiving first-generation valve implants. We undertook a meta-analysis of the existing literature to examine the incidence and predictors of PPI after TAVI according to generation of valve, valve type, and surgical risk.

METHODS AND RESULTS

We made a systematic literature search for studies with ≥100 patients reporting the incidence and adjusted predictors of PPI after TAVI. Subgroup analyses examined these features according to generation of valve, specific valve type, and surgical risk. We obtained data from 43 studies, encompassing 29 113 patients. Permanent pacemaker implantation rates ranged from 6.7% to 39.2% in individual studies with a pooled incidence of 19% (95% CI 16-21). Independent predictors for PPI were age [odds ratio (OR) 1.05, 95% confidence interval (CI) 1.01-1.09], left bundle branch block (LBBB) (OR 1.45, 95% CI 1.12-1.77), right bundle branch block (RBBB) (OR 4.15, 95% CI 3.23-4.88), implantation depth (OR 1.18, 95% CI 1.11-1.26), and self-expanding valve prosthesis (OR 2.99, 95% CI 1.39-4.59). Among subgroups analysed according to valve type, valve generation and surgical risk, independent predictors were RBBB, self-expanding valve type, first-degree atrioventricular block, and implantation depth.

CONCLUSIONS

The principle independent predictors for PPI following TAVI are age, RBBB, LBBB, self-expanding valve type, and valve implantation depth. These characteristics should be taken into account in pre-procedural assessment to reduce PPI rates. PROSPERO ID CRD42020164043.

Fractional flow reserve (FFR) guided vs angiography guided coronary artery bypass graft (CABG): a systematic review and meta-analysis

Background

A strategy of percutaneous coronary intervention (PCI) driven by FFR (Fractional Flow Reserve) has demonstrated to reduce adverse events through the “deferring” of unnecessary stenting procedures compared to PCI guided by angiographic evaluation of stenosis. Coronary Artery Bypass Graft (CABG) represents another option for revascularization, being superior to PCI in patients with diffuse disease. In this setting, some evidence has been provided about physiological driven CABG procedures, but studies reported contrasting results regarding clinical benefits and outcomes at follow up.

The aim of this meta-analysis is to evaluate clinical and procedural impact of FFR versus angiographic guided surgical revascularization and assess outcomes at follow up.

Methods

All randomized controlled trials (RCTs) or observational studies with multivariable adjustment or propensity matching were included. MACE (Major Adverse Cardiac Events) was the primary end point, while its single components (death, myocardial infarction and revascularization) along with number of grafts and percent of off-pump CABG were the secondary ones. Of 86 studies identified, 4 articles were included in this review, representing a combined total of 777 patients (426 angio-guided and 351 FFR-guided). Mean age was 66±2.1, 80% man, 74% hypertension, 71% hyperlipidemia, 33% diabetes, 39% smokers. Mean EuroSCORE I was 2.7. 18% a prior MI, and 25% a prior PCI. Coronary lesions were allocated as follow: 36% left anterior descending artery, 32% circumflex artery, 27% right coronary artery. Mean follow up was 30 months. At the follow up, rates of MACE did not differ (MACE OR 1.31:0.88–1.96), as those of death (OR 1.47:0.86–2.51), of MI (OR 1.80:0.89–3.63), and of target vessel revascularization (1.03: 0.54–1.97.). FFR-guided CABG was associated with more off-pump surgical procedure (OR 0.58, IC 0.34–0.97) and shorter hospitalization time (8.2±2.49 vs 8,87±3,25 p&lt;0.01). FFR- guided CABG was associated more frequently with off-pump surgical procedure (OR 0.58:0.34–0.97) with fewer anastomes (2.5 vs 3), leading to higher rates of global arteria revascularization in FFR group (56% vs. 45%) and higher rates of venous grafts in angio-guided group (55% vs. 44%). Shorter hospitalization time was recorded in FFR patients (8.2±2.49 vs 8,87±3,25 days, p&lt;0.01). Graft patency at follow up was not statistically higher in the FFR guided group (OR 0.67, CI 95% 0.32–1,39, all CI 95%).

Conclusions

FFR-guided surgical revascularization is associated with more off-pump procedures, a lower number of surgical anastomoses and more arterial grafts compared to angiography guided CABG. These differences lead to a shorter hospitalization time in the FFR-guided group compared to the angiography-guided group. No difference between two groups in MACE, overall death and MI was observed during the follow up. RCT with longer follow up are needed to evaluate long term outcomes.

Funding Acknowledgement

Type of funding source: None

Percutaneous vs. surgical revascularization for patients with unprotected left main stenosis: a meta-analysis of 5 years follow-up RCTs

Introduction

5-year survival of patients with ULM (Unprotected Left Main) stenosis according to the choice of revascularization (percutaneous vs. surgical) remains to be defined.

Methods and results

Randomized Controlled Trials (RTCs) comparing Percutaneous Coronary Intervention (PCI) vs. Coronary Artery Bypass Graft (CABG) with a follow-up of at least 5 years were included. All-cause death was the primary endpoint. MACCE (a composite endpoint of all-cause mortality, myocardial infarction [MI], stroke and repeat revascularization) along with its single components and cardiovascular (CV) death were the secondary ones. Analyses were stratified according to use of first vs. last generation coronary stents. Subgroup comparisons were performed according to Syntax Score (below or above 33) and to age (using cutoffs of each trial's subgroup analysis). 4 RCTs with 4394 patients were identified: 2197 were treated with CABG, 657 with first generation and 1540 with last generation stents. At 5 years rates of all-cause death did not differ (OR 0.93: 0.71–1.21), as those of CV death and stroke. CABG reduced rates of MACCE (OR 0.69: 0.60–0.79), mainly driven by MI (OR 0.48: 0.36–0.65) and revascularization (OR 0.53: 0.45–0.64). Benefit of CABG for MACCE was consistent, although with different extent, across values of Syntax Score (OR 0.76: 0.59–0.97 for values &lt;32 and OR 0.63: 0.47–0.84 for values ≥33) while was not evident for “younger” patients (OR 0.83: 0.65–1.07 vs. OR 0.65: 0.51–0.84 for “older” patients, all CI 95%).

Conclusion

For patients with ULM disease, PCI and CABG yielded same survival benefit at 5 years. CABG reduced risk of MI, revascularization and MACCE especially in older patients and in those with diffuse coronary disease.

Funding Acknowledgement

Type of funding source: None

Incidence, predictors and outcomes of Valve-in-valve (ViV) Transcatheter aortic valve replacement (TAVR): a systematic review and meta-analysis

Background

Surgical aortic valve replacement has been the treatment of choice for patients with aortic valve disease before the arrival of transcatheter aortic valve replacement (TAVI), although limited by degeneration of the bioprosthesis. “Redo” intervention itself is burdened by high risk of complications and valve-in-valve (ViV) TAVI could be a valid strategy of redo for patients with comorbidities. The aim of this meta-analysis is to give an overview of the state of the art of ViV TAVI in high-risk patients, analyzing efficacy, safety, intra-hospital outcomes and 1-year outcomes and assess predictors of survival at short and mid-term follow up.

Methods

Two independent reviewers screened all studies investigating patients undergoing ViV TAVI. PubMed database was searched for reports published in English according to the following highly sensitive strategy: (Transcatheter[All Fields] AND “aortic”[All Fields]) AND valve-in-valve[All Fields] AND “implantation”[All Fields] NOT (review[pt] OR editorial[pt] OR letter[pt])AND “humans”[MeSH Terms]). Mortality at 30 days and at 1 year were the primary end point, while procedural and short-term outcomes and echocardiographic parameters at hospital discharge were the secondary end points.

Results

Of 286 studies identified, 26 articles were included, with a total of 1448 patients. Median age was 78.8 years, 57.7% of the patients were male. Median STS-predicted risk of mortality was 9.4% while median Logistic EuroSCORE was 31.3%. Median age of bioprosthesis was 10 years with 84.6% of stented valves. Stenosis (45%), followed by regurgitation (31%) and mixed defects (21%) were the causes of prosthesis failure. Diameter of the degenerated valve was ≤21 mm in 25.4%, 22–25 mm in 55% and &gt;25mm in 11.7% of the patients. Transfemoral approach was preferred (76%), with a prevalence of balloon expandable valve (73.3%). Mean post procedural gradient was 16.7±0.8 mmHg. Mean follow up was 376 days. Overall and cardiovascular mortality at 30 days was 6.5% and 5.5% respectively, while at 1 year it was 14.5% and 8.9% respectively. Regarding short-term outcomes, overall bleeding (10.4%), pacemaker implantation (9.4%) and vascular complications (8.3%) were the most common peri-procedural complications, while stroke (2.3%), myocardial infarction (2.7%) and coronary obstruction (2.8%) were less frequent. At meta-regression analysis study year (p&lt;0.001), Logistic Euroscore (p&lt;0.01) and valve diameter ≤21 mm (p&lt;0.05) at 30 days, and stenosis as reason for failure (p=0.05) at 1 year were identified as possible predictors of survival.

Conclusions

Percutaneous valve-in-valve aortic valve implantation offers a valid strategy to treat high risk patients with a degenerative bioprosthesis. Short and mid-term outcomes are substantially superimposable to those of TAVI, except for coronary obstruction which appears more frequent. Future studies are needed to find predictors of long- term survival and outcomes in lower risk patients.

Outcome of VIV TAVI

Funding Acknowledgement

Type of funding source: None

Electrocardiographic and clinical predictors for permanent pacemaker requirement after transcatheter aortic valve implantation: a 10-year single center experience

BACKGROUND

The aim of this study is to identify clinical, electrocardiographic (ECG) and procedural predictors for permanent pacemaker (PPM) requirement after transaortic valve implantation (TAVI).

METHODS

All consecutive patients with severe symptomatic aortic stenosis (SSAS) undergoing TAVI at our single center were included in the study and prospectively followed. All patients had standard 12-leads ECGs recordings before and after TAVI and continuous ECG monitoring during hospital stay. Primary endpoint was to identify electrocardiographic predictors of PPM implantation after TAVI; secondary endpoint was to ascertain other clinical or procedure-related predictive factors of PPM need. PPM implantation was further arbitrarily divided into early and late one (beyond the 3^rd day).

RESULTS

Among the 431 patients undergoing TAVI between 2008 and 2018, 77 (18%) needed PPM implantation; 47 (11%) had an early procedure, and 30 (7%) a late implant. Preoperative right bundle branch block (RBBB) implies more than five-fold increase of the risk of PPM implantation (OR 5.19, CI 1.99-13.56, P=0.001), whereas the use of a self-expandable prosthesis is associated with an almost three-fold increase of the risk (OR 2.60, CI 1.28-5.28, P=0.008). In the late PPM implantation subgroup, only the history of syncope retains a significant association with such an increased risk (OR 2.71, CI 1.09-6.75, P=0.032).

CONCLUSIONS

The need of a PPM in the individual TAVI patient is hardly predictable. However, the finding of pre-existing RBBB, the use of self-expandable prosthesis and history of syncope can individuate patients at increased risk.

The Neochord Procedure After Failed Surgical Mitral Valve Repair

Surgical mitral valve reintervention is associated with significant morbidity and mortality, and repeat repair is not always feasible. We examine the clinical outcomes of the NeoChord procedure after failed conventional mitral valve repair. A total of 312 patients were treated with the NeoChord repair procedure between January 2014 and December 2018 at 5 European centers. Clinical and echocardiographic data were reviewed to identify patients who had a prior surgical mitral valve repair procedure. The primary endpoint (Patient Success) was a composite of placement of at least 2 neochordae and end-procedure mitral valve regurgitation (MR) ≤ mild, freedom from death, stroke, structural or functional procedure failure (MR > moderate), procedure or device-related unplanned procedures, cardiac-related rehospitalization, or worsening NYHA functional class at 1 and 2-year FU. Fifteen (15) patients were identified who required reoperation for failed surgical mitral valve repair. Mean time-to-reoperation was 2.7 years (2.2-6.1). Median intensive care unit stay was 24 hours and median hospitalization time was 7 days (6-8). No in-hospital deaths were observed. At discharge, mitral regurgitation was ≤ mild in 13 patients (86.7%). Patient success and freedom from more than mild MR were 92.3 ± 7.4% and 83.9 ± 10.4% at 1 and 2-year follow-up respectively. One high-risk patient presented with severe recurrent MR and died during surgical reintervention due to an acute aortic dissection. Selected patients can be successfully treated with the NeoChord procedure after failed surgical mitral valve repair. These results support a wider adoption of the NeoChord procedure as a first-line minimally invasive, alternative therapy to treat failed mitral valve repair.

Long-term outcomes after transcatheter aortic valve implantation in failed bioprosthetic valves

Aims

Due to bioprosthetic valve degeneration, aortic valve-in-valve (ViV) procedures are increasingly performed. There are no data on long-term outcomes after aortic ViV. Our aim was to perform a large-scale assessment of long-term survival and reintervention after aortic ViV.

Methods and results

A total of 1006 aortic ViV procedures performed more than 5 years ago [mean age 77.7 ± 9.7 years; 58.8% male; median STS-PROM score 7.3% (4.2–12.0)] were included in the analysis. Patients were treated with Medtronic self-expandable valves (CoreValve/Evolut, Medtronic Inc., Minneapolis, MN, USA) (n = 523, 52.0%), Edwards balloon-expandable valves (EBEV, SAPIEN/SAPIEN XT/SAPIEN 3, Edwards Lifesciences, Irvine, CA, USA) (n = 435, 43.2%), and other devices (n = 48, 4.8%). Survival was lower at 8 years in patients with small-failed bioprostheses [internal diameter (ID) ≤ 20 mm] compared with those with large-failed bioprostheses (ID &gt; 20 mm) (33.2% vs. 40.5%, P = 0.01). Independent correlates for mortality included smaller-failed bioprosthetic valves [hazard ratio (HR) 1.07 (95% confidence interval (CI) 1.02–1.13)], age [HR 1.21 (95% CI 1.01–1.45)], and non-transfemoral access [HR 1.43 (95% CI 1.11–1.84)]. There were 40 reinterventions after ViV. Independent correlates for all-cause reintervention included pre-existing severe prosthesis–patient mismatch [subhazard ratio (SHR) 4.34 (95% CI 1.31–14.39)], device malposition [SHR 3.75 (95% CI 1.36–10.35)], EBEV [SHR 3.34 (95% CI 1.26–8.85)], and age [SHR 0.59 (95% CI 0.44–0.78)].

Conclusions

The size of the original failed valve may influence long-term mortality, and the type of the transcatheter valve may influence the need for reintervention after aortic ViV.

P513Electrocardiographic and clinical predictors for permanent pacemaker requirement after transcatheter aortic valve implantation: a 10-year single center experience

Funding Acknowledgements

None of the author have conflict of interest to disclose.

Background

 As transcatheter aortic-valve implantation (TAVI) procedures have increased, the need of a permanent pacemaker (PPM) is a complication to be taken into account. 

Objective

 The aim of this study is to identify clinical, electrocardiographic (ECG) and procedural predictors for PPM requirement after TAVI.

Methods

 The present is a single centre, retrospective study. All consecutive patients with severe symptomatic aortic stenosis who underwent TAVI had continuous ECG monitoring. Pre and post TAVI 12-leads ECG were analysed. We arbitrarily divided the patients into early and late PPM implantation (beyond the 3rd day after TAVI). The primary endpoint of the study was to identify electrocardiographic predictors of PPM implantation after TAVI, and the secondary endpoint was to identify other clinical or procedure-related predictive factors.

Results

 Of 431 patients who underwent TAVI, 77 (18%) required a PPM, and 30 (7%) had late PPM implantations. Pre-operative RBBB implies more than five-fold increase of the risk of PPM implantation after TAVI (OR 5,43, CI 2.11 - 13.99, P = 0.000), whereas the history of syncope is associated with a two-fold increase of the risk (OR 2.00, CI 1.01 - 3.96, P = 0.044), and maintains its predictive value also in the late PPM subgroup (OR 2.76, CI 1.11 – 6.82, P = 0.028).

Conclusions

 It is hard to predict the need of a PPM in the individual patients, but careful evaluation of pre-operative 12-lead ECG looking for pre-existing RBBB and an history of syncope, can individuate the group of patients with an increased risk of PPM requirement.

Accuracy of cardiac magnetic resonance generated 3D models of the aortic annulus compared to cardiovascular computed tomography generated 3D models

To evaluate the accuracy of 3D models of the aortic-root generated from non-contrast cardiac magnetic resonance (CMR). Data were retrospectively collected from 30 consecutive patients who underwent surgical aortic valve replacement and had available records of both intra-operative assessment and pre-surgery annulus assessment by cardiovascular computed tomography (CCT) and CMR. The 3D models were independently segmented, modelled and printed by two blinded "manufacturers". The measurements on the models were carried out by two cardiac surgeons with Hegar dilator. Data were analyzed with non-parametric tests. There was no significant intra- or inter-observer variability (p ≥ 0.13). The agreement between the diameter of the 3D model derived from CMR images and either the anatomical reference of the intraoperative measurement (p = 0.10, r = 0.97) or the radiological reference of the 3D model generated from CCT (p = 0.71, r = 0.92) was very good. The process of segmentation plus the post-processing was about 17 ± 2 min for a model created by CMR, significantly higher than a model created from CCT (7 ± 2 min; p < 0.001). The printing time for a single model did not differ between the two modalities (p = 0.61) and was less than 60 min. The cost for a single model was approximately 0.5 €. 3D models generated from non-contrast CMR performed well when compared to the anatomical reference standard and are comparable to the pair CCT derived models.

P1412 A new light to improve the view of the anatomical details during micro-invasive trans-ventricular repair of degenerative prolapse of mitral valve

BACKGROUND

Mitral valve repair is the preferred surgical treatment for severe mitral regurgitation due to degenerative leaflet prolapse. Within the growing era of transcatheter treatments for valvular heart disease, an innovative micro-invasive trans-ventricular beating-heart procedure was developed. Three-dimensional (3D) transoesophageal echocardiographic guidance is crucial to assist the operator in instrument navigation and chords positioning. 3D ultrasound technology is constantly evolving and a special light, that can be mobilized within the 3D images, has recently been invented. This light allows to illuminate the structures from different points of view and increase the definition of the anatomical details.

PURPOSE

To show the advantages of this new 3D image analysis technology, described above, through a sequence of intra-procedural images of a mitral valve repair by trans-ventricular polytetrafluoroethylene (ePTFE) chords implantation.

METHODS

The procedure is performed using a device that is introduced through a posterolateral ventriculotomy and it is advanced towards the mitral valve under real-time 3D transoesophageal guidance. The prolapsing segment, in this case central part of posterior leaflet (Fig. 1 A, B and C), is grasped with the jaw of the instrument (J in Fig. 1D), then the chords are implanted, tensioned and secured outside the ventricle. Figure 1A shows the pre-operative image of posterior leaflet prolapse with flail (P2 segment) and the light illuminates the valve from above. The broken chords (arrow in Fig. 1A) can be recognized with high definition. The light can also be placed on the valve plane (Fig. 1B) or below (Fig. 1C). When illumination occurs from the left ventricular side, the coaptation loss due to the P2 flail is highlighted (arrow in Fig. 1C). After placement, tensioning and securing the chords outside the ventricle, the prolapse disappears and the correct coaptation is re-established (Fig. 1E). The coaptation deficit is no longer visible, even with the light placed below the valve and it is possible to see the light coming out of the aortic valve (Ao), opened in systole, with mitral valve closed (Fig. 1F).

RESULTS

At the end of the procedure the residual mitral regurgitation was trivial and no loss of coaptation can be evidenced even with the light placed in the left ventricle (Fig. 1F).

CONCLUSIONS

This new light allows to improve the anatomical definition of 3D echocardiographic images, allows better visualization of the coaptation defects and can be used as a further verification of the result especially in cases of micro-invasive mitral repair.

Abstract P1412 Figure 1

P951 Intraprocedural echocardiographic technique to locate the insertion points of artificial chordae during transventricular beating heart mitral valve repair: ultrasound ""starry sky""

BACKGROUND

Mitral valve repair is the preferred surgical treatment for severe mitral regurgitation due to degenerative leaflet prolapse. Within the growing era of transcatheter treatments for valvular heart disease, an innovative micro-invasive trans-ventricular beating-heart procedure was developed. Three-dimensional transoesophageal echocardiographic guidance is crucial to assist the operator in instrument navigation and chords positioning. Indeed, it is important an equidistant chords placement on the leaflet to ensure a uniform force distribution on the prolapsing segment and to avoid damaging of the previously inserted chords.

PURPOSE

To propose an intraoperative three-dimensional echocardiographic technique that allows operators to see the exact location of the polytetrafluoroethylene (ePTFE) chords used for the mitral repair.

METHODS

The procedure is performed using a device that is introduced through a posterolateral ventriculotomy and it is advanced towards the mitral valve under real-time 3D transoesophageal guidance. The prolapsing segments are grasped with the jaw of the instrument and the chords are implanted to achieve the proper distribution of forces and then tensioned and secured outside the ventricle.

The proposed technique exploits the greater echogenicity of the artificial chord loop compared to native chords and leaflets. By lowering of the gains, remaining in the three-dimensional mitral valve surgical view, the signals of the native structures are attenuated, the underlying ventricular cavity appears black and the insertion points are visible as an intense signal on the virtual free edge of the leaflet treated.

Figure 1 shows the intraoperative sequence of images of a case performed at our centre. The images were acquired using real time single beat three-dimensional reconstruction. Figure 1A shows the surgical view of the native valve with prolapse of the P2-P3 scallops. Image 1B reveals the prolapsing leaflet grasping and device location. After gain lowering, it’s possible to see the intense signal of the positioned artificial chord (Figure 1C). It can also be noted how this position matches with the position of the device at the time of grasping. Image 1D shows the partial disappearance of the prolapse during the tensioning test after the positioning of a second chord in a more medial position. Figure 1E shows the correct position of the ePTFE chords. We can notice the second chord placed in a medial position from the first one. This view, with dark ventricular chamber and intense signals of chordae loops, looks like a "STARRY SKY".

RESULTS

This technique allows to locate the correct insertion points of the artificial chords during the procedure.

CONCLUSIONS

This is a simple technique to guide operators during trans-ventricular beating heart mitral valve repair with ePTFE chords.

Abstract P951 Figure 1

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Use of a photo-realism 3D rendering technique to enhance echocardiographic visualization of the anatomical details during beating-heart mitral valve repair

The NeoChord procedure is an innovative microinvasive, transventricular, beating-heart chordal replacement technique for patients with severe degenerative mitral valve regurgitation resulting from prolapsed or flail leaflets. Use of three-dimensional (3D) transoesophageal echocardiographic imaging is crucial to the physician operator for device navigation during the procedure and to assess the functional results of the repair at the end of the procedure. Photo-realistic, 3D rendering techniques have been recently developed for medical use. Philips TrueVue (Philips Healthcare, Eindhoven, NL) is a photo-realism technique that employs the use of a virtual light source that simulates the interaction of light on 3-dimensional surfaces. Use of photo-realism techniques, in conjunction with 3D echocardiography, improves the visualization of morphological characteristics of the mitral valve before, during, and after beating-heart mitral valve repair procedures.

P1789Outcomes of different approaches for severe aortic stenosis: “"The Deferred-TAVI”, a multicentre study investigating medical and percutaneous therapy in the era of TAVI

Background

In the era of TAVI, also very high surgical risk patients can be treated and the importance of the Heart Team is to address the patient to the right therapy. In some cases due to comorbidities, lack of symptoms and patients' decision not always a final decision is achieved after the first clinical evaluation and the final strategy could be deferred for months.

Purpose

The study aims to analyze outcomes in patients with severe aortic stenosis differently treated according to the various approaches proposed by the Heart Team.

Methods

All the patients with a diagnosis of severe aortic stenosis considered at high and very high surgical risk were enrolled. Three international cardiology departments participated in this multicentre study. All the patients were divided into four groups according to the Heart Team decision of approach. Patients with indication to medical therapy only (DTO Drug therapy only), Patients first deferred from heart team decision, personal reasons or lack of symptoms and then addressed to medical therapy (D-DTO Deferred-Drug therapy only), Patients deferred and then addressed to TAVI within 3 months (D-TP Deferred TAVI Procedure), Patients with direct indication to TAVI (ITP Immediate TAVI procedure). Primary endpoint were overall survive at follow up comparing the differences between the four groups and the impact of the deferred strategy.

Results

795 patients were enrolled (80 DTO, 451 ITP, 264 initially deferred and then 155 D-DTO and 109 D-TP). Median follow-up was 465 days. Overall survive of the four groups at 1 year was 74% DTO, 73% D-DTO, 77% D-TP and 78% ITP, at 2 years 62% DTO, 38% D-DTO, 62% D-TP and 68% ITP, at 3 years 39% DTO, 11% D-DTO, 25% D-TP and 56% ITP (p≤0,001 at log rank test). At the multivariate analysis, compared to the referral group DTO, D-DTO was associated with higher mortality (HR=1,90; IC [95%]: 1,05–3,58; p=0,03 at 2 years; HR 1,66; IC [95%]: 1,01–2,76; p<0,05, at 3 years), while D-TP was not associated with lower mortality risk (HR 1,31 IC [95%]: 0,62–2,76; p=0,72 at 2 years, HR 1,37 IC [95%]: 0,77–2,44; p=0,77 at 3 years). ITP was associated with lower mortality risk only at 3 years (HR 0,60; IC [95%]: 0,42–0,99; p<0.05). Comparing the group deferred (D-DTO and D-TP) to the group not deferred (DTO and ITP), the deferred group was associated with higher mortality risk (HR 1,86; IC [95%]: 1,30–2.65; p=0,001 at 2 years, HR 2,21; IC [95%]: 1,61–3,05; p<0,001 at 3 years).

Conclusions

The Heart team decision on the approach of treatment strongly influence the survive of the patient. Compared to direct medical therapy, there is a higher risk of mortality for patients initially deferred and then treated with medical therapy and there is no survival benefit for patients initially deferred and then treated with TAVI. The choice of deferring the treatment of patients with severe aortic stenosis clearly decrease long term survive at follow up regardless the strategy of the approach.

"The Starry Sky." A new intraprocedural three-dimensional echocardiographic technique

The NeoChord procedure is a micro-invasive, trans-ventricular, beating-heart chordal replacement technique for patients with severe degenerative mitral valve regurgitation resulting from prolapsed or flail leaflets. Three dimensional transoesophageal echocardiographic guidance is crucial to assist the operator during the procedure. Equidistant placement of neochordae along the free edge of the prolapsing leaflet segment is important to ensure uniform stress distribution and to avoid damaging any of the previously placed neochordae. Lowering the image gain associated with the three-dimensional surgical view of the mitral valve allows for signal attenuation of the native structures delineating the precise placement location of the neochordae.