Use and performance of the evolut FX transcatheter aortic valve system

BACKGROUND

The next generation supra-annular, self-expanding Evolut FX transcatheter aortic valve (TAV) system was designed to improve catheter deliverability, provide stable and symmetric valve deployment, and assess commissural alignment during the procedure. The impact of these modifications has not been clinically evaluated.

METHODS

Procedural information was collected by survey in 2 Stages: Stage I comprised 23 centers with extensive experience with Evolut TAV systems, and Stage II comprised an additional 46 centers with a broad range of balloon- and self-expanding system experience. Operators were to compare the experience with the Evolut FX to the predicate Evolut PRO+ system.

RESULTS

There were 285 cases during Stage I from June 24 to August 12, 2022, and 254 cases during Stage II from August 15 to September 11, 2022. Overall, the cusp overlap technique was used in 88.6 %, and commissural alignment was achieved in 96.1 % of these cases. Compared to implanter's previous experience with the Evolut PRO+ system, less resistance was noted with the Evolut FX system: in 83.0 % of cases during vascular insertion, in 84.7 % of cases while tracking through the vasculature, in 84.4 % of cases while traversing over the arch, and 76.1 % of cases in advancing across the valve. Better symmetry of valve depth was observed in 423 of 525 cases (80.6 %).

CONCLUSION

Evolut FX system design modifications translated into improvements in catheter deliverability, deployment symmetry and stability, and commissural alignment as assessed by experienced self-expanding and balloon expandable operators.

Structural Valve Deterioration After Self-Expanding Transcatheter or Surgical Aortic Valve Implantation in Patients at Intermediate or High Risk

Importance

The frequency and clinical importance of structural valve deterioration (SVD) in patients undergoing self-expanding transcatheter aortic valve implantation (TAVI) or surgery is poorly understood.

Objective

To evaluate the 5-year incidence, clinical outcomes, and predictors of hemodynamic SVD in patients undergoing self-expanding TAVI or surgery.

Design, Setting, and Participants

This post hoc analysis pooled data from the CoreValve US High Risk Pivotal (n = 615) and SURTAVI (n = 1484) randomized clinical trials (RCTs); it was supplemented by the CoreValve Extreme Risk Pivotal trial (n = 485) and CoreValve Continued Access Study (n = 2178). Patients with severe aortic valve stenosis deemed to be at intermediate or increased risk of 30-day surgical mortality were included. Data were collected from December 2010 to June 2016, and data were analyzed from December 2021 to October 2022.

Interventions

Patients were randomized to self-expanding TAVI or surgery in the RCTs or underwent self-expanding TAVI for clinical indications in the nonrandomized studies.

Main Outcomes and Measures

The primary end point was the incidence of SVD through 5 years (from the RCTs). Factors associated with SVD and its association with clinical outcomes were evaluated for the pooled RCT and non-RCT population. SVD was defined as (1) an increase in mean gradient of 10 mm Hg or greater from discharge or at 30 days to last echocardiography with a final mean gradient of 20 mm Hg or greater or (2) new-onset moderate or severe intraprosthetic aortic regurgitation or an increase of 1 grade or more.

Results

Of 4762 included patients, 2605 (54.7%) were male, and the mean (SD) age was 82.1 (7.4) years. A total of 2099 RCT patients, including 1128 who received TAVI and 971 who received surgery, and 2663 non-RCT patients who received TAVI were included. The cumulative incidence of SVD treating death as a competing risk was lower in patients undergoing TAVI than surgery (TAVI, 2.20%; surgery, 4.38%; hazard ratio [HR], 0.46; 95% CI, 0.27-0.78; P = .004). This lower risk was most pronounced in patients with smaller annuli (23 mm diameter or smaller; TAVI, 1.32%; surgery, 5.84%; HR, 0.21; 95% CI, 0.06-0.73; P = .02). SVD was associated with increased 5-year all-cause mortality (HR, 2.03; 95% CI, 1.46-2.82; P < .001), cardiovascular mortality (HR, 1.86; 95% CI, 1.20-2.90; P = .006), and valve disease or worsening heart failure hospitalizations (HR, 2.17; 95% CI, 1.23-3.84; P = .008). Predictors of SVD were developed from multivariate analysis.

Conclusions and Relevance

This study found a lower rate of SVD in patients undergoing self-expanding TAVI vs surgery at 5 years. Doppler echocardiography was a valuable tool to detect SVD, which was associated with worse clinical outcomes.

Trial Registration

ClinicalTrials.gov Identifiers: NCT01240902, NCT01586910, and NCT01531374.

Comparison of Radiation Exposure Among Interventional Echocardiographers, Interventional Cardiologists, and Sonographers During Percutaneous Structural Heart Interventions

IMPORTANCE

Transesophageal echocardiography during percutaneous left atrial appendage closure (LAAO) and transcatheter edge-to-edge mitral valve repair (TEER) require an interventional echocardiographer to stand near the radiation source and patient, the primary source of scatter radiation. Despite previous work demonstrating high radiation exposure for interventional cardiologists performing percutaneous coronary and structural heart interventions, similar data for interventional echocardiographers are lacking.

OBJECTIVE

To assess whether interventional echocardiographers are exposed to greater radiation doses than interventional cardiologists and sonographers during structural heart procedures.

DESIGN, SETTING, AND PARTICIPANTS

In this single-center cross-sectional study, radiation doses were collected from interventional echocardiographers, interventional cardiologists, and sonographers at a quaternary care center during 30 sequential LAAO and 30 sequential TEER procedures from July 1, 2016, to January 31, 2018. Participants and study personnel were blinded to radiation doses through data analysis (January 1, 2020, to October 12, 2021).

EXPOSURES

Occupation defined as interventional echocardiographers, interventional cardiologists, and sonographers.

MAIN OUTCOMES AND MEASURES

Measured personal dose equivalents per case were recorded using real-time radiation dosimeters.

RESULTS

A total of 60 (30 TEER and 30 LAAO) procedures were performed in 60 patients (mean [SD] age, 79 [8] years; 32 [53.3%] male) with a high cardiovascular risk factor burden. The median radiation dose per case was higher for interventional echocardiographers (10.6 μSv; IQR, 4.2-22.4 μSv) than for interventional cardiologists (2.1 μSv; IQR, 0.2-8.3 μSv; P < .001). During TEER, interventional echocardiographers received a median radiation dose of 10.5 μSv (IQR, 3.1-20.5 μSv), which was higher than the median radiation dose received by interventional cardiologists (0.9 μSv; IQR, 0.1-12.2 μSv; P < .001). During LAAO procedures, the median radiation dose was 10.6 μSv (IQR, 5.8-24.1 μSv) among interventional echocardiographers and 3.5 (IQR, 1.3-6.3 μSv) among interventional cardiologists (P < .001). Compared with interventional echocardiographers, sonographers exhibited low median radiation doses during both LAAO (0.2 μSv; IQR, 0.0-1.6 μSv; P < .001) and TEER (0.0 μSv; IQR, 0.0-0.1 μSv; P < .001).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, interventional echocardiographers were exposed to higher radiation doses than interventional cardiologists during LAAO and TEER procedures, whereas sonographers demonstrated comparatively lower radiation doses. Higher radiation doses indicate a previously underappreciated occupational risk faced by interventional echocardiographers, which has implications for the rapidly expanding structural heart team.

First-in-Man Study Evaluating the Emblok Embolic Protection System During Transcatheter Aortic Valve Replacement

OBJECTIVES

This study sought to evaluate the feasibility of complete cerebral protection during transcatheter aortic valve replacement (TAVR) with a novel embolic protection device.

BACKGROUND

Evidences and data about new cerebral embolic protection devices are lacking and scarce.

METHODS

A prospective, nonrandomized, multicenter, first-in-man pilot study designed to evaluate the efficacy and safety of cerebral embolic protection utilizing the Emblok embolic protection system (Innovative Cardiovascular Solutions, Grand Rapids, Michigan) during TAVR. The Emblok is a transfemoral aortic filter that provide full coverage of the epiaortic vessels. Brain diffusion-weighted magnetic resonance imaging (DW-MRI) was performed at baseline and 2 to 5 days after TAVR. Primary endpoints were technical success and immediate cerebral embolic burden after TAVR, defined as number and volume of new brain lesions detected with DW-MRI at days 2 to 5 post-TAVR compared with baseline.

RESULTS

A total of 20 subjects were enrolled. The Emblok system was successfully positioned in all the cases. At 30-day follow-up, no major adverse cardiovascular and cerebrovascular events occurred. Nineteen (95%) patients had new ischemic defects at post-procedural DW-MRI. The median number of new lesions per patient was 10.00 (interquartile range [IQR]: 4.75 to 15.25). The total new lesion volume was 199.9 mm³ (IQR: 83.9 to 447.5 mm³) and the mean lesion volume per lesion was 42.5 mm³ (IQR: 21.5 to 75.6 mm³). Histopathologic analysis showed evidence of significant debris in 18 (90%) filters.

CONCLUSIONS

The Emblok embolic protection system appears to be feasible and safe during TAVR. The device was successfully placed and retrieved in all cases and no neurological events were observed. Cerebral total new lesion volume was similar to other trials on cerebral protection during TAVR, thus warranting a larger study. (European Study Evaluating the Emblok Embolic Protection System During TAVR; NCT03130491).

Use of EN Snare device for successful repositioning of the newest self-expanding transcatheter heart valve

Once a self-expanding transcatheter aortic valve replacement is fully deployed, a snare device must be used to retrieve it. Minimal data are available regarding technique, efficacy, and complications associated with the retrieval of such valves. Here, we present two patients in which an EN Snare^® Device (Merit Medical System, South Jordan, UT, USA) was safely and effectively used to retrieve and reposition the latest generation self-expanding transcatheter aortic valve replacement.

Repair of paravalvular prosthetic mitral valve leaks with septal occluder devices in severely high-risk patients: a word of caution

Paravalvular leak following a mitral valve replacement is a complication seen in approximately 1 of 10 replacements. The corrective method has traditionally been reoperation. Septal occluder devices are more commonly being utilized as an alternative percutaneous correction method. We report the use of septal occluder devices in the repair of mitral paravalvular leak in two patients at severely high EuroSCORE II mortality risk. In both patients, the occluder devices became unstable, leading to a recurrence of severe paravalvular leak.

Percutaneous ex-vivo femoral arterial bypass: a novel approach for treatment of acute limb ischemia as a complication of femoral arterial catheterization

This report describes the use of a percutaneous ex-vivo femoral arterial bypass in three patients with acute lower extremity ischemia that occurred as a complication of femoral artery catheterization. Utilizing standard equipment and techniques, a percutaneous ex-vivo femoral artery bypass can restore antegrade flow to the ischemic limb in patients with impaired aorto-iliac inflow circulation, which may arise from iatrogenic dissection or the need for large in-dwelling sheaths required for hemodynamic support. This technique is considered a temporizing measure when conventional therapies are not possible. Contrast angiography is recommended to localize and define the cause of limb ischemia, and to permit safe placement of vascular sheaths in the "donor and recipient" arteries.

Impact of mechanical reperfusion on clinical outcome in elderly patients with right ventricular infarction

BACKGROUND

Previous reports suggest that elderly patients with acute right ventricular infarction suffer in-hospital mortality of 50% and that hemodynamic compromise is irreversible. We hypothesized that mechanical reperfusion would improve such outcomes.

METHODS

We retrospectively analyzed in-hospital morbidity and mortality in 54 patients >70 years of age with acute inferior myocardial infarction undergoing primary angioplasty. The presence of right ventricular infarction was determined by a two dimensional echocardiogram.

RESULTS

Overall, 18 (33%) patients had inferior myocardial infarction and right ventricular infarction, whereas 36 (67%) patients had inferior myocardial infarction alone. All patients with inferior myocardial infarction alone were successfully reperfused, whereas one patient with right ventricular infarction suffered reperfusion failure. Right ventricular infarction patients more commonly suffered hemodynamic and arrhythmic complications (hypotension in 33 vs. 2.8%, P<0.01; ventricular arrhythmias in 61 vs. 25%, P<0.01; and bradyarrhythmias in 78 vs. 25%, P<0.01). Overall, 72% of right ventricular infarction patients survived, including many with hemodynamic compromise. In-hospital mortality, however, was greater in those with right ventricular infarction than in those without (28 vs. 8.3%, P=0.19).

CONCLUSION

Elderly patients with inferior myocardial infarction complicated by right ventricular infarction suffer greater morbidity and mortality than those without. With successful mechanical reperfusion, however, the majority survives, including those with hemodynamic compromise.