Safety and feasibility of early discharge after transcatheter aortic valve implantation with ACURATE Neo-the POLESTAR trial

BACKGROUND

Transcatheter aortic valve implantation (TAVI) serves a growing range of patients with severe aortic stenosis (AS). TAVI has evolved to a streamlined procedure minimizing length of hospital stay.

AIMS

To evaluate the safety and efficacy of an early discharge (ED) strategy after TAVI.

METHODS

We performed an international, multi-center, prospective observational single-arm study in AS patients undergoing TAVI with the ACURATE valve platform. Eligibility for ED was assessed prior to TAVI and based on prespecified selection criteria. Discharge ≤ 48 h was defined as ED. Primary Valve Academic Research Consortium (VARC)-3-defined 30-day safety and efficacy composite endpoints were landmarked at 48 h and compared between ED and non-ED groups.

RESULTS

A total of 252 patients were included. The median age was 82 [25th-75th percentile, 78-85] years and the median Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) score was 2.2% [25th-75th percentile, 1.6-3.3]. ED and non-ED were achieved in 173 (69%) and 79 (31%) patients respectively. Monitoring for conduction disturbances was the principal reason for non-ED (33%). Overall, at 30 days, all-cause mortality was 1%, new permanent pacemaker rate was 4%, and valve- or procedure-related rehospitalization was 4%. There was no difference in the primary safety and efficacy endpoint between the ED and non-ED cohorts (OR 0.84 [25th-75th percentile, 0.31-2.26], p = 0.73, and OR 0.97 [25th-75th percentile, 0.46-2.06], p = 0.94). The need for rehospitalization was similarly low for ED and non-ED groups.

CONCLUSION

Early discharge after TAVI with the ACURATE valve is safe and feasible in selected patients. Rhythm monitoring and extended clinical observation protracted hospital stay.

Procedural and clinical impact of intravascular lithotripsy for the treatment of peri-stent calcification

BACKGROUND

Use of intravascular lithotripsy (IVL) for treating peri-stent calcification is increasing. However, this indication remains 'off-label'. We aimed to investigate the efficacy and clinical outcomes of in-stent IVL.

METHODS

Patients from five European centers who underwent in-stent IVL were included between 2019 and 2023. Demographic, clinical, procedural and follow-up data were collected from electronic hospital records. Angiographic and intracoronary imaging (ICI) data were analyzed in a centralized core-laboratory.

RESULTS

Of 101 patients (71.2 ± 9.2 years), 56(55 %) received in-stent IVL for late stent failure (median 109 days post-PCI) due to calcific neoatherosclerosis or extra-stent calcification(late-IVL), while 45(45 %) underwent bail-out IVL due to stent infraexpasion (immediate-IVL). Both late-IVL and immediate-IVL significantly improved angiographic %diameter stenosis (73.7[59.6-89.8]% to 16.4 [10.4-26.9]%;p < 0.0001 and 28.6[22.5-43.3]% to 14.1[10.3-29.4]%;p < 0.0001, and minimum lumen area (MLA) (3.4 ± 1.2 to 8.6 ± 2.5 mm2;p < 0.002 and 5.4 ± 1.9 to 7.3 ± 1.9;p < 0.0001).Device(98 %) and procedural success(80 %) were high. MACE rates in-hospital (2 %), 30-days (3 %),6-months(5 %) and 1-year(7 %) were low and comparable in both groups. Acute diameter gain was lower in immediate-IVL (2.1 ± 0.7 mm vs. 0.5 ± 0.4 mm;p < 0.0001). This, however, was explained by significant differences in pre-IVL angiographic and ICI parameters (%diameter stenosis 73.7[59.6-89.8] vs. 28.6[22.5-43.3]%; p < 0.0001 and MLA (3.4 ± 1.2 vs 5.4 ± 1.9 mm2; p < 0.0001), whereas post-IVL percentage diameter stenosis (16.4(10.4-26.9) vs. 14.1(10.3-29.4);p = 0.914) and MLA (8.6 ± 2.5vs. 7.4 ± 1.9 mm2;p = 0.064) in late- and immediate-IVL were comparable.

CONCLUSIONS

IVL in-stent due to peri-stent calcification is an effective strategy, both late and immediately after stent implantation. Overall, MACE rates at short- and mid-term were low and comparable in both groups, although clinical findings should be taken with caution.

Impact of chronic obstructive pulmonary disease on right ventricular function and remodeling after aortic valve replacement

BACKGROUND

Both chronic obstructive pulmonary disease (COPD) and right ventricular (RV) dysfunction are common factors that have been associated with poor prognosis after aortic valve replacement (AVR). Since there is still uncertainty about the impact of COPD on RV function and dilatation in patients undergoing AVR, we sought to explore RV function and remodeling in the presence and absence of COPD as well as their prognostic implications.

METHODS

Patients who received surgical or transcatheter AVR due to severe AS were screened for COPD. Demographic and clinical data were collected at baseline while echocardiographic measurements were performed at baseline and 1 year after AVR. The study end-point was all-cause mortality.

RESULTS

In total 275 patients were included, with 90 (33%) patients having COPD. At 1-year follow-up, mild worsening of tricuspid annular planar systolic excursion and RV dilatation were observed in patients without COPD, while there were significant improvements in RV longitudinal strain, RV wall thickness but dilatation of RV outflow tract distal dimension in the COPD group compared to the baseline. On multivariable analysis, the presence of COPD provided significant incremental prognostic value over RV dysfunction and remodeling.

CONCLUSIONS

At 1-year after AVR, RV function and dimensions mildly deteriorated in non-COPD group whereas COPD group received significant benefit of AVR in terms of RV function and hypertrophy. COPD was independently associated with >2-fold all-cause mortality and had incremental prognostic value over RV dysfunction and remodeling.

Prognostic value of left ventricular myocardial work indices in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement

AIMS

Left ventricular myocardial work (LVMW) is a novel echocardiographic-based method to assess left ventricular (LV) function using pressure-strain loops taking into account LV afterload. The aim of this study was to evaluate the prognostic value of LVMW indices in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR).

METHODS AND RESULTS

LV global work index (LV GWI), LV global constructive work (LV GCW), LV global wasted work (LV GWW), and LV global work efficiency (LV GWE) were calculated in 281 patients with severe AS [age 82, interquartile range (IQR) 78-85 years, 52% male] before the TAVR procedure. LV systolic pressure was derived non-invasively by adding the mean aortic gradient to the brachial systolic pressure to adjust for afterload and calculate LVMW indices. Overall, the average LV GWI was 1872 ± 753 mmHg%, GCW 2240 ± 797 mmHg%, GWW 200 (IQR 127-306) mmHg%, and GWE 89 (IQR 84-93)%. During a median follow-up of 52 (IQR 41-67) months, 64 patients died. While LV GWI was independently associated with all-cause mortality (Hazard ratio per-tertile-increase 0.639; 95%CI 0.463-0.883; P = 0.007), LV GCW, GWW, and GWE were not. When added to a basal model, LV GWI yielded a higher increase in predictivity compared to the left ventricular ejection fraction as well as LV global longitudinal strain and LV GCW, and also across the different haemodynamic categories (including low-flow low-gradient) of AS.

CONCLUSION

LV GWI is independently associated with all-cause mortality in patients undergoing TAVR and has a higher prognostic value compared to both conventional and advanced parameters of LV systolic function.

Periprocedural continuation versus interruption of oral anticoagulant drugs during transcatheter aortic valve implantation: rationale and design of the POPular PAUSE TAVI trial

About one-third of patients undergoing transcatheter aortic valve implantation (TAVI) use oral anticoagulants (OAC), mainly due to atrial fibrillation. General guidelines advise interrupting OAC in patients with a high risk of bleeding undergoing interventions. However, preliminary observational data suggest that the continuation of OAC during TAVI is safe and may reduce the risk of periprocedural thromboembolic events. The Periprocedural Continuation Versus Interruption of Oral Anticoagulant Drugs During Transcatheter Aortic Valve Implantation (POPular PAUSE TAVI) is a multicentre, randomised clinical trial with open-label treatment and blinded endpoint assessment. Patients are randomised 1:1 to periprocedural continuation versus interruption of OAC and are stratified for vitamin K antagonist or direct oral anticoagulant use. The primary endpoint is a composite of cardiovascular mortality, all stroke, myocardial infarction, major vascular complications and type 2-4 bleeding within 30 days after TAVI, according to the Valve Academic Research Consortium-3 criteria. Secondary endpoints include separate individual and composite outcomes, quality of life and cost-effectiveness. Since continuation of OAC is associated with the ancillary benefit that it simplifies periprocedural management, the primary outcome is first analysed for non-inferiority; if non-inferiority is proven, superiority will be tested. Recruitment started in November 2020, and the trial will continue until a total of 858 patients have been included and followed for 90 days. In summary, POPular PAUSE TAVI is the first randomised clinical trial to assess the safety and efficacy of periprocedural continuation versus interruption of OAC in patients undergoing TAVI.

Catheter-Based Techniques for Addressing Atrioventricular Valve Regurgitation in Adult Congenital Heart Disease Patients: A Descriptive Cohort

INTRODUCTION

Increasing survival of adult congenital heart disease (ACHD) patients comes at the price of a range of late complications-arrhythmias, heart failure, and valvular dysfunction. Transcatheter valve interventions have become a legitimate alternative to conventional surgical treatment in selected acquired heart disease patients. However, literature on technical aspects, hemodynamic effects, and clinical outcomes of percutaneous atrioventricular (AV) valve interventions in ACHD patients is scarce.

METHOD

This is a descriptive cohort from CAHAL (Center of Congenital Heart Disease Amsterdam-Leiden). ACHD patients with severe AV valve regurgitation who underwent a transcatheter intervention in the period 2020-2022 were included. Demographic, clinical, procedural, and follow-up data were collected from patient records.

RESULTS

Five ACHD patients with severe or torrential AV valve regurgitation are described. Two patients underwent a transcatheter edge-to-edge repair (TEER), one patient underwent a valve-in-valve procedure, one patient received a Cardioband system, and one patient received both a Cardioband system and TEER. No periprocedural complications occurred. Post-procedural AV valve regurgitation as well as NYHA functional class improved in all patients. The median post-procedural NYHA functional class improved from 3.0 (IQR [2.5-4.0]) to 2.0 (IQR [1.5-2.5]). One patient died 9 months after the procedure due to advanced heart failure with multiorgan dysfunction.

CONCLUSION

Transcatheter valve repair is feasible and safe in selected complex ACHD patients. A dedicated heart team is essential for determining an individualized treatment strategy as well as pre- and periprocedural imaging to address the underlying mechanism(s) of AV regurgitation and guide the transcatheter intervention. Long-term follow-up is essential to evaluate the clinical outcomes of transcatheter AV valve repair in ACHD patients.

Evolution and Prognostic Impact of Right Ventricular-Pulmonary Artery Coupling After Transcatheter Aortic Valve Replacement

BACKGROUND

There is limited evidence regarding the association between right ventricular-to-pulmonary artery (RV-PA) coupling and outcomes after transcatheter aortic valve replacement (TAVR).

OBJECTIVES

This study aimed to explore the evolution of RV-PA coupling in patients with severe aortic stenosis undergoing TAVR and its prognostic impact.

METHODS

A total of 900 patients who underwent TAVR in 2 tertiary centers and with echocardiographic analysis performed within 3 months before and after the procedure were included. RV-PA coupling was measured as the ratio of tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP). RV-PA uncoupling was defined by TAPSE/PASP <0.55, whereas a TAPSE/PASP <0.32 identified a severe uncoupling. The primary endpoint was all-cause mortality.

RESULTS

A total of 520 patients (58%) showed RV-PA uncoupling before TAVR, whereas post-TAVR RV-PA uncoupling was observed in 407 patients (45%). During a median follow-up of 40 months, 250 deaths (28%) occurred. Post-TAVR RV-PA uncoupling was independently associated with an increased risk of mortality (adjusted HR: 1.474; 95% CI: 1.115-1.948; P = 0.006), whereas pre-TAVR uncoupling did not. Among patients with post-TAVR RV-PA uncoupling, the presence of severe uncoupling identified a subgroup with the worst survival (P = 0.008). Patients with RV-PA coupling recovery after TAVR showed similar outcomes as compared with patients with normal coupling. Conversely, the presence of either persistent or new-onset RV-PA uncoupling following TAVR was associated with an increased mortality risk.

CONCLUSIONS

Post-TAVR RV-PA uncoupling is an independent predictor of long-term mortality, irrespective of coupling before intervention. Assessment of TAPSE/PASP response after TAVR may be helpful to improve risk stratification.

Anomalous Aortic Origin of the Right Coronary Artery: Invasive Haemodynamic Assessment in Adult Patients With High-Risk Anatomic Features

Background

Anomalous aortic origin of a right coronary artery (AAORCA) with an interarterial course merits further evaluation; however, robust risk assessment strategies for myocardial ischemia and sudden cardiac death are currently lacking. The aim of this study is to explore the potential role of fractional flow reserve (FFR), instantaneous wave-free ratio (iFR), and intravascular ultrasound (IVUS) in patients with AAORCA.

Methods

Consecutive adult patients with AAORCA with an interarterial course were included. Computed tomography angiography, noninvasive ischemia detection, and FFR, iFR, and IVUS were performed at baseline and during adrenaline-induced stress. External compression was evaluated with IVUS.

Results

Eight patients (63% female, mean age: 53 ± 9.5 years) were included. Five patients (63%) were symptomatic, and computed tomography angiography revealed high-risk anatomy of the AAORCA in all patients. Only in 1 (12.5%) patient FFR and iFR were positive; however, this was attributed at large to concomitant diffuse atherosclerosis. In 2 of 8 (25%), IVUS revealed external compression; however, the ostial coronary surface area remained unchanged. In all patients, a conservative treatment strategy was pursued. During a mean follow-up of 29.3 months (standard deviation ±2.6 months), symptoms spontaneously disappeared in 4 of 5 (80%) and no adverse cardiac events occurred in any of the patients.

Conclusions

Despite the presence of high-risk anatomy in all patients, none had proven ischemia prompting a conservative treatment strategy. No adverse cardiac events occurred during follow-up, and in the majority of patients, symptoms spontaneously disappeared. Therefore, FFR, iFR, and IVUS with pharmacologic stress merit further investigation and might contribute to ischemia-based risk stratification and management strategies in adult patients with AAORCA.

Changes in Computed-Tomography-Derived Segmental Left Ventricular Longitudinal Strain After Transcatheter Aortic Valve Implantation

Patients with severe aortic stenosis (AS) may show left ventricular (LV) apical longitudinal strain sparing. Transcatheter aortic valve implantation (TAVI) improves LV systolic function in patients with severe AS. However, the changes in regional longitudinal strain after TAVI have not been extensively evaluated. This study aimed to characterize the effect of the pressure overload relief after TAVI on LV apical longitudinal strain sparing. A total of 156 patients (mean age 80 ± 7 years, 53% men) with severe AS who underwent computed tomography before and within 1 year after TAVI (mean time to follow-up 50 ± 30 days) were included. LV global and segmental longitudinal strain were assessed using feature tracking computed tomography. LV apical longitudinal strain sparing was evaluated as the ratio between the apical and midbasal longitudinal strain and was defined as an LV apical to midbasal longitudinal strain ratio >1. LV apical longitudinal strain remained stable after TAVI (from 19.5 ± 7.2% to 18.7 ± 7.7%, p = 0.20), whereas LV midbasal longitudinal strain showed a significant increase (from 12.9 ± 4.2% to 14.2 ± 4.0%, p ≤0.001). Before TAVI, 88% of the patients presented with LV apical strain ratio >1% and 19% presented with an LV apical strain ratio >2. After TAVI, these percentages significantly decreased to 77% and 5% (p = 0.009, p ≤0.001), respectively. In conclusion, LV apical sparing of strain is a relatively common finding in patients with severe AS who underwent TAVI and its prevalence decreases after the afterload relief after TAVI.

Contemporary Management Strategies of Baffle Leaks in Adults with a Failing Systemic Right Ventricle Late after Atrial Switch: A Case Series and Literature Overview

Baffle leaks are a frequently encountered and often overlooked complication after the atrial switch procedure for transposition of the great arteries. Baffle leaks are present in up to 50% of non-selected patients, and while they initially may not cause clear symptoms, they can complicate the hemodynamic course and influence the prognosis in this complex patient group. A shunt from the pulmonary venous atrium (PVA) to the systemic venous atrium (SVA) can lead to pulmonary overflow and subpulmonary left ventricular (LV) volume overload, while a shunt from the SVA to the PVA can result in (exercise-associated) cyanosis and paradoxical embolism. We report three cases of baffle leaks in patients with systemic right ventricular (sRV) failure late after the atrial switch procedure. Two symptomatic patients who presented with exercise-associated cyanosis due to SVA to PVA shunting over the baffle leak underwent successful percutaneous baffle leak closure with a septal occluder device. One patient with overt sRV failure and signs of subpulmonary LV volume overload due to PVA to SVA shunting was managed conservatively, as baffle leak closure was expected to lead to an increase in sRV end-diastolic pressure and aggravation of sRV dysfunction. These three cases illustrate the considerations made, challenges faced, and necessity of a patient-tailored approach when addressing baffle leaks.

Association Between Chronic Obstructive Pulmonary Disease and All-Cause Mortality After Aortic Valve Replacement for Aortic Stenosis

Chronic obstructive pulmonary disease (COPD) and aortic stenosis (AS) are the most common diseases in which age plays a major role in the increase of their prevalence and when they co-exist, the outcomes prognosis worsens significantly. The aim of the present study was to evaluate the association between pulmonary functional parameters and all-cause mortality after aortic valve replacement (transcatheter or surgical). A total of 400 patients with severe AS and preoperative pulmonary functional test were retrospectively analyzed. Echocardiography and pulmonary functional parameters before aortic valve replacement were collected. COPD severity was defined according to criteria from the Society of Thoracic Surgeons. COPD was present in 128 patients (32%) with severe AS. Patients without COPD had smaller left ventricular (LV) mass and LV end-systolic volume and better LV function than the group with COPD. During a median follow-up of 32 months, 92 patients (23%) died. The survival rates were significantly lower in patients with moderate and severe COPD (log-rank p = 0.003). In the multivariable Cox regression analysis, any grade of COPD was associated with an approximately 2-fold increased risk of all-cause mortality (hazard ratio 1.933; 95% confidence interval 1.166 to 3.204; p = 0.011 for mild COPD and hazard ratio 2.028; 95% confidence interval 1.154 to 3.564; p = 0.014 for moderate or severe COPD). In addition to other clinical factors, any grade of COPD was associated with 2-fold increased risk of all-cause mortality.

Feature-tracking computed tomography left atrial strain and long-term survival after transcatheter aortic valve implantation

AIMS

Aortic stenosis (AS) induces left atrial (LA) remodelling through the increase of left ventricular (LV) filling pressures. Peak LA longitudinal strain (PALS), reflecting LA reservoir function, has been proposed as a prognostic marker in patients with AS. Feature-tracking (FT) multi-detector computed tomography (MDCT) allows assessment of LA strain from MDCT data. The aim of this study is to investigate the association between PALS using FT MDCT and survival in patients with severe AS who underwent transcatheter aortic valve implantation (TAVI).

METHODS AND RESULTS

A total of 376 patients (mean age 80 ± 7 years, 53% male) who underwent MDCT before TAVI and had suitable data for assessment of PALS using dedicated FT software, were included. The patients were classified into four groups according to PALS quartiles; PALS > 19.3% (Q1, highest reservoir function), 15.0-19.3% (Q2), 9.1-14.9% (Q3), and ≤9.0% (Q4, lowest reservoir function). The primary outcome was all-cause mortality. During a median of 45 (22-68) months follow-up, 148 patients (39%) died. On multivariable Cox regression analysis, PALS was independently associated with all-cause mortality [hazard ratio (HR): 1.044, 95% confidence interval (CI): 1.012-1.076, P = 0.006]. Compared with patients in Q1, patients in Q3 and Q4 were associated with higher risk of mortality after TAVI [HR: 2.262 (95% CI: 1.335-3.832), P = 0.002 for Q3, HR: 3.116 (95% CI: 1.864-5.210), P < 0.001 for Q4].

CONCLUSION

PALS assessed with FT MDCT is independently associated with all-cause mortality after TAVI.

Prognostic Value of Nonalcoholic Fatty Liver Disease in Patients With Severe Aortic Stenosis Who Underwent Transcatheter Aortic Valve Implantation

Nonalcoholic fatty liver disease (NAFLD) is associated with an increased risk of cardiovascular events. Although the association between NAFLD and aortic valve sclerosis has been described, the prevalence and prognostic implications of NAFLD among patients with severe aortic stenosis (AS) have not been described. In addition, the effect of the presence of severe tricuspid regurgitation (TR) on the prevalence of NAFLD remains unexplored. Accordingly, we investigated the prognostic implications of NAFLD among patients with severe AS with and without concomitant significant TR. A total of 538 patients (aged 80 ± 7 y, 49.6% men) who underwent noncontrast computed tomography before transcatheter aortic valve implantation (TAVI) between 2007 and 2019 were included. NAFLD was defined as a liver-to-spleen attenuation ratio <1.0 on noncontrast computed tomography. NAFLD was present in 118 patients (21.9%). There were no significant differences in pulmonary arterial pressure, right atrial pressure, or the prevalence of significant TR between patients with and without NAFLD. During a median follow-up of 47 months (interquartile range 20 to 70 months), 224 patients (41.6%) died. Univariate Cox regression analysis demonstrated that NAFLD was not significantly associated with all-cause death among patients treated with TAVI (hazard ratio 1.32, 95% confidential interval 0.97 to 1.79, p = 0.07). In conclusion, among patients with severe AS who underwent TAVI, the prevalence of significant TR and the clinical outcomes were similar in patients with and without NAFLD.

Bail out lithotripsy to treat delayed valve-in-valve TAVR-related coronary obstruction

Coronary access difficulty and stent compression by the juxtaposed aortic valve leaflet hamper percutaneous management of delayed coronary artery obstruction (CAO) after valve-in-valve (Edwards Sapien 3 in St. Jude Trifecta) transcatheter aortic valve replacement (TAVR). Here, we present a case of delayed post-TAVR CAO treated with intravascular lithotripsy and multistenting to overcome stent compression by the adjacent calcified leaflet.

Interaction between sex and left ventricular reverse remodeling and its association with outcomes after transcatheter aortic valve implantation

Women with severe aortic stenosis (AS) have better long-term prognosis after transcatheter aortic valve implantation (TAVI) compared to men. Whether this is caused by sex-related differences in left ventricular (LV) reverse remodeling after TAVI is unknown. Patients with severe AS who underwent transfemoral TAVI between 2007 and 2018 were selected. LV dimensions, volumes, and ejection fraction (LVEF) were assessed by transthoracic echocardiography before TAVI and at 6 and 12 months follow-up after TAVI. LV reverse remodeling was defined as the percentual LV mass index (LVMi) reduction compared to baseline. The primary outcome was all-cause mortality. A total of 459 patients (80 ± 8 years; 52% male) were included. At 6 and 12 months follow-up, both sexes showed significant reductions in LV volumes and LVMi accompanied by improvement in LVEF, without significant differences between the sexes over time. During a median follow-up of 2.8 [IQR 1.9-4.3] years, 181 (39%) patients died. Women showed better outcomes compared to men (log-rank p = 0.024). In addition, male sex was independently associated with all-cause mortality in multivariable Cox regression (HR 1.423, 95% CI 1.039-1.951, p = 0.028). No association was observed between the interaction of percentual LVMi reduction and sex with outcomes (p = 0.64). Men and women with severe AS had similar improvement in LVEF, and similar reductions in LV volumes and LVMi at 6 and 12 months after TAVI. Women showed better survival after TAVI as compared to men. The superior outcomes noted in women after TAVI are not associated with sex differences in LV reverse remodeling.

COMPARE LAAO: Rationale and design of the randomized controlled trial "COMPARing Effectiveness and safety of Left Atrial Appendage Occlusion to standard of care for atrial fibrillation patients at high stroke risk and ineligible to use oral anticoagulation therapy"

BACKGROUND

Left atrial appendage occlusion (LAAO) provides an alternative to oral anticoagulation (OAC) for stroke prevention in patients with atrial fibrillation (AF). In patients with a long-term or permanent contraindication for OAC randomized controlled trial (RCT) data is lacking.

STUDY OBJECTIVES

To assess the efficacy and safety of LAAO in AF patients who are ineligible to use OAC. The co-primary efficacy endpoint is (1) time to first occurrence of stroke (ischemic, hemorrhagic, or undetermined) and (2) time to first occurrence of the composite of stroke, transient ischemic attack (TIA), and systemic embolism (SE). The primary safety endpoint is the 30-day rate of peri-procedural complications.

STUDY DESIGN

This is a multicenter, investigator-initiated, open-label, blinded endpoint (PROBE), superiority-driven RCT. Patients with AF, a CHA₂DS₂-VASc score ≥2 for men and ≥3 for women and a long-term or permanent contraindication for OAC will be randomized in a 2:1 fashion to the device- or control arm. Patients in the device arm will undergo percutaneous LAAO and will receive post-procedural dual antiplatelet therapy (DAPT) per protocol, while those in the control arm will continue their current treatment consisting of no antithrombotic therapy or (D)APT as deemed appropriate by the primary responsible physician. In this endpoint-driven trial design, assuming a 50% lower stroke risk of LAAO compared to conservative treatment, 609 patients will be followed for a minimum of 1 and a maximum of 5 years. Cost-effectiveness and budget impact analyses will be performed to allow decision-making on reimbursement of LAAO for the target population in the Netherlands.

SUMMARY

The COMPARE LAAO trial will investigate the clinical superiority in preventing thromboembolic events and cost-effectiveness of LAAO in AF patients with a high thromboembolic risk and a contraindication for OAC use.

NCT TRIAL NUMBER

NCT04676880.

Effects of Left Bundle Branch Block and Pacemaker Implantation on Left Ventricular Systolic Function After Transcatheter Aortic Valve Implantation

Permanent pacemaker implantation (PPI) and left bundle branch block (LBBB) frequency after transcatheter aortic valve implantation (TAVI) and their effect on left ventricular ejection fraction (LVEF) remain controversial. We evaluated the incidence of PPI and new-onset LBBB after TAVI and their impact on LVEF at 6-month follow-up. Moreover, the impact of right ventricular (RV) pacing burden on changes in LVEF after TAVI was analyzed. The electrocardiograms of 377 patients (age 80 ± 7 years, 52% male) treated with TAVI were collected at baseline, after the procedure, at discharge, and at each outpatient follow-up. LVEF was measured at baseline before TAVI and 6 months after the procedure. Patients were divided into 3 groups according to the occurrence of LBBB, the need for PPI, or the absence of new conduction abnormalities. In patients with PPI, the influence of RV pacing burden on LVEF was analyzed. New-onset LBBB after TAVI occurred in 92 patients (24%), and PPI was required in 55 patients (15%). In patients without new conduction abnormalities, LVEF significantly increased during follow-up (56 ± 14% to 61 ± 12%, p <0.001). Patients with a baseline LVEF ≤50% presented with a significant recovery in LVEF, although the recovery was less pronounced in patients with new-onset LBBB. Moreover, patients with a baseline LVEF ≤50% who received PPI showed an improvement in LVEF at 6 months regardless of the RV pacing burden. New-onset LBBB hampers the recovery of LVEF after TAVI. Among patients with an LVEF ≤50%, pressure overload relief counteracts the effects of new-onset LBBB or RV pacing.

Sex differences in left ventricular remodelling in patients with severe aortic valve stenosis

AIMS 

Women with severe aortic stenosis (AS) have better long-term outcome after transcatheter aortic valve implantation (TAVI) but worse survival after surgical aortic valve replacement compared with men. Whether this is related to sex differences in left ventricular (LV) remodelling is unknown. The aim of this study was to examine the sex differences in LV remodelling with multidetector row computed tomography (MDCT) and outcome in patients with severe AS undergoing TAVI between 2007 and 2018.

METHODS AND RESULTS 

A total of 289 patients (age 80 ± 6 years, 54% male) were included. LV volumes, mass, and function were analysed on pre-procedural MDCT scans. Women showed smaller LV volumes and mass compared with men. Patients were classified into four LV remodelling patterns: concentric hypertrophy (50%) was the most frequent pattern of LV remodelling followed by eccentric hypertrophy (33%), normal geometry (13%), and concentric remodelling (4%). Men showed more concentric remodelling compared with women (91% vs. 9%, respectively, P = 0.011). However, no differences were observed in the remaining LV remodelling patterns. During a median follow-up of 3.8 (IQR 2.2-5.1) years after TAVI, 87 (30%) patients died. Women demonstrated better outcome after TAVI compared with men (log-rank χ2 = 4.29, P = 0.038). No association was observed between the interaction of the LV remodelling patterns and sex with outcome.

CONCLUSION 

LV concentric hypertrophy and eccentric hypertrophy are similarly observed in men and women with severe AS but concentric remodelling was more common in men. Women demonstrated better outcome after TAVI when compared with men. The interaction between the LV remodelling patterns and sex was not associated with survival.

Aspirin with or without Clopidogrel after Transcatheter Aortic-Valve Implantation

BACKGROUND

The effect of single as compared with dual antiplatelet treatment on bleeding and thromboembolic events after transcatheter aortic-valve implantation (TAVI) in patients who do not have an indication for long-term anticoagulation has not been well studied.

METHODS

In a randomized, controlled trial, we assigned a subgroup of patients who were undergoing TAVI and did not have an indication for long-term anticoagulation, in a 1:1 ratio, to receive aspirin alone or aspirin plus clopidogrel for 3 months. The two primary outcomes were all bleeding (including minor, major, and life-threatening or disabling bleeding) and non-procedure-related bleeding over a period of 12 months. Most bleeding at the TAVI puncture site was counted as non-procedure-related. The two secondary outcomes were a composite of death from cardiovascular causes, non-procedure-related bleeding, stroke, or myocardial infarction (secondary composite 1) and a composite of death from cardiovascular causes, ischemic stroke, or myocardial infarction (secondary composite 2) at 1 year, with both outcomes tested sequentially for noninferiority (noninferiority margin, 7.5 percentage points) and superiority.

RESULTS

A total of 331 patients were assigned to receive aspirin alone and 334 were assigned to receive aspirin plus clopidogrel. A bleeding event occurred in 50 patients (15.1%) receiving aspirin alone and in 89 (26.6%) receiving aspirin plus clopidogrel (risk ratio, 0.57; 95% confidence interval [CI], 0.42 to 0.77; P = 0.001). Non-procedure-related bleeding occurred in 50 patients (15.1%) and 83 patients (24.9%), respectively (risk ratio, 0.61; 95% CI, 0.44 to 0.83; P = 0.005). A secondary composite 1 event occurred in 76 patients (23.0%) receiving aspirin alone and in 104 (31.1%) receiving aspirin plus clopidogrel (difference, -8.2 percentage points; 95% CI for noninferiority, -14.9 to -1.5; P<0.001; risk ratio, 0.74; 95% CI for superiority, 0.57 to 0.95; P = 0.04). A secondary composite 2 event occurred in 32 patients (9.7%) and 33 patients (9.9%), respectively (difference, -0.2 percentage points; 95% CI for noninferiority, -4.7 to 4.3; P = 0.004; risk ratio, 0.98; 95% CI for superiority, 0.62 to 1.55; P = 0.93). A total of 44 patients (13.3%) and 32 (9.6%), respectively, received oral anticoagulation during the trial.

CONCLUSIONS

Among patients undergoing TAVI who did not have an indication for oral anticoagulation, the incidence of bleeding and the composite of bleeding or thromboembolic events at 1 year were significantly less frequent with aspirin than with aspirin plus clopidogrel administered for 3 months. (Funded by the Netherlands Organization for Health Research and Development; POPular TAVI EU Clinical Trials Register number, 2013-003125-28; ClinicalTrials.gov number, NCT02247128.).

Prespecified Risk Criteria Facilitate Adequate Discharge and Long-Term Outcomes After Transfemoral Transcatheter Aortic Valve Implantation

Background

Despite the availability of guidelines for the performance of transcatheter aortic valve implantation (TAVI), current treatment pathways vary between countries and institutions, which impact on the mean duration of postprocedure hospitalization.

Methods and Results

This was a prospective, multicenter registry of 502 patients to validate the appropriateness of discharge timing after transfemoral TAVI, using prespecified risk criteria from FAST‐TAVI (Feasibility and Safety of Early Discharge After Transfemoral [TF] Transcatheter Aortic Valve Implantation), based on hospital events within 1‐year after discharge. The end point—a composite of all‐cause mortality, vascular access–related complications, permanent pacemaker implantation, stroke, cardiac rehospitalization, kidney failure, and major bleeding—was reached in 27.0% of patients (95% CI, 23.3–31.2) within 1 year after intervention; 7.5% (95% CI, 5.5–10.2) had in‐hospital complications before discharge and 19.6% (95% CI, 16.3–23.4) within 1 year after discharge. Overall mortality within 1 year after discharge was 7.3% and rates of cardiac rehospitalization 13.5%, permanent pacemaker implantation 4.2%, any stroke 1.8%, vascular‐access–related complications 0.7%, life‐threatening bleeding 0.7%, and kidney failure 0.4%. Composite events within 1 year after discharge were observed in 18.8% and 24.3% of patients with low risk of complications/early (≤3 days) discharge and high risk and discharged late (>3 days) (concordant discharge), respectively. Event rate in patients with discordant discharge was 14.3% with low risk but discharged late and increased to 50.0% in patients with high risk but discharged in ≤3 days.

Conclusions

The FAST‐TAVI risk assessment provides a tool for appropriate, risk‐based discharge that was validated with the 1‐year event rate after transfemoral TAVI.

Registration

URL: https://www.ClinicalTrials.gov; Unique identifier: NCT02404467.

Anticoagulation with or without Clopidogrel after Transcatheter Aortic-Valve Implantation

BACKGROUND

The roles of anticoagulation alone or with an antiplatelet agent after transcatheter aortic-valve implantation (TAVI) have not been well studied.

METHODS

We performed a randomized trial of clopidogrel in patients undergoing TAVI who were receiving oral anticoagulation for appropriate indications. Patients were assigned before TAVI in a 1:1 ratio not to receive clopidogrel or to receive clopidogrel for 3 months. The two primary outcomes were all bleeding and non-procedure-related bleeding over a period of 12 months. Procedure-related bleeding was defined as Bleeding Academic Research Consortium type 4 severe bleeding, and therefore most bleeding at the puncture site was counted as non-procedure-related. The two secondary outcomes were a composite of death from cardiovascular causes, non-procedure-related bleeding, stroke, or myocardial infarction at 12 months (secondary composite 1) and a composite of death from cardiovascular causes, ischemic stroke, or myocardial infarction (secondary composite 2), both tested for noninferiority (noninferiority margin, 7.5 percentage points) and superiority.

RESULTS

Bleeding occurred in 34 of the 157 patients (21.7%) receiving oral anticoagulation alone and in 54 of the 156 (34.6%) receiving oral anticoagulation plus clopidogrel (risk ratio, 0.63; 95% confidence interval [CI], 0.43 to 0.90; P = 0.01); most bleeding events were at the TAVI access site. Non-procedure-related bleeding occurred in 34 patients (21.7%) and in 53 (34.0%), respectively (risk ratio, 0.64; 95% CI, 0.44 to 0.92; P = 0.02). Most bleeding occurred in the first month and was minor. A secondary composite 1 event occurred in 49 patients (31.2%) receiving oral anticoagulation alone and in 71 (45.5%) receiving oral anticoagulation plus clopidogrel (difference, -14.3 percentage points; 95% CI for noninferiority, -25.0 to -3.6; risk ratio, 0.69; 95% CI for superiority, 0.51 to 0.92). A secondary composite 2 event occurred in 21 patients (13.4%) and in 27 (17.3%), respectively (difference, -3.9 percentage points; 95% CI for noninferiority, -11.9 to 4.0; risk ratio, 0.77; 95% CI for superiority, 0.46 to 1.31).

CONCLUSIONS

In patients undergoing TAVI who were receiving oral anticoagulation, the incidence of serious bleeding over a period of 1 month or 1 year was lower with oral anticoagulation alone than with oral anticoagulation plus clopidogrel. (Funded by the Netherlands Organization for Health Research and Development; POPular TAVI EU Clinical Trials Register number, 2013-003125-28; ClinicalTrials.gov number, NCT02247128.).

Prognostic Influence of Feature Tracking Multidetector Row Computed Tomography-Derived Left Ventricular Global Longitudinal Strain in Patients with Aortic Stenosis Treated With Transcatheter Aortic Valve Implantation

Computed tomography plays a central role in the evaluation of patients with severe aortic stenosis who underwent transcatheter aortic valve implantation (TAVI). Advances in left ventricular (LV) analysis with multidetector row computed tomography (MDCT) permit measurement of LV global longitudinal strain (GLS). The present study aimed at evaluating the association between feature tracking (FT) MDCT derived LV GLS and all-cause mortality in patients treated with TAVI. A total of 214 patients with severe aortic stenosis (51% male, 80 ± 7 years) who underwent TAVI and with dynamic MDCT data allowing LV GLS measurement with novel FT algorithm were included. LV GLS was measured at baseline and were divided according to a previously published cut-off value of LV GLS associated with all-cause mortality (≤-14% [more preserved LV systolic function] vs >-14% [more impaired LV systolic function]). Patients were followed for the occurrence of all-cause mortality. Mean FT MDCT-derived LV GLS was -12.5 ± 4%. During a median follow-up of 45 months (interquartile range: 29 to 62 months), 67 (31%) patients died. The cumulative rate of all-cause mortality for the patients with FT MDCT-derived LV GLS ≤-14% was 15% versus28% for the patients with FT MDCT-derived LV GLS >-14%, Log rank p = 0.001). FT MDCT-derived LV GLS was independently associated with all-cause mortality (hazard ratio: 0.851; 95% confidence interval: 0.772 to 0.937; p = 0.001). In conclusion, impaired FT MDCT-derived LV GLS is independently associated with all-cause mortality in patients treated with TAVI. Besides aortic valve area and calcification, FT MDCT-derived LV GLS is an important prognostic marker.

One-Year Follow-Up of Conduction Abnormalities After Transcatheter Aortic Valve Implantation With the SAPIEN 3 Valve

Long-term evolution of new-onset conduction abnormalities and need of permanent pacemaker implantation (PPI) after transcatheter aortic valve implantation (TAVI) have not been extensively evaluated. We describe the incidence and time course of new conduction abnormalities and the rate of PPI with the new-generation transcatheter aortic valve prosthesis Edwards SAPIEN 3 (S3). In total, 266 patients with severe aortic stenosis who underwent TAVI were retrospectively analyzed. Twelve-lead electrocardiograms at baseline, after TAVI, at discharge, at 1-, 6-, and 12-month follow-up were evaluated to identify conduction abnormalities and PPI requirements to investigate the correlates of PPI. After TAVI, a significant increase in PR interval duration and in QRS complex width was observed. New-onset left bundle branch block was observed in 65 patients (24%) after TAVI. The number of patients with left bundle branch block was maximum at hospital discharge and decreased at 12-month follow-up (39% and 32%, respectively). Thirty-five patients (13%) required PPI during the follow-up. However, paced rhythm was only observed in 7% of the patients with a complete 12-month follow-up. Patients who underwent PPI had a higher prevalence of first-degree atrioventricular block, complete right bundle branch block, and wider QRS complex at baseline. Baseline right bundle branch block and QRS width immediately after TAVI were the only variables independently associated with PPI. In conclusion, conduction disorders have a temporary nature after TAVI and showed a trend toward stabilization during the following months. With this new-generation device, the incidence of new conduction abnormalities requiring PPI is relatively low.

Beyond the clinical impact of aortic and pulmonary valve implantation: health-related quality of life, informal care and productivity†

OBJECTIVES

Our aim was to provide estimates of patient-reported health-related quality of life (HRQoL), use of informal care and productivity in patients after surgical aortic and pulmonary valve replacement and transcatheter aortic valve implantation.

METHODS

Consecutive cohorts of 1239 adult patients who had surgical aortic valve replacement or surgical pulmonary valve replacement and 433 patients who had transcatheter aortic valve implantation at 2 Dutch heart centres were cross-sectionally surveyed at a median time of 2.9 and 3.2 years after the intervention, respectively. The survey included questions on HRQoL (EQ-5D-5L and SF-12-v2), use of informal care and productivity in paid and unpaid work. All outcomes were compared with age and sex-matched individuals from the general population.

RESULTS

The response rate was 56% (n = 687) of patients who had surgical valve replacement and 59% (n = 257) of those who had transcatheter aortic valve implantation. Compared with the general population, patients reported poorer HRQoL on physical health domains, whereas their scores were comparable for mental health domains. After a heart valve implantation, patients reported using informal care more frequently than the general population, but labour participation was comparable. Patients with late complications [antibiotic treatment for endocarditis (n = 4), stroke (n = 11), transient ischaemic attack (n = 15)] reported lower HRQoL, greater use of informal care and greater productivity loss than patients without complications.

CONCLUSIONS

Patients who had aortic and pulmonary valve implantations experience relatively mild limitations in daily life compared to the general population. The consequences of a heart valve implantations beyond clinical outcomes should be considered to create realistic patient expectations of life after a heart valve implantation and unbiased resource allocation decisions at national levels.

Predictors of residual tricuspid regurgitation after percutaneous closure of atrial septal defect

Aims

Functional tricuspid regurgitation (TR) associated with atrial septal defects (ASDs) is frequently present due to right-sided volume-overload. Tricuspid valve (TV) repair is often considered in candidates for surgical ASD closure, and percutaneous TV repair is currently under clinical investigation. In this study, we develop a prediction model to identify patients with residual moderate/severe TR after percutaneous ASD closure.

Methods and results

In this observational study, 172 adult patients (26% male, age 49 ± 17 years) with successful percutaneous ASD closure had pre- and post-procedural echocardiography. Right heart dimensions/function were measured. TR was assessed semi-quantitatively. A prediction model for 6-month post-procedural moderate/severe TR was derived from uni-and multi-variable logistic regression. Clinical follow-up (FU) was updated and adverse events were defined as cardiovascular death or hospitalization for heart failure. Pre-procedural TR was present in 130 (76%) patients (moderate/severe: n = 64) of which 72 (55%) had ≥1 grade reduction post-closure. Independent predictors of post-procedural moderate/severe TR (n = 36) were age ≥60 years [odds ratio (OR) 2.57; P = 0.095], right atrial end-diastolic area ≥10cm2/m2 (OR 3.36; P = 0.032), right ventricular systolic pressure ≥44 mmHg (OR 6.44; P = 0.001), and tricuspid annular plane systolic excursion ≤2.3 cm (OR 3.29; P = 0.037), producing a model with optimism-corrected C-index = 0.82 (P < 0.001). Sensitivity analysis excluding baseline none/mild TR yielded similar results. Patients with moderate/severe TR at 6-month FU had higher adverse event rates [hazard ratio = 6.2 (95% confidence interval 1.5-26); log-rank P = 0.004] across a median of 45 (30-76) months clinical FU.

Conclusion

This study shows that parallel to reduction of volume-overload and reverse remodelling after percutaneous ASD closure, TR improved substantially despite significant TR at baseline. Our proposed risk model helps identify ASD patients in whom TR regression is unlikely after successful percutaneous closure.

Transcatheter aortic valve thrombosis: the relation between hypo-attenuated leaflet thickening, abnormal valve haemodynamics, and stroke

Aims

The presence of hypo-attenuated leaflet thickening (HALT) and/or reduced leaflet motion on multi-detector row computed tomography (MDCT) has been proposed as a possible marker for early transcatheter aortic valve thrombosis. However, its association with abnormal valve haemodynamics on echocardiography (another potential marker of thrombosis) and clinical outcomes (stroke) remains unclear. The present study evaluated the prevalence of HALT on MDCT and abnormal valve haemodynamics on echocardiography. In addition, the occurrence of ischemic stroke and/or transient ischemic attack (TIA) was assessed.

Methods and results

A total of 434 patients (mean age 80 ± 7 years, 51% male) who underwent transcatheter aortic valve replacement (TAVR) were evaluated. Transcatheter valve haemodynamics were assessed on echocardiography at discharge, 6 months, and thereafter yearly (up to 3 years post-TAVR). The presence of HALT and/or reduced leaflet motion was assessed on MDCT performed 35 days [interquartile range 19-210] after TAVR in 128 of these 434 patients. Possible TAVR valve thrombosis was defined by mean transvalvular gradient ≥20 mmHg and aortic valve area (AVA) ≤1.1cm2 on echocardiography or by the presence of HALT or reduced leaflet motion on MDCT. The occurrence of ischemic stroke/TIA at follow-up was recorded. HALT and/or reduced leaflet motion was present in 12.5% of 128 patients undergoing MDCT, and was associated with a slightly higher mean transvalvular gradient (12.4 ± 8.0 mmHg vs. 9.4 ± 4.3 mmHg; P = 0.026) and smaller AVA (1.49 ± 0.39 cm2 vs. 1.78 ± 0.45 cm2, P = 0.017). Only one patient with HALT on MDCT revealed abnormal valve haemodynamics on echocardiography. At 3-year follow-up, abnormal valve haemodynamics on echocardiography were observed in 3% of patients. HALT on MDCT and abnormal valve haemodynamics on echocardiography were not associated with increased risk of ischemic stroke/TIA.

Conclusion

On MDCT, 12.5% of patients showed HALT or reduced leaflet motion, whereas only one of these patients had abnormal valve haemodynamics on echocardiography. Neither HALT nor increased transvalvular gradient were associated with stroke/TIA.

Computed tomography for planning transcatheter tricuspid valve therapy

Aims

Percutaneous transcatheter tricuspid valve therapy is an evolving treatment option for patients with significant tricuspid regurgitation (TR) deemed too fragile for open heart surgery. The present study proposes comprehensive anatomical evaluation of the tricuspid valve, right ventricle (RV), and vena cavae and its spatial relationships with the right coronary artery (RCA) using computed tomography (CT) and investigates the implications for suitability for current technologies.

Methods and results

A total of 250 patients (mean age 80 ± 7.2 years, 52.4% men) undergoing CT were divided according to the presence of moderate or severe TR (≥3+, n = 40) and less than moderate TR (<3+, n = 210). Tricuspid valve annulus, RV, and vena cavae dimensions and the course of the RCA relative to the tricuspid annulus were evaluated. Patients with TR ≥ 3+ showed significantly larger dimensions of the tricuspid annulus, RV and vena cavae. In 64.8% of patients, the RCA coursed along the tricuspid valve annulus. Patients with TR <3+ showed more frequently a course of the RCA superior to the tricuspid annulus at the levels of the anterior and the posterior tricuspid leaflet compared with their counterparts (12.4% vs. 0%, P = 0.019). A less favourable course of the RCA (≤2.0 mm distance to the annulus) for current annuloplasty techniques was observed at the level of the anterior tricuspid and posterior leaflets in respective 12.5 and 27.5% of patients with TR ≥3+.

Conclusion

The present study proposes a first systematic approach based on CT to define the patient suitability for current transcatheter tricuspid valve devices.

Influence of the Quantity of Aortic Valve Calcium on the Agreement Between Automated 3-Dimensional Transesophageal Echocardiography and Multidetector Row Computed Tomography for Aortic Annulus Sizing

Accurate aortic annulus sizing is key for selection of appropriate transcatheter aortic valve implantation (TAVI) prosthesis size. The present study compared novel automated 3-dimensional (3D) transesophageal echocardiography (TEE) software and multidetector row computed tomography (MDCT) for aortic annulus sizing and investigated the influence of the quantity of aortic valve calcium (AVC) on the selection of TAVI prosthesis size. A total of 83 patients with severe aortic stenosis undergoing TAVI were evaluated. Maximal and minimal aortic annulus diameter, perimeter, and area were measured. AVC was assessed with computed tomography. The low and high AVC burden groups were defined according to the median AVC score. Overall, 3D TEE measurements slightly underestimated the aortic annulus dimensions as compared with MDCT (mean differences between maximum, minimum diameter, perimeter, and area: -1.7 mm, 0.5 mm, -2.7 mm, and -13 mm², respectively). The agreement between 3D TEE and MDCT on aortic annulus dimensions was superior among patients with low AVC burden (<3,025 arbitrary units) compared with patients with high AVC burden (≥3,025 arbitrary units). The interobserver variability was excellent for both methods. 3D TEE and MDCT led to the same prosthesis size selection in 88%, 95%, and 81% of patients in the total population, the low, and the high AVC burden group, respectively. In conclusion, the novel automated 3D TEE imaging software allows accurate and highly reproducible measurements of the aortic annulus dimensions and shows excellent agreement with MDCT to determine the TAVI prosthesis size, particularly in patients with low AVC burden.

Feasibility and safety of early discharge after transfemoral transcatheter aortic valve implantation - rationale and design of the FAST-TAVI registry

BACKGROUND

There is an increasing trend towards shorter hospital stays after transcatheter aortic valve implantation (TAVI), in particular for patients undergoing the procedure via transfemoral (TF) access. Preliminary data suggest that there exists a population of patients that can be discharged safely very early after TF-TAVI. However, current evidence is limited to few retrospective studies, encompassing relatively small sample sizes.

METHODS

The Feasibility And Safety of early discharge after Transfemoral TAVI (FAST-TAVI) registry is a prospective observational registry that will be conducted at 10 sites across Italy, the Netherlands and the UK. Patients will be included if they have been scheduled to undergo TF-TAVI with the balloon-expandable SAPIEN 3 transcatheter heart valve (THV; Edwards Lifesciences, Irvine, CA). The primary endpoint is a composite of all-cause mortality, vascular-access-related complications, permanent pacemaker implantation, stroke, re-hospitalisation due to cardiac reasons, kidney failure and major bleeding, occurring during the first 30 days after hospital discharge. Patients will be stratified according to whether they were high or low risk for early discharge (≤3 days) (following pre-specified criteria), and according to whether or not they were discharged early. Secondary endpoints will include time-to-event (Kaplan-Meier) analysis for the primary outcome and its individual components, analysis of the relative costs of early and late discharge, and changes in short- and long-term quality of life. Multivariate logistic regression will be used to identify factors that indicate that a patient may be suitable for early discharge.

DISCUSSION

The data gathered in the FAST-TAVI registry should help to clarify the safety of early discharge after TF-TAVI and to identify patient and procedural characteristics that make early discharge from hospital a safe and cost-effective strategy.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02404467 (registration first received March 23rd 2015).

Aortic valve stenosis: what do people know? A heart valve disease awareness survey of over 8,800 people aged 60 or over

AIMS

Little is known about the level of public knowledge and concern towards aortic valve disease. Therefore, a survey was conducted to evaluate the awareness of the general population regarding different diseases with special emphasis on aortic stenosis (AS).

METHODS AND RESULTS

A total of 8,860 people aged 60 years or older in nine European countries took part in the survey. Cancer was the disease that respondents were most concerned about (27.5%), while only 1.7% were most concerned about heart valve disease. Seventeen percent (17%) of survey participants claimed to be familiar with heart valve disease, yet only 7% could correctly identify AS; 44.3% of respondents knew the correct number of valves in the human heart. After providing some general information about AS, 41.1% of respondents then said they were more concerned about the condition; 4.5% even recognised the symptoms in themselves. Over half of the respondents (54.2%) claimed that their general practitioners only rarely or never use the stethoscope to check their heart, which may eventually lead to an underdiagnosis of AS.

CONCLUSIONS

Despite its high prevalence, high morbidity and mortality, as well as good treatment options, the vast majority of respondents were neither concerned nor fully aware of AS.

Impact of Different Iterations of Devices and Degree of Aortic Valve Calcium on Paravalvular Regurgitation After Transcatheter Aortic Valve Implantation

The iterations of the SAPIEN prosthesis might impact the incidence and grade of paravalvular regurgitation (PVR). The aim of this study was to assess the impact of iterations of balloon-expandable valves (SAPIEN, SAPIEN XT, and SAPIEN 3) and degree of aortic valve calcification (AVC) on the severity of PVR after transcatheter aortic valve implantation (TAVI). Comprehensive echocardiographic examinations and multidetector computed tomography (MDCT) were performed in 272 patients (127 men, 81 ± 7 years old, logistic EuroScore of 21 ± 13%) who underwent TAVI with 23- and 26-mm balloon-expandable valves. The degree of AVC was assessed with MDCT. PVR grade was assessed with echocardiography. The cover index was calculated as (prosthesis area - MDCT annulus area)/prosthesis area. SAPIEN, SAPIEN XT, and SAPIEN 3 prostheses were implanted in 103 patients (38%), 105 patients (38.5%), and 64 patients (23.5%), respectively. Significant PVR (≥moderate) occurred in 14%, 10%, and 0% of patients receiving the SAPIEN, SAPIEN XT, and SAPIEN 3, respectively (p = 0.010). Across the groups, the aortic annulus size, degree of calcification, and cover index were comparable. Larger burden of AVC was independently associated with significant PVR (odds ratio 3.48, p = 0.006) after adjusting for age, body surface area, gender, aortic annulus area, cover index, and prosthesis iteration. SAPIEN 3 was associated with lower frequency of significant PVR (odds ratio 0.31, p = 0.002). In conclusion, the incidence of significant PVR significantly decreased over time with improvement in valve design. SAPIEN 3 was associated with less significant PVR after TAVI independently of the AVC burden.

Prosthesis Dislocation After Transapical Valve-In-Valve Mitral Valve Implantation

Transapical valve-in-valve mitral valve implantation (TA-MVI) has been described as an alternative treatment option in patients with degenerated bioprostheses in the mitral position. We report the first case of prosthesis dislocation and migration into the left atrium after TA-MVI. A new prosthesis was implanted using the same approach. The dislocated prosthesis was successfully removed through the left atrial appendage through an extended anterolateral thoracotomy without the use of cardiopulmonary bypass.

Acute effect of MitraClip implantation on mitral valve geometry in patients with functional mitral regurgitation: insights from three-dimensional transoesophageal echocardiography

AIMS

Our aim was to evaluate the acute effects of transcatheter edge-to-edge mitral valve repair using the MitraClip device on mitral valve geometry in patients with functional mitral regurgitation (FMR).

METHODS AND RESULTS

Forty-two patients (age 73 years [IQ range 66.1-78.0], 55% men, 62% ischaemic FMR) with moderate-to-severe and severe FMR treated with the MitraClip were included. Three-dimensional transoesophageal echocardiography was performed prior to and immediately after MitraClip implantation. Acute changes of mitral annular and leaflet geometry were assessed with dedicated mitral modelling software. FMR less than moderate grade was achieved in 36 (86%) patients. After MitraClip implantation, the mitral annulus became more elliptical (ellipticity from 122±17% to 129±18%; p=0.04) with a non-significant reduction in anteroposterior diameter (33±6 to 32±5 mm, p=0.08). The coaptation area increased from 350 mm2 (IQ range 289-493 mm2) to 434 mm2 (IQ range 328-523 mm2, p=0.008). In particular, a larger part of the anterior mitral leaflet was included in the coaptation, leaving a smaller exposed anterior leaflet length of the A2 segment (from 27±6 mm to 25±5 mm, p<0.05) while the exposed length of the posterior leaflet (P2 level) remained unchanged (12±4 mm pre- vs. 13±4 mm post-repair, p=0.15). There was no change in total leaflet area (1,811±582 mm2 pre- vs. 1,870±506 mm2 post-repair, p=0.18). Annular height to intercommissural width ratio and tenting volume remained unchanged, suggesting no increase in leaflet stress.

CONCLUSIONS

The MitraClip device affects MV geometry in FMR patients by increasing mitral annular ellipticity and coaptation area.

Rationale and design of POPular-TAVI: antiPlatelet therapy fOr Patients undergoing Transcatheter Aortic Valve Implantation

BACKGROUND

Despite improving experience and techniques, ischemic and bleeding complications after transcatheter aortic valve implantation (TAVI) remain prevalent and impair survival. Current guidelines recommend the temporary addition of clopidogrel in the initial period after TAVI to prevent thromboembolic events. However, explorative studies suggest that this is associated with a higher rate of major bleeding without a decrease in thromboembolic complications.

METHODS

The POPular TAVI trial is a prospective randomized, controlled, open-label multicenter clinical trial to test the hypothesis that monotherapy with aspirin or oral anticoagulation (OAC) after TAVI is safer than the addition of clopidogrel for 3 months, without compromising clinical benefit. This trial encompasses 2 cohorts: cohort A, patients are randomized 1:1 to aspirin vs aspirin + clopidogrel, and cohort B, patients on OAC therapy are randomized 1:1 to OAC vs OAC + clopidogrel. Primary outcome is freedom from non-procedure-related bleeding at 1 year. Secondary net-clinical benefit outcome is freedom from the composite of cardiovascular death, non-procedural-related bleeding, myocardial infarction, or stroke at 1 year. The primary outcome is analyzed for superiority, whereas the secondary outcome is analyzed for noninferiority. Recruitment began in February 2014, and the trial will continue until a total of 1,000 patients (684 expected in cohort A and 316 in cohort B) are included and followed up for 1 year.

SUMMARY

The POPular TAVI trial (NCT02247128) is the first large randomized controlled trial to test if monotherapy with aspirin or OAC vs additional clopidogrel after TAVI reduces bleeding with a favorable net-clinical benefit.

Surgical sutureless and transcatheter aortic valves: hemodynamic performance and clinical outcomes in propensity score-matched high-risk populations with severe aortic stenosis

OBJECTIVES

In propensity score-matched patients with severe aortic stenosis treated with surgical aortic valve replacement (AVR) with the 3f Enable sutureless prosthesis (Medtronic, Minneapolis, Minnesota) or transcatheter aortic valve replacement (TAVR), the hemodynamic performance of both valves and mid-term survival of patients were evaluated.

BACKGROUND

Data on hemodynamic performance of surgical sutureless bioprostheses in high operative risk patients with aortic stenosis are scarce.

METHODS

Of 258 patients undergoing TAVR or surgical aortic valve replacement with the 3f Enable valve, 80 (79 ± 5 years of age, 100% men) were included in the current analysis on the basis of propensity score 1:1 matching for baseline clinical and hemodynamic characteristics. All patients had hemodynamic echocardiographic evaluation at baseline and discharge. Mid-term survival was analyzed.

RESULTS

Compared with the 3f Enable valve, TAVR prostheses (Edwards SAPIEN XT [Edwards Lifesciences, Irvine, California] and CoreValve [Medtronic]) had larger effective orifice area index (1.00 ± 0.30 cm(2)/m(2) vs. 0.76 ± 0.22 cm(2)/m(2); p < 0.001), lower pressure gradient (8.14 ± 4.21 mm Hg vs. 10.72 ± 4.01 mm Hg; p = 0.006), less frequent prosthesis-patient mismatch (30.0% vs. 67.5%; p = 0.001), and low flow (46.2% vs. 72.5%; p = 0.02), but more frequent aortic regurgitation (87.5% vs. 20.0%; p < 0.001). The presence of prosthesis-patient mismatch was independently associated with a low-flow state at discharge (odds ratio: 4.70; p = 0.004) and independently associated with the use of the sutureless prosthesis (odds ratio: 3.90; p = 0.02). However, the survival of the 2 groups was comparable after 1.5-year (interquartile range: 0.79 to 2.01 years) follow-up (log-rank test, p = 0.95).

CONCLUSIONS

TAVR prostheses demonstrated better hemodynamics than the 3f Enable valve but a higher incidence of aortic regurgitation. However, these differences did not influence mid-term survival of patients.

Impact of age on transcatheter aortic valve implantation outcomes: a comparison of patients aged ≤ 80 years versus patients > 80 years

OBJECTIVE

To investigate the procedural outcomes and the long-term survival of patients undergoing transcatheter aortic valve implantation (TAVI) and compare study results of patients ≤ 80 years and patients > 80 years old.

METHODS

A total of 240 patients treated with TAVI were divided into two groups according to age ≤ 80 years (n = 105; 43.8%) and > 80 years (n = 135; 56.2%). The baseline characteristics and the procedural outcomes were compared between these two groups of patients.

RESULTS

With the exception of peripheral artery disease and hypercholesterolemia, which were more frequently observed in the older age group, baseline characteristics were comparable between groups. Complication rates did not differ significantly between patients ≤ 80 years and patients > 80 years. There were no differences in 30-day mortality rates between patients aged ≤ 80 years and patients > 80 years old (9.5% vs. 7.4%, respectively; P = 0.557). After a median follow-up of 28 months (interquartile range: 16-42 months), 50 (47.6%) patients aged ≤ 80 years died compared to 57 (42%) deaths in the group of patients > 80 years old (P = 0.404).

CONCLUSION

The results of the present single center study showed that age did not significantly impact the outcomes of TAVI.