Transcatheter aortic valve implantation in patients with significant septal hypertrophy

BACKGROUND

Previous reports suggest septal hypertrophy with an interventricular septum depth (IVSD) ≥ 14 mm may adversely affect outcomes after transcatheter aortic valve implantation (TAVI) due to suboptimal valve placement, valve migration, or residual increased LVOT pressure gradients.

AIMS

This analysis investigates the impact of interventricular septal hypertrophy on acute outcomes after TAVI.

METHODS

Between 2009 and 2021, 1033 consecutive patients (55.8% male, 80.5 ± 6.7 years, EuroSCORE II 6.3 ± 6.5%) with documented IVSD underwent TAVI at our center and were included for analysis. Baseline, periprocedural, and 30-day outcome parameters of patients with normal IVSD (< 14 mm; group 1) and increased IVSD (≥ 14 mm; group 2) were compared. Data were retrospectively analyzed according to updated Valve Academic Research Consortium-3 (VARC-3) definitions. Comparison of outcome parameters was adjusted for baseline differences between groups using logistic and linear regression analyses.

RESULTS

Of 1033 patients, 585 and 448 patients were allocated to groups 1 and 2, respectively. There was no significant difference between groups regarding transfemoral access rate (82.6% (n = 478) vs. 86.0% (n = 381), p = 0.157). Postprocedural mean transvalvular pressure gradient was significantly increased in group 2 (group 1, 7.8 ± 4.1 mmHg, vs. group 2, 8.9 ± 4.9 mmHg, p = 0.046). Despite this finding, there was no significant difference between groups regarding the rates of VARC-3 adjudicated composite endpoint device success (90.0% (n = 522) vs. 87.6% (n = 388), p = 0.538) or technical success (92.6% (n = 542) vs. 92.6% (n = 415), p = 0.639). Moreover, the groups showed no significant differences regarding the rates of paravalvular leakage ≥ moderate (3.1% (n = 14) vs. 2.6% (n = 9), p = 0.993), postprocedural permanent pacemaker implantation (13.4% (n = 77) vs. 13.8% (n = 61), p = 0.778), or 30-day mortality (5.1% (n = 30) vs. 4.5% (n = 20), p = 0.758).

CONCLUSION

Although transvalvular mean pressure gradients were significantly higher in patients with increased IVSD after TAVI, acute outcomes were comparable between groups suggesting no early impact of adverse hemodynamics due to elevated IVSD. However, how these differences in hemodynamic findings may affect mid- and long-term outcomes, especially in terms of valve durability, needs to be evaluated in further investigations.

Intravascular Lithotripsy-Assisted Transfemoral Transcatheter Aortic Valve Implantation in Patients with Severe Iliofemoral Calcifications: Expanding Transfemoral Indications

(1) Background: Transfemoral transcatheter aortic valve implantation (TAVI) has become the standard treatment for most patients with severe symptomatic aortic stenosis. Intravascular lithotripsy may facilitate transfemoral TAVI (IVL-TAVI) even in patients with severely calcified iliofemoral disease. We assessed technical aspects and clinical outcomes of this novel approach compared to alternative transaxillary access (TAX-TAVI). (2) Methods: IVL-TAVI was performed for severe iliofemoral calcifications precluding standard transfemoral access in 30 patients from 2019 to 2022 at a single academic heart center. IVL was performed as part of the TAVI procedure in all cases. Results were compared to a control group of 44 TAX-TAVI procedures performed for the same indication from 2016 to 2021. The safety outcome was a composite of all-cause death, stroke, access-related bleeding ≥ type 2 within 24 h and major vascular access site complications at 30 days. The efficacy outcome was defined as a technical success according to VARC-3. (3) Results: Median age was 78.2 [74.3, 82.6] years, 45.9% were female and mean STS-PROM was 3.6% [2.3, 6.0]. Iliofemoral calcifications were more severe in the IVL-TAVI vs. TAX-TAVI groups (lesion length: 63.0 mm [48.6, 80.3] vs. 48.5 mm [33.1, 68.8]; p = 0.043, severe calcification at target lesion: 90.0% vs. 68.2%; p = 0.047, and median arc calcification 360.0° [297.5, 360.0] vs. 360.0° [180.0, 360.0]; p = 0.033). Technical success was achieved in 93.3% vs. 81.8% (p = 0.187) in IVL- and TAX-TAVI and the safety outcome occurred in 10.0% vs. 31.8% in IVL- and TAX-TAVI (p = 0.047), respectively. (4) Conclusions: IVL-assisted transfemoral TAVI was feasible and safe with favorable outcomes compared to TAX-TAVI. IVL may further expand the number of patients eligible for transfemoral TAVI and may help overcome limitations of an alternative access.

Prognostic impact and diagnostic value of invasively derived hemodynamic measures in patients with severe aortic stenosis undergoing TAVI

BACKGROUND

Ejection time (ET), acceleration time (AT) and time between left ventricular and aortic systolic pressure peaks (T-LVAo) might be of diagnostic and prognostic use in patients with aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI).

AIM

We aimed to assess the diagnostic value and prognostic impact of invasively measured ET, AT, and T-LVAo in patients undergoing TAVI.

METHODS

A total of 1274 patients received invasive measurement of ET, AT and T-LVAo prior to TAVI. Anatomic AS severity was assessed by CT-derived aortic valve calcification density (AVC_d). Impact on all-cause mortality was retrospectively analyzed.

RESULTS

In multivariable linear regression, T-LVAo showed the strongest correlation with AVC_d. No prognostic impact of T-LVAo was found according to uni- and multivariable analyses. In contrast, using an individual C-statistic derived cutoff (C_D), patients with ET or AT ≥ C_D showed lower mortality rates compared to patients with ET or AT < C_D (1-year mortality: ET ≥ vs. < C_D: 15.01vs. 33.1%, AT ≥ vs < C_D 16.3 vs. 26.5%, p < 0.001). Moreover, multivariable analysis identified ET ≥ C_D (HR 0.61 [95% CI 0.43-0.87; p < 0.007]) to be associated with beneficial outcome after TAVI, independent from clinical risk factors and echocardiography-derived parameters.

CONCLUSION

Among the studied hemodynamic parameters T-LVAo provides the highest diagnostic value, whereas ET is an outcome predictor beyond clinical risk factors and echocardiographic parameters in AS patients following TAVI. These parameters could be of considerable use in diagnostic evaluation and risk assessment of patients scheduled for TAVI. T-LVAo (yellow): defined as time between left ventricular and aortic systolic pressure peaks. ET (green): Ejection Time defined as time from the start to flow end. AT (orange): Acceleration time defined as time from the start to the peak flow. AOP: aortic pressure, AVC: aortic valve calcification, CI: confidence interval, HGAS: high-gradient aortic stenosis, LGAS: low-gradient aortic stenosis, LVP: left ventricular pressure, SD: standard deviation.

Stroke events after transcatheter aortic valve implantation: Temporal relationships and affected brain regions

BACKGROUND

Despite continuous improvements in transcatheter aortic valve implantation (TAVI), periprocedural strokes remain a devastating complication. Randomized controlled trials failed to demonstrate a reduction in clinically apparent strokes or mortality after TAVI due to cerebral embolic protection (CEP). To identify potential targets of CEP strategies during TAVI, we evaluated affected brain regions, and temporal patterns of stroke onset in a routine clinical sample.

METHODS AND RESULTS

A total of 3,164 consecutive patients treated with TAVI from 2008 to 2019 at a single center were screened for cerebrovascular events. Affected cerebral regions were determined according to clinical symptoms and brain imaging. Rates of disabling stroke and non-disabling stroke at 30 days were 2.2% and 1.4%, respectively. The frequency of all strokes decreased from 5.0% to 3.0% over time (P = .012). Patients with impaired left-ventricular function (OR 2.19), increased CHA2DS2-VASc (OR 1.39) and moderate/severe spontaneous echo contrast (OR 3.60) had a higher stroke risk. Acute symptom onset occurred during TAVI (19.4%), within 24 hours (40.3%) or later (25.0%); 98.3% of strokes were of ischemic origin. In intraprocedural strokes, 53.2% of lesions were found in locations considered protected by current CEP devices, and 37.5% of patients with intraprocedural strokes were exclusively affected in these areas. Baseline or procedural parameters were not associated with embolic distribution patterns.

CONCLUSIONS

Most strokes occurred early after TAVI - but not necessarily during the procedure - and affected multiple brain regions only partially protected by current CEP devices. Efficient prevention of cerebrovascular events may require strategies beyond the TAVI procedure to minimize stroke risk and additional randomized controlled trials will be required to clarify the role of CEP in efficient stroke prevention during TAVI.

Periprocedural Strategies for Stroke Prevention in Patients Undergoing Transcatheter Aortic Valve Implantation

Cerebrovascular events remain a serious complication in patients undergoing transcatheter aortic valve implantation with an incidence of 2–3% at 30 days. While expanding TAVI to younger low-risk patients, prevention of periprocedural strokes becomes even more important. Different cerebral embolic protection devices have been tested but a clear clinical benefit has not been demonstrated in randomized trials. Due to the multifactorial aetiology with different predisposing factors, stroke prevention should include procedural and periprocedural strategies. This article aims to summarize different approaches and discuss open questions.

Impact of left ventricular outflow tract calcification in patients undergoing transfemoral transcatheter aortic valve implantation

BACKGROUND

Left ventricular outflow tract (LVOT) calcification is known to be associated with adverse outcomes after transcatheter aortic valve implantation (TAVI) in patients receiving first-generation transcatheter heart valves (THV).

AIMS

The aim of the present study was to assess the prevalence of LVOT calcification as well as its impact on outcomes in a contemporary TAVI patient cohort.

METHODS

This retrospective single-centre analysis includes 1,207 patients who underwent transfemoral TAVI between 2012 and 2018 and in whom adequate contrast-enhanced multislice computed tomgraphy (MSCT) imaging for quantification of LVOT calcification was available.

RESULTS

Significant LVOT calcification, defined as >10 mm³, was present in 37.4% (n=451) of the patient cohort. After applying propensity score matching there was no difference between patients without (w/o; n=358) and with (w; n=358) significant LVOT calcification with respect to baseline clinical characteristics. At 30 days, the composite of all-cause mortality and non-disabling/disabling stroke occurred more often in patients w LVOT calcification compared to those w/o (4.6 vs 10.1%, p=0.008). Moreover, the composite VARC-3 endpoint of device success at 30 days was in favour of patients w/o LVOT calcification (82.2% vs 73.4%, p=0.007). According to Kaplan-Meier analysis, all-cause mortality one year after TAVI was higher in patients w vs w/o LVOT calcification (12.9 vs 21.4 %, p=0.004).

CONCLUSIONS

In patients undergoing TAVI, the presence of significant LVOT calcification is common and associated with worse short-term clinical and functional outcomes as well as higher one-year mortality rates compared to patients w/o LVOT calcification.

Diagnostic value and prognostic impact of various invasively derived hemodynamic parameters in patients with severe aortic stenosis undergoing TAVI

Background

Ejection time (ET) and Acceleration time (AT) have been described as echocardiographic markers for aortic stenosis (AS).1 Moreover, in a recent study time between invasively measured left ventricular and aortic systolic pressure peaks (T-LVAo) was associated with anatomic AS severity.2 However, the diagnostic value of these parameters has not been validated in a larger patient cohort and their prognostic impact in AS patients undergoing transcatheter aortic valve implantation (TAVI) remains unknown.

Purpose

We aimed to assess the diagnostic value and prognostic impact of ET, AT, and T-LVAo as assessed by invasive measurements in patients undergoing TAVI for severe AS.

Methods

This retrospective single-centre analysis studied 1478 patients undergoing TAVI from 2014 to 2019 for severe AS. All patients received echocardiographic, multislice computed tomography (MSCT) and invasive hemodynamic evaluation with simultaneous pressure measurements in left ventricle and aorta prior to TAVI. Anatomic AS severity was assessed according to MSCT-derived aortic valve calcification density (AVCd) defined as calcium volume per annulus area. All hemodynamic parameters were calculated offline using a dedicated software.

Results

Median patients' age was 81.2 (76.8–84.7) years and 807 (54.6%) were women. Predicted operative risk for mortality was 3.8 (2.6–5.7)% according to STS Score. Medians of invasively derived parameters were 70.0 ms (46.0–98.0) for T-LVAo, 308.0 ms (276.0–336.0) for ET, 180.0 ms (146.0–206.0) for AT. In spline analysis correlation of T-LVAo (Spearman: r=0.35; p&lt;0.001) and ET (Spearman: r=0.18; p&lt;0.001) with AVCd was significant but weak. AT showed negligible correlation with ACVd (Spearman: r=−0.05; p=0.089). The optimal cutoff for death (CD) according to C-statistic was 274 ms for ET and 158 ms for AT. Patients with ET or AT ≥ CD showed lower short and mid-term mortality rates compared to patients with ET or AT &lt; CD (ET ≥ vs. &lt; CD: mortality at 1-year: 14.5 vs. 31.9%, 3-years: 28.3 vs. 53.5%, all p&lt;0.001; AT ≥ vs &lt; CD: mortality at 1-year: 15.5 vs. 25.9%, p&lt;0.001, 3-years: 34.0 vs. 41.0%, p=0.0032). Moreover, multivariate analysis for mortality identified ET (HR 0.58 [95% CI 0.43–0.77; p&lt;0.001]) and AT (HR 0.65 [95% CI 0.49–0.86; p=0.0027]) to be associated with beneficial outcome after TAVI, independent from clinical risk factors and echocardiography-derived parameters like LVEF, mean gradient or stroke volume index. In contrast, T-LVAo showed no prognostic impact according to uni- or multivariate analyses.

Conclusion

T-LVAo provides the highest diagnostic value among the investigational hemodynamic parameters, however correlation with AVCd was weak. ET and AT are strong independent outcome predictors beyond clinical risk factors and standard echocardiographic parameters in AS patients following TAVI. Accordingly, use of ET and AT might improve risk assessment in patients scheduled for TAVI.

Funding Acknowledgement

Type of funding sources: None.

Heyde syndrome: prevalence and outcomes in patients undergoing transcatheter aortic valve implantation

Background

Heyde syndrome (HS) is known as the association of severe aortic stenosis (AS) and recurrent gastrointestinal bleeding (GIB) from angiodysplasia. Data on the prevalence of HS and results after TAVI remain scarce.

Methods

2548 consecutive patients who underwent TAVI for the treatment of AS from 2008 to 2017 were evaluated for a history of GIB and the presence of HS. The diagnosis of HS was defined as a clinical triad of severe AS, a history of recurrent GIB, and an endoscopic diagnosis of angiodysplasia. These patients (Heyde) were followed to investigate clinical outcomes, bleeding complications and the recurrence of GIB and were compared to patients with GIB unrelated to HS (Non-Heyde).

Results

A history of GIB prior to TAVI was detected in 190 patients (7.5%). Among them, 47 patients were diagnosed with HS (1.8%). Heyde patients required blood transfusions more frequently compared to Non-Heyde patients during index hospitalization (50.0% vs. 31.9%, p = 0.03). Recurrent GIB was detected in 39.8% of Heyde compared to 21.2% of Non-Heyde patients one year after TAVI (p = 0.03). In patients diagnosed with HS and recurrent GIB after TAVI, the rate of residual ≥ mild paravalvular leakage (PVL) was higher compared to those without recurrent bleeding (73.3% vs. 38.1%, p = 0.05).

Conclusion

A relevant number of patients undergoing TAVI were diagnosed with HS. Recurrent GIB was detected in a significant number of Heyde patients during follow-up. A possible association with residual PVL requires further investigation to improve treatment options and outcomes in patients with HS.

Graphic abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s00392-021-01905-z.

Early commercial experience with a newly designed balloon-expandable transcatheter heart valve: 30-day outcomes and implications of preprocedural computed tomography

OBJECTIVES

We herein report a single-centre experience with the SAPIEN 3 Ultra balloon-expandable transcatheter aortic valve implantation (TAVI) system.

METHODS

Between March 2019 and January 2020, a total of 79 consecutive patients received transfemoral TAVI using the SAPIEN 3 Ultra device. Data were retrospectively analysed according to updated Valve Academic Research Consortium-2 definitions. Detailed analysis of multislice computed tomography data was conducted to identify potential predictors for permanent pacemaker (PPM) implantation and residual paravalvular leakage (PVL) post TAVI.

RESULTS

Device success and early safety were 97.5% (77/79) and 94.9% (75/79) with resulting transvalvular peak/mean pressure gradients of 21.1 ± 8.2/10.9 ± 4.4 and PVL >mild in 0/79 patients (0%). Mild PVL was seen in 18.9% (15/79) of cases. Thirty-day mortality was 2.5% (2/79). The Valve Academic Research Consortium-2 adjudicated clinical end points disabling stroke, acute kidney injury and myocardial infarction occurred in 1.3% (1/79), 5.1% (4/79) and 0% (0/79) of patients. Postprocedural PPM implantation was necessary in 7.6% (6/79) of patients. Multislice computed tomography analysis revealed significantly higher calcium amounts of the right coronary cusp in patients in need for postprocedural PPM implantation and a higher eccentricity index in patients with postinterventional mild PVL.

CONCLUSIONS

First experience with this newly designed balloon-expandable-transcatheter heart valve demonstrates adequate 30-day outcomes and haemodynamic results with low mortality, low rates of PPM implantation and no residual PVL >mild. The herein-presented multislice computed tomography values with an elevated risk for PPM implantation and residual mild PVL may help to further improve outcomes with this particular transcatheter heart valve in TAVI procedures.

Prevention of coronary obstruction in patients at risk undergoing transcatheter aortic valve implantation: the Hamburg BASILICA experience

OBJECTIVES

This study aimed to assess the clinical outcome of the bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary obstruction (BASILICA) technique in a single-center patient cohort considered at high or prohibitive risk of transcatheter aortic valve implantation (TAVI)-induced coronary obstruction.

METHODS

Between October 2019 and January 2021, a total of 15 consecutive patients (age 81.0 [78.1, 84.4] years; 53.3% female; EuroSCORE II 10.6 [6.3, 14.8] %) underwent BASILICA procedure prior to TAVI at our institution. Indications for TAVI were degeneration of stented (n = 12, 80.0%) or stentless (n = 1, 6.7%) bioprosthetic aortic valves, or calcific stenosis of native aortic valves (n = 2, 13.3%), respectively. Individual risk of TAVI-induced coronary obstruction was assessed by pre-procedural computed tomography analysis. Procedural and 30-day outcomes were documented in accordance with Valve Academic Research Consortium (VARC)-2 criteria.

RESULTS

BASILICA was attempted for single left coronary cusp in 12 patients (80.0%), for single right coronary cusp in 2 patients (13.3%), and for both cusps in 1 patient (6.7%), respectively. The procedure was feasible in 13 patients (86.7%) resulting in effective prevention of coronary obstruction, whilst TAVI was performed without prior successful bioprosthetic leaflet laceration in two patients (13.3%). In one of these patients (6.7%), additional chimney stenting immediately after TAVI was performed. No all-cause deaths or strokes were documented after 30 days.

CONCLUSION

The BASILICA technique appears to be a feasible, safe and effective concept to avoid iatrogenic coronary artery obstruction during TAVI in both native and bioprosthetic valves of patients at high or prohibitive risk. ClinicalTrials.gov Identifier: NCT04227002 (Hamburg AoRtic Valve cOhoRt).

Spontaneous echo contrast, left atrial appendage thrombus and stroke in patients undergoing transcatheter aortic valve implantation

AIMS

The relevance of spontaneous echo contrast (SEC) and left atrial appendage thrombus (LAAT) in patients undergoing transcatheter aortic valve implantation (TAVI) remains unclear. In this study, we aimed to assess the prevalence of SEC and LAAT and evaluate the impact on periprocedural outcome after TAVI.

METHODS AND RESULTS

A total of 2,549 consecutive patients underwent TAVI between 2008 and 2017. After exclusion of cases with insufficient imaging, concomitant procedures or severe intraprocedural complications, 1,558 cases were analysed. Three groups were defined according to (pre)thrombotic formations - moderate or severe SEC (n=89), LAAT (n=53), and reference (n=1,416). The primary outcome was disabling ischaemic stroke within 24 hours. The prevalence was 4.4% for LAAT and 5.4% for moderate/severe SEC. The primary outcome occurred more frequently in patients with moderate/severe SEC (6.8%) compared to the reference (2.1%) and LAAT (1.9%) groups (p=0.020). SEC was identified as an independent risk factor for the primary outcome (OR 3.54 [95% CI: 1.30-9.61], p=0.013). LAAT was associated with an impaired unadjusted one-year survival (43.4%) compared to the SEC (27.3%) and reference groups (18.7%, p<0.001).

CONCLUSIONS

SEC and LAAT were detected in a relevant number of patients undergoing TAVI. SEC may represent an important risk factor for intraprocedural stroke; increased mortality was observed in patients with LAAT.

Prognostic value of the H2 FPEF score in patients undergoing transcatheter aortic valve implantation

Aims

The aim of this study was to assess the prognostic value of the H₂FPEF score in patients undergoing transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS) and preserved left ventricular ejection fraction (EF).

Methods and results

In this multicentre study, a total of 832 patients from two German high‐volume centres, who received TAVI for severe AS and preserved EF (≥50%), were identified for calculation of the H₂FPEF score. Patients were dichotomized according to low (0–5 points; n = 570) and high (6–9 points; n = 262) H₂FPEF scores. Kaplan–Meier and Cox regression analyses were applied to assess the prognostic impact of the H₂FPEF score. We observed a decrease in stroke volume index (−2.04 mL/m²/point) and mean transvalvular gradients (−1.14 mmHg/point) with increasing H₂FPEF score translating into a higher prevalence of paradoxical low‐flow, low‐gradient AS among patients with high H₂FPEF score. One year after TAVI, the rates of all‐cause (low vs. high H₂FPEF score: 8.0% vs. 19.4%, P < 0.0001) and cardiovascular (CV) mortality (1.9% vs. 9.0%, P < 0.0001) as well as the rate of CV mortality or rehospitalization for congestive heart failure (6.4% vs. 23.2%, P < 0.0001) were higher in patients with high H₂FPEF score compared with those with low H₂FPEF score. After multivariable analysis, a high H₂FPEF score remained independently predictive of all‐cause mortality [hazard ratio 1.59 (1.28–2.35), P = 0.018] and CV mortality or rehospitalization for congestive heart failure [hazard ratio 2.92 (1.65–5.15), P < 0.001]. Among the H₂FPEF score variables, atrial fibrillation, pulmonary hypertension, and elevated left ventricular filling pressure were the strongest outcome predictors.

Conclusions

The H₂FPEF score serves as an independent predictor of adverse CV and heart failure outcome among TAVI patients with preserved EF. A high H₂FPEF score is associated with the presence of paradoxical low‐flow, low‐gradient AS, the HFpEF in patients with AS. By identifying patients in advanced stages of HFpEF, the H₂FPEF score might be useful as a risk prediction tool in patients with preserved EF scheduled for TAVI.

Prevalence and prognostic impact of left ventricular outflow tract calcification in patients with severe aortic stenosis undergoing transfemoral TAVI using second-generation devices

Introduction

Left ventricular outflow tract (LVOT) calcification is known to be associated with adverse outcomes after TAVI in patients receiving first-generation transcatheter heart valves (THV). Second-generation THV have been shown to improve outcomes of TAVI patients. Thus, aim of this study is to assess the prevalence of LVOT calcification as well as its impact on procedural and clinical outcomes in patients with severe aortic stenosis undergoing transfemoral TAVI with second-generation THV in a real-world patient cohort.

Methods

In this retrospective single-center analysis patients receiving transfemoral TAVI with second-generation THV for the treatment of aortic stenosis (AS) between 05/2012 and 06/2018 and with adequate CT data were included (n=836). Amount of LVOT calcification was measured quantitatively from contrast-enhanced multislice CT using a dedicated software. Baseline characteristics and outcomes were compared according to presence of significant LVOT calcification (none/≤10 mm3 vs. &gt;10 mm3). Procedural and clinical outcome were assessed in accordance with VARC-2 criteria. All-cause mortality was assessed by Kaplan-Meier method, median follow-up was 1.4 years.

Results

Significant LVOT calcification was present in 37.0% of patients. Patients with LVOT calcification were older (all results as follows without (w/o) vs. with (w) LVOT calcification: 81.4 (77.1, 84.8) vs. 82.3 (78.0, 86.3) years, p=0.006), but presented similar STS scores compared to those without LVOT calcification (5.4±4.7 vs. 5.4±3.5%, p=0.94). Moreover, patients with LVOT calcification had higher mean transvalvular gradients at baseline (30.0 (21.0, 41.0) vs. 37.0 (25.7, 47.0) mmHg, p&lt;0.001) and higher aortic valve calcium volume (380.7 (226.8, 632.1) vs. 663.6 (364.5, 1070.3) mm3, p&lt;0.001). There were no significant differences in rate of device success (97.0 vs. 94.2%, p=0.11), renal failure (2.6 vs. 2.3%, p=1.00), myocardial infarction (0.9 vs. 1.2%, p=1.00) or rate of permanent pacemaker implantation at 30 days after TAVI (16.6 vs. 17.2%, p=0.91). However, rate of TIA/stroke was significantly higher in patients with LVOT calcification (2.1 vs. 6.2%, p=0.0098). Furthermore, patients with LVOT calcification had a higher rate of more than mild paravalvular leakage at discharge (3.8 vs. 7.6%, p=0.033). Rate of 1 year all-cause mortality (17.8 vs. 21.2%, p=0.23) was not significantly different between both groups.

Conclusions

Significant LVOT calcification is present in a substantial proportion of patients receiving TAVI. In such patients, higher rates of cerebrovascular events and more than mild PVL occurred compared to those without significant LVOT calcification even with currently available second-generation THV. Although these findings did not translate into higher mortality rates in the present study, they underline the need for further optimization of THV technology in order to improve outcomes among all TAVI patients.

Figure 1. 1-year mortality

Funding Acknowledgement

Type of funding source: None

The adverse impact of HFpEF in patients with aortic stenosis: evaluation of the H2FPEF score for risk assessment among patients with preserved ejection fraction undergoing TAVI

Background

The H2FPEF score enables identification of patients with high probability of prevalent heart failure with preserved ejection fraction (HFpEF). High H2FPEF scores have proven to be associated with adverse outcome in patients with known HFpEF.

Objective

The aim of this study was to assess the prognostic impact of the H2FPEF score in patients undergoing Transcatheter Aortic Valve Implantation (TAVI) for severe aortic stenosis (AS) and preserved left ventricular ejection fraction (EF).

Methods

In this multi-centre study a total of 832 patients from two German high-volume centres, who received TAVI for severe AS and preserved EF (≥50%), were identified for calculation of the H2FPEF score. Score variables included BMI &gt;30 kg/m2, arterial hypertension, atrial fibrillation, systolic pulmonary artery pressure &gt;31 mmHg, age &gt;60 years, and invasively assessed elevated LV filling pressure. Patients were dichotomized according to low (1–5 points; n=570) and high H2FPEF scores (6–9 points; n=262). Kaplan-Meier and Cox regression analyses were applied to assess the prognostic impact of the H2FPEF score. Median follow-up time was 1.08 years.

Results

Patients presenting with high H2FPEF scores had higher prevalence of moderate to severe mitral and tricuspid regurgitation compared to those with low H2FPEF scores. Stroke volume index (SVI) (Figure 1A) and mean transvalvular gradient (Pmean) consistently decreased with increasing H2FPEF score. All-cause mortality 30 days after TAVI was significantly higher in patients with high H2FPEF scores (p&lt;0.0001). This finding was consistent both after 1 year (p&lt;0.0001) and 3 years (p&lt;0.0001) (Figure 1B). Multivariate analysis revealed a high H2FPEF score to be independently predictive for all-cause mortality (HR 1.62, 95% CI: 1.11–2.38, p=0.013). Among the single H2FPEF score parameters atrial fibrillation was the strongest independent predictor of adverse outcome.

Conclusion

An elevated H2FPEF score of ≥6 is independently predictive for mortality in patients with preserved EF undergoing TAVI for severe AS, which might be due to a higher proportion of paradoxical low flow low gradient AS in these patients. Our findings provide evidence that the H2FPEF score may help identify AS patients with preserved ejection fraction that are at higher risk for adverse outcome after TAVI.

Spline/SVI (A) and 3y-mortality KM (B)

Funding Acknowledgement

Type of funding source: None

TAVR for low-flow, low-gradient aortic stenosis: Prognostic impact of aortic valve calcification

BACKGROUND

Compared to high gradient aortic stenosis (AS), patients with low-flow, low-gradient AS have higher mortality after transcatheter aortic valve replacement (TAVR), but distinct outcome predictors in this patient subset are yet to be determined. The present study investigated the prognostic impact of aortic valve calcification (AVC) in patients with low-flow, low-gradient AS undergoing TAVR.

METHODS

This retrospective single-center analysis includes all patients undergoing TAVR for severe low-flow, low-gradient AS (n = 526), ie, low EF low gradient AS (LEF-LG AS; n = 290) and paradoxical low-flow, low-gradient AS (PLF-LG AS; n = 236), in whom AVC was quantified from contrast-enhanced multislice computed tomography images. AVC_density was defined as calcium volume per annulus area. Patients were trichotomized according to sex-specific AVC_density tertiles in both subgroups. All-cause mortality was assessed by Kaplan-Meier analyses and independent outcome predictors were determined by multivariable analyses.

RESULTS

In both subgroups, patients with high AVC_density had higher mean transvalvular gradients at baseline and higher rates of PVL after TAVR. High AVC_density was associated with lowest 1- and 3-year mortality after TAVR in the LEF-LG AS but not in the PLF-LG AS group. According to multivariable analysis AVC_density was independently associated with better survival in LEF-LG AS patients (HR 0.73 [0.60-0.88], P = .0011), but not in those with PLF-LG AS (HR 0.91 [0.73-1.14], P = .42).

CONCLUSIONS

Quantification of AVC may not only be of diagnostic but also of prognostic value, as it facilitates the selection of LEF-LG AS patients with higher probability of beneficial outcome after TAVR.

Role of active nanoliposomes in the surface and bulk mechanical properties of hybrid hydrogels

Nanoliposomes are widely used as delivery vehicles for active compounds. Nanoliposomes from rapeseed phospholipids were incorporated into interpenetrating polymer network hydrogels of gelatin methacryloyl and alginate. The multiscale physicochemical properties of the hydrogels are studied both on the surface and through the thickness of the 3D network. The obtained composite hydrogels exhibited strong mechanical properties and a highly porous surface. The blend ratio, as well as the concentration of nanoliposomes, affects the properties of the hydrogels. Nanofunctionalized hydrogels induced keratinocyte ​growth. These advantageous characteristics may open up many applications of the developed hydrogels in drug delivery and tissue engineering.

P3470Comparative effectiveness and safety of non-vitamin K oral anticoagulants and warfarin in non-valvular atrial fibrillation - a cohort study in 3 Nordic countries

Background

Non-vitamin K oral anticoagulants (NOACs) are an alternative to warfarin in the prevention of stroke in non-valvular atrial fibrillation (NVAF). Nordic countries have high quality of warfarin treatment, making them an especially suitable setting for assessing effectiveness and safety of NOACs against warfarin.

Purpose

The BEYOND Pooled (BEnefit of NOACs studY of nOn-valvular AF patieNts in NorDic countries) study compared risks of ischaemic or haemorrhagic stroke/systemic embolism (S/SE), and risk of bleeding with acute hospitalisation with an overnight stay (bleeding) in NVAF patients treated with apixaban, dabigatran or rivaroxaban, each compared with warfarin treatment.

Methods

A cohort study of treatment-naïve adult NVAF patients dispensed apixaban, dabigatran, rivaroxaban or warfarin was identified from 01 Jan 2013 to 31 Dec 2016. The population and study variables were identified from national registries in Denmark, Norway and Sweden. After 1:1 propensity score (PS) matching for each NOAC-warfarin comparison, individual-level data were pooled across the countries. Cox proportional-hazards regression was used to estimate adjusted hazard ratios (aHRs) of the endpoints.

Results

PS matched NOAC cohort sizes were: apixaban (55,696) dabigatran (28,526) and rivaroxaban (30,701), and the total follow-up in the PS-matched population was 291,171 years (mean 1.3 years). During the follow-up, 35,450 oral anticoagulation (OAC) patients had a S/SE and 38,620 OAC patients had bleeding. Adjusted HRs for the two endpoints are presented in the table. PH assumption has not been formally tested but cum incidence curves did not indicate substantial differences in the effects over time.

Table 1. Adjusted hazard ratios (aHR) of stroke/systemic embolism and bleeding for non-vitamin K oral anticoagulants versus warfarin Endpoint Apixaban vs Warfarin: aHR (95% CI) Dabigatran vs Warfarin: aHR (95% CI) Rivaroxaban vs Warfarin: aHR (95% CI) Stroke/SE 0.93 (0.85–1.03) 0.89 (0.80–1.00) 0.97 (0.88–1.08) Bleeding 0.72 (0.67–0.77) 0.87 (0.80–0.95) 1.12 (1.04–1.20)

Conclusions

Relative to warfarin, apixaban and dabigatran were associated with lower rates of bleeding whereas rivaroxaban was associated with a higher rate. The three NOACs had comparable rates of stroke and systemic embolism relative to warfarin.

Acknowledgement/Funding

This study was funded by the Pfizer/Bristol-Myers Squibb Alliance.

P3858High H2FPEF score is an independent predictor of adverse outcome in patients with severe aortic stenosis and preserved ejection fraction undergoing TAVR

Background

Recently, the H2FPEF score has been developed in an evidence-based approach relying on simple clinical and echocardiographic variables. It enables the identification of patients with high probability of prevalent heart failure with preserved ejection fraction (HFpEF) which is associated with a dismal prognosis. Left ventricular diastolic dysfunction, a key mechanism in HFpEF, is also a common finding in patients with severe aortic stenosis.

Objective

To assess the prognostic impact of the H2FPEF score in patients with preserved ejection fraction and severe aortic stenosis undergoing Transcatheter Aortic Valve Replacement (TAVR).

Methods

Among 1148 patients with preserved ejection fraction who received TAVR at our institution between 2013 and 2018, data for calculation of the H2FPEF score was available in 535 patients. Score variables include BMI >30 kg/m2, arterial hypertension, atrial fibrillation, pulmonary hypertension >35 mmHg, age >60 years, and elevated LV filling pressure. Patients were dichotomized according to “low” (1–5 points; n=377) and “high” H2FPEF scores (6–9; n=158). Kaplan-Meier survival curves and Cox regression analyses were used to assess the prognostic impact of H2FPEF scores. Median follow-up time was 0.3 years.

Results

TAVR patients presenting with high H2FPEF scores had higher prevalence of moderate to severe mitral regurgitation (19.4% vs. 33.6%, p<0.001) as well as tricuspid regurgitation (15.2% vs. 35.1%, p<0.001), and presented with lower stroke volume index (42.2 ml/m2 vs. 36.0 ml/m2, p<0.001) compared to those with low H2FPEF scores. All-cause mortality one year after TAVR was significantly higher in patients in the high H2FPEF score group (10.5% vs. 21.0%, p=0.0019, Figure 1). Multivariate analysis revealed a high H2FPEF score to be independently predictive for 1-year all-cause mortality (HR 2.66, 95% CI: 1.41–5.02, p=0.025). Among the single H2FPEF score variables, atrial fibrillation (HR 3.45, 95% CI: 1.86–6.40, p<0.001) and systolic pulmonary hypertension >55 mmHg (HR=2.68, 95% CI: 0.97–7.40, p=0.057) were strong independent predictors of adverse outcome.

Figure 1. All-cause mortality of patients undergoing TAVR after one year stratified by low (1–5 points) and high (6–9) H2FPEF score

Conclusion

An elevated H2FPEF score of >6 is independently predictive for mortality in patients with preserved ejection fraction undergoing TAVR for severe aortic stenosis. Our findings provide evidence that the H2FPEF score, which was meant for diagnostic use originally, is able to serve as a prognostic tool in patients with preserved ejection fraction undergoing TAVR, highlighting the adverse impact of diastolic dysfunction in patients with preserved ejection fraction and aortic stenosis.

P1848Prevalence and outcomes in patients with Heyde syndrome after transcatheter aortic valve implantation, a single centre experience

Introduction

Heyde syndrome is known as the association of severe aortic stenosis (AS) and recurrent gastrointestinal bleeding (GIB) from angiodysplasia. To date only few data exist regarding the prevalence of Heyde syndrome and results after transcatheter aortic valve implantation (TAVI) for the treatment of AS.

Purpose

We sought to evaluate the prevalence of Heyde syndrome in a routine clinical cohort of patients undergoing TAVI and analyze the effectiveness of treatment of AS regarding recurrent GIB in these patients.

Methods

We conducted a retrospective single-center analysis of 2545 consecutive patients who underwent TAVI for the treatment of AS in 2008–2017. Patients with a history of GIB were identified. The diagnosis of Heyde syndrome was defined as a clinical triad of presence of severe AS, a history of recurrent GIB, and an endoscopic diagnosis of angiodysplasia. GIB of unknown origin or related to other causes was defined as bleeding unrelated to angiodysplasia. Clinical outcomes of patients with Heyde syndrome were evaluated with emphasis on bleeding complications and recurrence of GIB.

Results

A history of GIB prior to TAVI was detected in 190 patients (7.5%) of the TAVI cohort. Among them, 143 patients had a GIB unrelated to angiodysplasia (5.6%) and 47 patients (1.8%) were diagnosed with Heyde syndrome. Median age and STS-PROM were 80.7 (75.3, 84.0) years and 4.7 (2.7, 9.0) respectively in Heyde patients. TAVI was successfully performed in all cases (66% endovascular access, 34% transapical access). The effective orifice areas increased from 0.8±0.1 cm2 to 2.1±0.5 cm2. Periprocedural major/life-threatening bleeding was found in 6 patients (12.8%), mainly access-related and none due to GIB. In 51% of Heyde-patients transfusion of 4.5±5.7 packed red blood cells was required during the index hospitalisation. During a mean follow-up of 12 months, recurrent GIB after TAVI was detected in 32% of patients with Heyde syndrome. In contrast only 18% of patients with GIB unrelated to angiodysplasia (Non-Heyde) had recurrent GIB after TAVI. In patients diagnosed with Heyde syndrome and recurrent GIB after TAVI the rate of residual mild or moderate paravalvular regurgitation was higher compared to those with an unremarkable course (73% vs. 37%, p=0.045).

Figure 1. 1-year Follow-Up

Conclusions

A relevant number of patients presenting for treatment of AS can be diagnosed with Heyde syndrome. In these patients TAVI can be successfully performed with moderate incidence of periprocedural bleeding complications but significant transfusion rates. Regardless of successful treatment of AS, recurrent GIB was detected in a significant number of Heyde patients during follow-up. The possible association with residual paravalvular regurgitation requires further investigation to improve treatment options in patients with Heyde syndrome.

Virus Infection and Blood Coagulation

By means of a new model, the fowl plague of chickens, further evidence is given that viruses may trigger blood coagulation. Macroscopically, hemorrhages were observed, whereas microscopic studies revealed platelet and fibrin thrombi in the small vessels of various organs. Hematologic studies demonstrated an increase in the clotting time and a decrease in the activities of clotting factors I, II, VIII and X, and drop in platelet counts. Heparin could diminish the hemorrhages but did not influence the survival time of the animals.

Comparison of latest generation transfemoral self-expandable and balloon-expandable transcatheter heart valves

OBJECTIVES

We herein aimed to compare acute 30-day outcomes of latest-generation self-expandable and balloon-expandable transcatheter heart valves.

METHODS

From 2012 through 2016, 104 consecutive patients (study group, 69.2% female, 81.7 ± 5.5 years, logEuroSCORE I 15.9 ± 9.3%) received transfemoral transcatheter aortic valve implantation using the Symetis ACURATE neo® transcatheter heart valve. A control group of patients after transfemoral transcatheter aortic valve implantation with the Edwards Sapien 3™ transcatheter heart valve was retrieved from our database and matched to the study group. Data were retrospectively analysed according to updated Valve Academic Research Consortium definitions.

RESULTS

Device success was 94.2% (98 of 104) and 98.1% (102 of 104) in study and control groups, respectively (P = 0.157). All-cause 30-day mortality was 3.9 (4 of 104) vs 0.9% (1 of 104) (P = 0.317). Resultant transvalvular peak/mean gradients and effective orifice area were 14.2 ± 5.7 vs 22.6 ± 6.8 mmHg (P < 0.001)/7.3 ± 2.8 vs 11.8 ± 3.5 mmHg (P < 0.001) and 2.0 ± 0.4 vs 1.7 ± 0.4 cm2 (P = 0.063). Paravalvular leakage ≥moderate was observed in 4.8% (5 of 104) and 1.9% (2 of 104) (P = 0.257). Rate of permanent pacemaker implantation was 10.6% (11 of 104) vs 16.4% (17 of 104) (P = 0.239).

CONCLUSIONS

Next-generation self-expandable transcatheter heart valves preserve superiority in terms of post-interventional haemodynamics without presenting former drawbacks: rate of postoperative permanent pacemaker implantation and severity of residual paravalvular leakage were similar to balloon-expandable transcatheter heart valves.

Comparative analysis of balloon- versus mechanically-expandable transcatheter heart valves considering landing zone calcification

BACKGROUND

The balloon-expandable Sapien 3 (Edwards Lifesciences, Irvine, CA, USA) and the mechanically-expandable Lotus valve (Boston Scientific, Marlborough, MA, USA) are established devices for transcatheter aortic valve implantation. We sought to compare both transcatheter heart valves (THV) under consideration of the extent of THV landing zone calcification.

METHODS

This retrospective analysis includes consecutive patients with severe aortic stenosis treated with Sapien 3 (S3; n=212) or Lotus (n=61) THV via transfemoral access. Outcome was assessed according to VARC II definitions. Rate of paravalvular leakage (PVL), periprocedural stroke, and permanent pacemaker implantation (PPI) was adjusted for THV landing zone calcification as calculated by multi-slice computed tomography.

RESULTS

There was no difference in preoperative risk (all results as follows S3 vs. Lotus: STS-PROM 5.9±5.6% vs. 4.8±2.6%, p=0.14), rate of device success (95.3% vs. 95.1%, p=0.67), 30-day mortality (1.9% vs. 4.9%, p=0.16), periprocedural stroke (1.4% vs. 4.9%, p=0.27), and major access site complications (9.4% vs. 9.8%, p=0.93). PPI was more frequent (19.4% vs. 34.4%, p=0.01) and significant PVL was less frequent (≥mild PVL: 17.6% vs. 3.7%, p=0.04) after Lotus implantation. No association was found between landing zone calcification and periprocedural stroke rate (OR 1.19, 95%CI 0.92-1.54, p=0.17) or need for PPI (OR 1.04, 95%CI 0.91-1.18, p=0.57). The extent of landing zone calcification was associated with risk for PVL ≥mild (OR 1.21, 95%CI 1.03-1.42, p=0.02). After adjusting for landing zone calcification risk for PVL ≥mild was lower with the Lotus valve (OR 0.15, 95%CI 0.02-0.54, p=0.01).

CONCLUSION

Both THVs yield comparable procedural and clinical outcomes except for a higher PPI rate with the Lotus valve, which is independent from the extent of landing zone calcification. The extent of landing zone calcification is associated with an increased risk for PVL for both THV, but is significantly reduced with the Lotus valve.

The wearable cardioverter defibrillator as a bridge to reimplantation in patients with ICD or CRT-D-related infections

Background

The approach to treat device infection in patients with implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy defibrillator (CRT-D) is a challenging procedure. Optimal treatment is complete extraction of the infected device. To protect these patients from sudden cardiac arrest while waiting for reimplantation and to avoid recurrent infection, a wearable cardioverter defibrillator (WCD) seems to be a valuable solution.

Therefore, we investigated the management and outcome of patients with ICD or CRT-D infections using the WCD as a bridge to re-implantation after lead extraction procedures.

Methods

We conducted a retrospective study on consecutive patients who underwent ICD or CRT-D removal due to device-related local or systemic infections. All patients were prescribed a WCD at our center between 01/2012 and 10/2015. All patients returned to our outpatient clinic for regular ICD or CRT-D monitoring initially 1 and 3 months after reimplantation followed by 6-months intervals.

Results

Twenty-one patients (mean age 65.0 ± 8.0 years, male 76.2%) were included in the study. Complete lead extraction was achieved in all patients. While waiting for reimplantation one patient experienced a symptomatic episode of sustained ventricular tachycardia. This episode was converted successfully into sinus rhythm by a single 150 J shock.

Mean follow-up time 392 ± 206 days, showing survival rate of 100% and freedom from reinfection in all patients.

Conclusion

The WCD seems to be a valuable bridging option for patients with ICD or CRT-D infections, showing no recurrent device infection.

Lead extraction with high frequency laser sheaths: a single-centre experience

OBJECTIVES

Extraction of chronically implanted cardiac implantable electrophysiological devices leads can be difficult. Excimer laser-assisted extraction with 40 Hz sheaths has shown good results in challenging cases. In 2012, a new 80 Hz high-frequency laser sheath became available that delivers twice as many pulses per second. Here, we report our clinical experience with the new GlideLight 80 Hz laser sheath.

METHODS

Between January 2012 and August 2016, 292 leads were treated in 151 patients using 80 Hz GlideLight laser sheath. Lead extraction indications included systemic infection or lead endocarditis n =  35 (23.2%), local infection n =  73 (48.3%), lead dysfunction n =  32 (21.2%), system upgrade n =  5 (3.3%), tricuspid regurgitation n =  3 (2.0%) and other indications n =  3 (2.0). All patient-related and procedural data were collected into a database and analysed.

RESULTS

Mean patient's age was 66.2 ± 14.4 years, 73.5% were male. Ninety-one (31.2%) atrial, 159 (54.4%) ventricular and 42 (14.4%) coronary sinus leads had to be extracted. The mean time from initial lead implantation was 98.0 ± 65.2 months. Mean laser treatment time was 67.5 ± 71.3 s, mean laser pulses delivered were 5130 ± 6592. Clinical success was achieved in 99.3% of the cases, while complete procedural success was observed in 96.7%. A failure of extraction was seen in 2 (1.3%) patients. An overall complication rate of 2.0%, including two major (1.3%) and one minor (0.7%) complications, was observed. No periprocedural mortality was seen.

CONCLUSIONS

The new GlideLight high-frequency laser sheath allows for a high safety and efficacy in extraction of chronically implanted pacemaker- and implantable cardioverter-defibrillator leads.

Effect of refrigeration time on the lipid oxidation and fatty acid profiles of catfish (

The effects of refrigeration at 4 °C during 9 days on the quality and stability of catfish oil were evaluated using a change in fatty acid composition by gas chromatography (GC), commonly used analytical indexes (acid and peroxide values), and analysis by Fourier transform infrared (FTIR) spectroscopy. The results revealed that lipid deterioration, hydrolysis and oxidation occurred throughout the cold storage (4 °C). Refrigeration induced the lipolysis of triglycerides by lipases and phospholipases. It also affected the fatty acids composition of the catfish. The progressive loss of unsaturation was monitored by the decrease in the absorbance band at 3012 cm-1 on FTIR spectra and the lowest value was observed in the catfish muscle at 9 days of refrigeration. Eicosapentaenoic C20:5ω3 (EPA) and docosahexaenoic C22:6ω3 (DHA) acids were the polyunsaturated fatty acids most affected during refrigeration. Refrigeration for less than 5 days was found to be the best conditions for the preservation of the catfish.