Hemodynamic implications of mitral annular calcification in patients undergoing transcatheter aortic valve implantation for severe aortic stenosis

PURPOSES

Predicting hemodynamic changes of stenotic mitral valve (MV) lesions with mitral annular calcification (MAC) following transcatheter aortic valve implantation (TAVI) may inform clinical decision-making. This study aimed to investigate the association between the MAC severity quantified by computed tomography (CT) and changes in mean transmitral gradient (mTMG), mitral valve area (MVA) and stroke volume index (SVi) following TAVI.

METHODS AND RESULTS

A total of 708 patients (median age 81, 52% male) with severe aortic stenosis (AS) underwent pre-procedural CT and pre- and post-TAVI transthoracic echocardiography. According to the classification of MAC severity determined by CT, 299 (42.2%) patients had no MAC, 229 (32.3%) mild MAC, 102 (14.4%) moderate MAC, and 78 (11.0%) severe MAC. After adjusting for age and sex, there was no significant change in mTMG following TAVI (Δ mTMG = 0.07 mmHg, 95% CI -0.10 to 0.23, P = 0.92) for patients with no MAC. In contrast, patients with mild MAC (Δ mTMG = 0.21 mmHg, 95% CI 0.01 to 0.40, P = 0.018), moderate MAC (Δ mTMG = 0.31 mmHg, 95% CI 0.02 to 0.60, P = 0.019) and severe MAC (Δ mTMG = 0.43 mmHg, 95% CI 0.10 to 0.76, P = 0.0012) had significant increases in mTMG following TAVI, with greater changes associated with increasing MAC severity. In contrast, there was no significant change in MVA or SVi following TAVI.

CONCLUSION

In patients with severe AS undergoing TAVI, MAC severity was associated with greater increases in post-procedural mTMG whereas MVA or SVi remained unchanged. MAC severity should be considered for potential subsequent MV interventions if TAVI does not improve symptoms.

Aortic regurgitation: A multimodality approach

Aortic regurgitation (AR) is a common valvular pathology. Multimodality noninvasive cardiovascular imaging is routinely used to assess the mechanism of AR, degree, and its hemodynamic impact on the cardiovascular system. Collecting this information is crucial in establishing the prognosis and in guiding patient management and follow-up. While echocardiography remains the primary test to assess AR, a comprehensive assessment of this valvulopathy can be obtained by combining the information from different techniques. This state-of-the-art review is intended to provide an update ed overview of the applications, strengths, and limits of transthoracic echocardiography, cardiac magnetic resonance, and cardiac computed tomography in patients with AR.

Insights into new-onset rhythm conduction disorders detected by multi-detector row computed tomography after transcatheter aortic valve implantation

New-onset rhythm conduction disorders are frequent after transcatheter aortic valve implantation (TAVI). Multidetector row computed tomography may shed light on the pathophysiology of rhythm conduction disorders in patients who undergo TAVI with the Edwards SAPIEN valve. A total of 94 patients (mean age 81 ± 7 years, 48% men) treated with TAVI with the Edwards SAPIEN valve who underwent pre- and post-TAVI multidetector row computed tomography were included. Patients with preexisting right bundle branch block or left bundle branch block (LBBB) and permanent pacemakers were excluded. Pacemaker implantation or new-onset LBBB at 1-month follow-up was the combined end point. Overall, 1 pacemaker was implanted, and 14 cases of new-onset LBBB were recorded. Among several clinical and multi-detector row computed tomographic variables, overexpansion of the transcatheter valve >15% of native annular area (odds ratio 5.277, 95% confidence interval 1.398 to 19.919, p = 0.014) and depth of frame into the left ventricular outflow tract (odds ratio 1.401, 95% confidence interval 1.066 to 1.770, p = 0.010) were independently related to the need for a pacemaker or new-onset LBBB. In conclusion, overexpansion of the transcatheter prosthesis by >15% of native aortic annular area and implantation depth of the frame into the left ventricular outflow tract were independently associated with the need for a pacemaker or new-onset LBBB in patients who underwent TAVI with the Edwards SAPIEN valve.