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Background: Outcomes of transcatheter aortic valve replacement (TAVR) in patients with high-gradient (HG) severe aortic stenosis (AS) and reduced left-ventricular (LV) ejection fraction (EF) are unknown., Methods: Patients undergoing TAVR for native severe AS between 2009 and 2018 were retrospectively included and classified into 3 groups: HG (≥ 40 mm Hg) and preserved EF (≥ 50%), HG low EF (< 50%), and low gradient (LG < 40 mm Hg) low EF. The primary endpoint was a composite of cardiovascular mortality and readmission for heart failure at 1 year after TAVR., Results: Of the 526 patients included, 323 (61%) had HG preserved EF, 69 (13%) had HG low EF, and 134 (26%) had LG low EF. HG low EF group had higher prevalence of atrial fibrillation and heart failure and higher Society of Thoracic Surgeons score compared with the HG preserved EF group. Patients in the LG low EF group were older and had higher prevalence of coronary artery disease compared with those in the HG groups. All-cause mortality at 30 days (4.0%) was similar across the 3 groups. After adjustment, the risk of primary endpoint was similar in the HG low-EF vs preserved EF groups. Conversely, the risk of primary endpoint was higher in the LG low EF group vs the HG preserved EF group (hazard ratio [HR], 2.24; 95% confidence interval [CI],1.36-3.70; P = 0.002) and vs HG low EF group (HR, 3.50; 95% CI, 1.55-7.90; P = 0.003), whereas the risk of all-cause mortality was similar across the 3 groups., Conclusions: The outcome of patients with HG low EF severe AS following TAVR is as good as that of patients with HG preserved EF., (Copyright © 2020 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Valvular heart calcification is common in patients with chronic kidney disease (CKD), especially in those receiving hemodialysis therapy, and it is associated with poor prognosis. Furthermore, progression of valvular heart disease (VHD) and structural valve deterioration of bioprosthetic valves are faster in these patients. Mechanisms involved in the pathophysiology of VHD are similar between patients with and without impaired kidney function, but CKD is associated with a bone metabolism dysregulation, which might lead to a procalcifying phenotype within vessels and heart valves. CKD is also associated with left ventricular remodelling and dysfunction, which might contribute to increase the risk of heart failure and death in patients with VHD. Even if promising pharmacotherapeutic avenues are in development, no medical treatment can prevent or reduce the valvular calcific process. Patients with advanced CKD should undergo transthoracic echocardiography for detection of VHD, and if present, follow-up should be more frequent than what is recommended in the guidelines. Transcatheter valve replacement might be preferred over surgical replacement in patients with CKD and severe aortic valve stenosis., (Copyright © 2019 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: Limited studies reported the rate and clinical impact of peridevice leaks (PDL) after percutaneous left atrial appendage closure (LAAC)., Methods: All consecutive patients with a nonvalvular atrial fibrillation admitted for LAAC between November 2011 and October 2016 were prospectively enrolled. The follow-up included clinical, transesophageal echocardiography, and/or cardiac computed tomography angiogram (CCTA). PDL was defined by the presence of contrast within the left atrial appendage on CCTA, and Major Adverse Cardiac Event (MACE) included stroke, device-related thrombosis, and cardiovascular death., Results: Overall, 77 patients (mean CHA 2 DS 2 -VASc score = 4.4 ± 1.5 and mean HAS-BLED = 3.4 ± 1.1) were implanted using Amplatzer Cardiac Plug (n = 24), Amulet (n = 37), or Watchman devices (n = 16). Indications were stroke recurrence despite adequate oral anticoagulation (OAC, n = 6) or contraindication to long-term OAC (n = 71). From 3-month to 12-month CCTA follow-up, the PDL rate decreased from 68.5% to 56.7% (P = 0.02), without any difference between the various devices. Patients with PDL were more often in permanent atrial fibrillation, and had a larger landing zone diameter, a lower ratio of device compression, and a more frequent off-axis position of the device. A device compression ratio < 10% was the only parameter associated with PDL occurrence. During follow-up (median 236 days) the MACE rate was 9.1%, with no statistically significant difference between patients with vs without PDL (12% vs 4.3%, P = 0.3)., Conclusions: The PDL rate detected by CCTA after LAAC was high, especially in cases with a low device compression ratio (< 10%), but decreased over time. The incidence of MACE was quantitatively greater with PDL, but the difference was not statistically significant. Larger studies are needed to determine the clinical importance of PDL., (Copyright © 2018 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: Various cardiovascular magnetic resonance (CMR) imaging indices are used to assess pulmonary hypertension (PH; mean pulmonary artery pressure ≥ 25 mm Hg). We compared the value of CMR indices to diagnose precapillary PH in treatment-naive patients evaluated for the first time for known or suspected pulmonary vascular disease., Methods: Right heart catheterization and CMR were performed within 48 hours of each other in 85 consecutive subjects. The tricuspid annular plane systolic excursion, right ventricular (RV) fractional area change (RVFAC), RV ejection fraction, systolic eccentricity index, and RV end-diastolic area over left ventricular end-diastolic area ratio were calculated. The pulmonary artery trunk diameter, main pulmonary artery relative area change, and mean flow velocity were also calculated., Results: There were 20 non-PH subjects (14 women/6 men, 55 ± 14 years of age, mean pulmonary artery pressure [mPAP] = 20 ± 4 mm Hg) and 65 precapillary PH subjects (32 women/33 men, 60 ± 15 years of age; P = not significant; mPAP = 46 ± 12 mm Hg; 54% with chronic thromboembolic PH). All CMR indices showed essentially the same (good) value to rule in precapillary PH. The RV end-diastolic area over left ventricular end-diastolic area ratio and RVFAC, which are relatively easy to measure, had a large area under the receiver operating characteristic curve (0.93, with optimal cut-off > 0.96, and 0.92, with optimal cut-off ≤ 35%, respectively), not significantly different from RV ejection fraction. In addition, RVFAC > 45% was documented in none of 65 PH and in 10 of 20 non-PH; thus, in a population similar to ours, RVFAC measurement could potentially have avoided unnecessary catheterization in 50% of non-PH subjects., Conclusions: In treatment-naive subjects in whom pulmonary vascular disease is highly suspected, right-sided CMR indices distinguish between PH and non-PH patients. RVFAC might have particular value in excluding precapillary PH., (Copyright © 2015 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)