Search

IMPORTANCE: Transcatheter aortic valve replacement (TAVR) failure is often managed by an urgent implantation of a supplementary valve during the procedure (2-valve TAVR [2V-TAVR]). Little is known about the factors associated with or sequelae of 2V-TAVR. OBJECTIVE: To examine the incidence, causes, and outcomes of 2V-TAVR. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study was performed using data from an international registry of 21 298 TAVR procedures performed from January 1, 2014, through February 28, 2019. Among the 21 298 patients undergoing TAVR, 223 patients (1.0%) undergoing 2V-TAVR were identified. Patient-level data were available for all the patients undergoing 2V-TAVR and for 12 052 patients (56.6%) undergoing 1V-TAVR. After excluding patients with missing 30-day follow-up or data inconsistencies, 213 2V-TAVR and 10 010 1V-TAVR patients were studied. The 2V-TAVR patients were compared against control TAVR patients undergoing a 1-valve TAVR (1V-TAVR) using 1:4 17 propensity score matching. Final analysis included 1065 (213:852) patients. EXPOSURES: Urgent implantation of a supplementary valve during TAVR. MAIN OUTCOMES AND MEASURES: Mortality at 30 days and 1 year. RESULTS: The 213 patients undergoing 2V-TAVR had similar age (mean [SD], 81.3 [0.5] years) and sex (110 [51.6%] female) as the 10 010 patients undergoing 1V-TAVR (mean [SD] age, 81.2 [0.5] years; 110 [51.6%] female). The 2V-TAVR incidence decreased from 2.9% in 2014 to 1.0% in 2018 and was similar between repositionable and nonrepositionable valves. Bicuspid aortic valve (odds ratio [OR], 2.20; 95% CI, 1.17-4.15; P = .02), aortic regurgitation of moderate or greater severity (OR, 2.02; 95% CI, 1.49-2.73; P < .001), atrial fibrillation (OR, 1.43; 95% CI, 1.07-1.93; P = .02), alternative access (OR, 2.59; 95% CI, 1.72-3.89; P < .001), early-generation valve (OR, 2.32; 95% CI, 1.69-3.19; P < .001), and self-expandable valve (OR, 1.69; 95% CI, 1.17-2.43; P = .004) were associated with higher 2V-TAVR risk. In 165 patients (80%), the supplementary valve was implanted because of residual aortic regurgitation after primary valve malposition (94 [46.4%] too high and 71 [34.2%] too low). In the matched 2V-TAVR vs 1V-TAVR cohorts, the rate of device success was 147 (70.4%) vs 783 (92.2%) (P < .001), the rate of coronary obstruction was 5 (2.3%) vs 3 (0.4%) (P = .10), stroke rate was 9 (4.6%) vs 13 (1.6%) (P = .09), major bleeding rates were 25 (11.8%) vs 46 (5.5%) (P = .03) and annular rupture rate was 7 (3.3%) vs 3 (0.4%) (P = .03). The hazard ratios for mortality were 2.58 (95% CI, 1.04-6.45; P = .04) at 30 days, 1.45 (95% CI, 0.84-2.51; P = .18) at 1 year, and 1.20 (95% CI, 0.77-1.88; P = .42) at 2 years. Nontransfemoral access and certain periprocedural complications were independently associated with higher risk of death 1 year after 2V-TAVR. CONCLUSIONS AND RELEVANCE: In this cohort study, valve malposition was the most common indication for 2V-TAVR. Incidence decreased over time and was low overall, although patients with a bicuspid or regurgitant aortic valve, nontransfemoral access, and early-generation or self-expandable valve were at higher risk. These findings suggest that compared with 1V-TAVR, 2V-TAVR is associated with high burden of complications and mortality at 30 days but not at 1 year.

ABSTRACTFrailty is a multi-system clinical syndrome characterized by reduced physiological reserve and increased vulnerability to stressors. There is now established evidence recognizing its incremental value as a predictor of suboptimal outcomes in patients undergoing transcatheter aortic valve replacement (TAVR) beyond conventional surgical risk scores and objective frailty assessment is integrated in major guidelines. Several frailty assessment tools have been developed and validated for use in patients undergoing TAVR with varying complexity, clinical pragmatism and outcomes assessed. In contemporary TAVR practice, frailty assessment guides patient selection, informs care requirements, and identifies those who may require supplemental treatment. Further opportunities to improve patient care in this area include identification of interventions that can mitigate the deleterious impact of frailty, evaluation of the role of frailty assessment in low surgical risk patients, and development of frailty management models that can be delivered virtually. In this review, we aim to provide an overview of the concept of frailty, the available assessment tools, peri-procedural considerations in frail patients undergoing TAVR and future directions.

ABSTRACTDegeneration of surgical bioprosthetic heart valves (BPVs) occurs in up to one third of surviving patients within a decade of implantation and is a common cause of cardiovascular morbidity. Valve-in-valve transcatheter aortic valve replacement (VIV TAVR) is a safe and effective treatment for patients with failed BPVs who are unsuitable for reoperation. However, there may be patient-prosthesis mismatch (PPM) following VIV TAVR, particularly in patients with small BPVs. This may influence both morbidity and mortality. Bioprosthetic valve fracture (BVF) has emerged as a novel technique to prevent PPM. It involves high-pressure inflation of a non-compliant balloon to fracture the ring of the BPV, allowing for further expansion of the implanted transcatheter heart valve (THV) and thereby reducing residual transvalvular gradients. Early experience with this technique has been promising. This review will describe the procedural technique of BVF, explore the lessons learned from bench testing and early clinical experience, and discuss the limitations of the current literature as well as future directions.Abbreviations:ACn: ACURATE neo; BPV: Bioprosthetic heart valve; BVF: Bioprosthetic valve fracture; BVR: Bioprosthetic valve remodeling; EOA: Effective orifice area; NYHA: New York Heart Association; PPM: Patient-prosthesis mismatch; PWI: Pin-wheeling index; S3: Sapien 3; SAVR: Surgical aortic valve replacement; TAVR: Transcatheter aortic valve replacement; TPVR: Transcatheter pulmonary valve replacement; THV: Transcatheter heart valve; VIV: Valve-in-valve

Supplemental Digital Content is available in the text.

ABSTRACTBackground:Data concerning transcatheter aortic valve replacement (TAVR) in patients with prior mitral surgery is limited and preliminary reports seem encouraging. We sought to describe TAVR outcomes in the presence of mitral prosthesis.Methods:Clinical, imaging and angiographic records of patients with previous mitral valve surgery who underwent TAVR in three Israeli tertiary hospitals were analyzed. Amongst the patients, 28 received a balloon-expandable valve, nine received a self-expandable valve, and one received a mechanically-expandable valve. Aorto-mitral distance and angle were obtained from reconstructed multi-sliced CT images. Primary endpoint was a composite of procedural mortality, need for a second valve, complete AV block, significant paravalvular leak (PVL), and intensive care unit (ICU) admission > 5 days.Results:Thirty-eight patients (74% women) with a mean age of 76 ± 7 years underwent TAVR. Euroscore2 and Society of Thoracic Surgeons (STS) score were 12 ± 9% and 6 ± 5%, respectively. Mean aorto-mitral distance was 9 ± 1 mm and aorto-mitral angle was 117 ± 14°. Mean TAVR implantation depth was 6.1 ± 3 mm. The composite end-point occurred in 15.8% of patients (n = 6), driven by need for a second valve (n = 1), and by three patients that underwent valve snaring due to mitral valve impingement, complete aortic valve (AV) block, and PVL. The 90-day and 1-year mortality was 8% and 21%, respectively. A statistically significant association (HR = 11.2, 95%CI 2.8–45.5, p= 0.012) was found between low implantation depth (>8 mm) and the composite end-points.Conclusion:TAVR in the presence of mitral valve prosthesis adds to the complexity of the procedure and promotes higher procedural risk. Meticulous pre-procedural anatomic assessment and patient selection are mandatory. Implantation depth of less than 8 mm seems prudent.

ABSTRACTBioprosthetic surgical heart valves (SHVs) tend to degenerate with time, and valve re-operation carries substantial risks. Transcatheter heart valve (THV) implantation into a degenerative biological bioprosthesis (valve-in-valve [ViV] procedure) has evolved as a viable strategy in suitable cases of SHV degeneration, and nearly all heart valves have already been treated using the ViV technique. The creation of an optimal effective orifice area and a sufficient, yet atraumatic, expansion and sealing of the neo-valve (in-valve) apparatus is key for optimal ViV implantation. Several aspects are necessary to achieve this, including a detailed appreciation of the SHV and THV, pre-procedural learning of the anatomy, optimal access selection, and avoidance of any interference with the perivalvular structures. This review based on the authors’ personal experience and an updated review of the literature is aimed at covering contemporary accumulated knowledge of ViV therapeutics in the aortic, mitral, and tricuspid positions, focusing on practical issues and challenges for optimal patient outcomes.

Supplemental Digital Content is available in the text.

Transcatheter aortic valve implantation (TAVI) is recommended for patients with severe symptomatic aortic stenosis (AS) who are at prohibitive/high risk for surgical aortic valve replacement (SAVR). Patients with severe AS may experience acute decompensated heart failure (HF) that is resistant to medical therapy. We report our TAVI experience in treating patients with unstable AS who require urgent intervention for their aortic valve disease.

The choice between mechanical valves (MVs) and bioprosthetic valves (BVs) in patients undergoing aortic valve surgery is complex, requiring a balance between the inferior durability of BV and the indicated long-term anticoagulation therapy with MV. This is especially challenging in the middle age group (< 70 years), which has seen an increased use of BV over recent years.

IMPORTANCE: Chronic kidney disease (CKD) is prevalent in the population of patients undergoing transcatheter aortic valve replacement (TAVR). Data on the association of TAVR with kidney function are scarce, as are data on the relationship between changes in kidney function after TAVR and mortality. OBJECTIVE: To describe the changes in kidney function (both periprocedural and at steady state) after TAVR and to explore the association of TAVR with midterm mortality. DESIGN, SETTING, AND PARTICIPANTS: This single-center, retrospective cohort study was conducted at a public, tertiary academic medical center, which serves as a regional referral center for valvular heart interventions. Consecutive cases of patients undergoing TAVR from November 5, 2008, to December 31, 2019, were included in the study, with available baseline and post-TAVR data on kidney function. EXPOSURES: Steady state (1 month) change in kidney function after TAVR. Significant improvement or deterioration in renal function was defined as a greater than or equal to 10% change in estimated glomerular filtration rate (eGFR). MAIN OUTCOMES AND MEASURES: Overall mortality at 2-year follow-up. RESULTS: A total of 894 patients (mean [SD] age, 82.2 [7.1] years; 452 women ([51.2%]) were evaluated. A total of 362 patients (40.5%) were treated from 2017 to 2019, 348 patients (38.9%) were treated from 2013 to 2016, and 184 patients (20.5%) were treated from 2008 and 2012. Patients had a mean (SD) Society of Thoracic Surgeons (STS) score of 5.2% (4.0%) and a mean (SD) eGFR of 65.1 (23.1) mL/min/1.73 m2. Acute kidney injury occurred in 115 (11.1%) patients by 48 hours, of whom 73 (63.5%) resolved by discharge. One month after TAVR, eGFR improved by at least 10% in 329 patients (36.8%) and deteriorated by at least 10% in 233 patients (26.1%). Overall, CKD stage remained stable or improved in 720 patients (80.6%), and only 5 patients (0.97%) progressed to stage 5 CKD 1 month after TAVR. A deterioration of 10% or greater in eGFR 1 month after TAVR was associated with a hazard ratio of 2.16 (95% CI, 1.24-5.24; P?=?.04) at 2-year mortality. Patients who showed CKD status resolution (eGFR improvement to >60 mL/min/1.73 m2 after TAVR) had a similar 2-year mortality to those with baseline eGFR greater than 60 mL/min/1.73 m2 and vice versa. Factors associated with steady state CKD status resolution after TAVR included lower STS score, higher left ventricular ejection fraction, higher baseline eGFR, no acute kidney injury at discharge from the TAVR admission, and lower contrast-eGFR ratio. CONCLUSIONS AND RELEVANCE: In this cohort study, kidney outcomes after TAVR were reassuring; greater than 80% of patients showed stable or improved kidney function 1 month after the procedure. Improvement in kidney function was associated with a lower 2-year mortality, whereas deterioration in kidney function was associated with increased mortality. Our data suggest that cardiorenal syndrome was a possible cause of CKD in patients in need of TAVR and that there was potential for improvement in both renal and cardiac function after this procedure.

Supplemental Digital Content is available in the text.

Introduction:Randomized clinical trials demonstrated the benefits of percutaneous coronary interventions (PCI) in diverse clinical settings. Patients with cancer were not included in these studies.Methods:Literature search of PubMed, Cochrane, Medline, SCOPUS, EMBASE and ClinicalTrials was conducted to identify studies that assessed one-year all-cause, cardiovascular and non-cardiovascular mortality in patients with historical or active cancer. Using the random effects model, we computed risk ratios (RR) and standardized mean differences and their 95% confidence intervals for the dichotomous and continuous measures and outcomes, respectively.Results:Overall, 171 articles were evaluated and 5 studies were included in this meta-analysis. In total, 33, 175 patients receiving PCI were analyzed, of whom 3, 323 patients had cancer and 29, 852 with no cancer history. Patients in the cancer group had greater all-cause mortality [RR 2.22 (1.51-3.26; p <0.001)] (Figure 1A), including cardiovascular mortality [RR 1.34 (1.1-1.65; p=0.005)] (Figure 1B) and non-cardiovascular mortality [RR 2.93 (1.32-6.49; p=<0.008)] (Figure 1C), at one-year compared to non-cancer patients. Patients in the cancer group had greater one-month all-cause mortality [RR 2.01 (1.24-3.27; p=0.005)] and greater non-cardiovascular mortality [RR 5.77 (3.07-10.86; p=<0.001)]butno difference in one-month cardiovascular mortality between the two groups.Meta-regression analysis showed the difference in all-cause and cardiovascular one-year mortality between both groups of patients were not attributable to differences in baseline characteristics, index PCI characteristics, or medications prescribed at discharge.Conclusions:Patients with cancer undergoing PCI have worse mid-term outcomes compared to non-cancer patients. Cancer patients should be managed by a multi-specialist team, in an effort to close the mortality gap.

Supplemental Digital Content is available in the text.