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An 82-year-old woman was referred for transcatheter aortic valve replacement (TAVR) following hospitalizations for heart failure due to severe aortic stenosis. She was deemed inoperable by the heart team because of her age and her limited mobility due to multiple sclerosis. Pre-procedural computed

Neurological events after transcatheter (TAVR) or surgical aortic valve replacement (SAVR) are potentially devastating and associated with a poor prognosis. With technological improvements and increased operator experience, their incidence is markedly declining, justifying the need for surrogate endpoints to be used in future comparative trials. Moreover, imaging studies after TAVR and SAVR suggest that neurological events are mainly embolic in nature; however, there is significant discrepancy between imaging findings and clinically overt symptoms, raising the possibility of more subtle subclinical cognitive decline. Different modalities have been used to assess both overt and subclinical neurological events after SAVR and TAVR. The purpose of this report is to systematically review and describe currently used imaging, functional, and neurocognitive testing modalities and to better understand how they could be integrated in future prospective studies.

Introduction The proportion of patients with heart failure (HF) and severe tricuspid regurgitation (TR) that are potential candidates for a percutaneous tricuspid valve intervention is unknown. The aim of this study was to evaluate in a real-world setting the echocardiographic characteristics of Heart Failure HF patients with severe TR. Methods This was a retrospective cohort study of 2133adult patients enrolled in the HF clinic at the McGill University Health Center from 2007 to 2017, totaling 10 300 echocardiograms. Included in our study were patientswith a clinical diagnosis of HF and available echocardiographic follow up. All data after heart transplant or ventricular assist device was excluded. The severity of TR was classified according to the American Society of Echocardiography guidelines. All patients who never had severe TR during their follow-up were included in the control group. Results There were 321 patients with severe TR at any time during the follow-up period (mean age 66±16 years; 61% male), whereas 1812 patients did not have severe TR (mean age 60±15 years; 60% male). Among patients with severe TR, left ventricular ejection fraction (LVEF) was low (≤50%) in 76%, compared to the control group in which LVEF was low in 71% (p=0.07). Severe mitral regurgitation (MR) was present in 26% of the severe TR group compared to 5% in the control group (p 50mmHg) was present in 53% of the severe TR group, compared to 20% in control group (p Conclusions In patients with HF, severe TR is associated with worse echocardiographic parameters including severe MR, pulmonary hypertension, RV dilatation and RV systolic dysfunction. Half of patients with severe TR could be eligible for tricuspid valve intervention.

Transcatheter aortic valve implantation (TAVI) is a relatively new technology for the treatment of severe and symptomatic aortic valve stenosis. TAVI offers an alternative therapy for patients unable to be treated surgically because of contraindications or severe comorbidities. It is being rapidly dispersed in Canada, as it is worldwide. The objective of this article is to present our recommendations for the use of TAVI, based on a multidisciplinary evaluation of recently published evidence. We systematically searched and summarized published data (2008-2011) on benefits, risks, and cost-effectiveness of TAVI. We also examined ethical issues and organizational aspects of delivering the intervention. We discussed the soundness and applicability of our recommendations with clinical experts active in the field. The published TAVI results for high-risk and/or inoperable patients are promising in terms of survival, function, quality of life, and cost-effectiveness, although we noted large variability in the survival rates at 1 year and in the frequency of important adverse outcomes such as stroke. Until more data from randomized controlled trials and registries become available, prudence and discernment are necessary in the choice of patients most likely to benefit. Patients need to be well-informed about gaps in the evidence base. Our recommendations support the use of TAVI in the context of strict conditions with respect to patient eligibility, the patient selection process, organizational requirements, and the tracking of patient outcomes with a mandatory registry.

Background: Whether the efficacy and safety of dual antiplatelet therapy (DAPT) are uniform between sexes is unclear. We sought to compare clinical outcomes between short- (≤6 months) versus long-term (≥1 year) DAPT after drug-eluting stent (DES) placement in women and men. Methods and Results: We pooled individual patient data from 6 randomized trials of DAPT (EXCELLENT, OPTIMIZE, PRODIGY, RESET, SECURITY, ITALIC PLUS). The primary outcome was 1-year risk of major adverse cardiac events (MACE). The main secondary outcome was 1-year risk of any bleeding. Out of the 11,473 randomized patients included in the pooled dataset, 3,454 (30%) were females. At 1-year follow-up, women had higher risk of MACE (3.6% vs. 2.8%; P = 0.01) but similar risk of bleeding (1.9% vs. 1.6%; P = 0.16) as compared with men. Compared with long-term DAPT, short-term DAPT was associated with similar rates of MACE in both women (HR 0.88; 95% CI 0.62–1.25) and men (HR 1.25; 95% CI 0.95–1.6; P interaction = 0.08)]. At 1-year follow-up, short-term DAPT was associated with lower rates of bleeding as compared with long-term DAPT in both women (HR 0.84; 95% CI 0.51–1.37) and men (HR 0.58; 95% CI 0.40–0.84; P–interaction = 0.25). The presence of MVD was associated with higher MACE rates in the short-term DAPT group in women (HR: 1.16; CI 0.60–2.23) and men (HR: 2.29; CI 1.22–4.29; P interaction = 0.25). Conclusions: Short-term DAPT is associated with similar rates of MACE but lower risk of bleeding when as compared with prolonged DAPT. There was no significant difference between sexes in the population studied. © 2016 Wiley Periodicals, Inc.

Transcatheter aortic valve implantation (TAVI) has become a well-established intervention with reproducible and excellent early and mid-term outcomes. A minimalist approach to TAVI is already the standard of care in many experienced centers. In this report, we share our experience and opinions on how we can further simplify the TAVI procedure in hope to establish the best possible outcomes.

Purpose: To compare the procedure and safety outcomes of the transradial approach (TRA) with the femoral approach (FA) for treating aortoiliac and femoropopliteal stenoses and occlusions. Methods: A single-center retrospective study was conducted involving 188 patients (mean age 66.4±10.8 years; 116 men) with lower limb claudication or critical limb ischemia who underwent aortoiliac (131, 62.4%) or femoropopliteal (79, 37.6%) interventions on 210 lesions over a 3-year period. Operator discretion determined TRA suitability; exclusions included Raynaud’s disease, upper limb occlusive disease, previous TRA difficulties, or planned hemodialysis. Lesion characteristics, clinical endpoints, and access site complications were compared. Results: FA was used primarily in 123 patients and the TRA (12 left and 53 right radial arteries) in 65 procedures. Eleven (16.9%) TRAs failed vs 9 (7.3%) FAs (p=0.42). Crossover to FA was due to occlusive lesions requiring alternative equipment in 9 cases and to tortuosity of the aortic arch vessels in 2 patients. The 134 FA interventions (balloon angioplasty, stents) were retrograde (112, 83.6%) or antegrade (22, 16.4%). There were significantly more TASC C/D lesions in the FA group (p=0.02). Sheath sizes (5-F to 8-F) did not differ between groups, and no significant differences were found between FA vs TRA in terms of procedure time (50.0±28.9 vs 46.8±25.1 minutes, p=0.50) or length of stay (2.2±0.6 vs 2.1±0.3 days, p=0.24). While there were no strokes, access site complications occurred in 6.0% of the FA patients vs 3.7% of the TRA patients (p=0.12). Conclusion: The transradial approach for aortoiliac and femoropopliteal interventions is safe and efficacious compared with the transfemoral approach for a range of lesion subtypes. Nevertheless, there remains a need for improvements in peripheral device and catheter technology to decrease transradial failure rates.

Although the trans-radial approach (TR) has been applied to various subsets of patients in percutaneous coronary intervention, the feasibility, efficacy, acute procedural and long-term outcomes of TR versus trans-femoral approach (TF) for alcohol septal ablation (ASA) have not yet been determined.The aim of this study was to compare the short and long-term outcomes of ASA with the TR approach compared to the TF approach.We retrospectively analyzed 240 patients who underwent an ASA procedure at our institution from November 1999 to November 2015. The TR approach was performed in 172 cases and the TF approach in the remaining 68 cases.The use of TR approach progressively increased from 62% in 1999-2005 to 91% in 2011-2015 (p=0.0001). The TF and TR group had similar age, baseline NYHA class (NYHA 3 or 4) and mean left ventricular outflow tract peak gradient before ASA. Total contrast used (TR: 73.2±47.2ml; TF: 88.7±49.3ml, p=0.11), total radiation Air kerma area product (TR: 43.7±48.0Gycm(-2); TF: 55.9±48.2Gycm(-2); p=0.39) and peak left ventricular outflow tract gradient immediately after ASA (TR: 19.1±19.6mmHg; TF: 20.4±18.0mmHg, p=0.63) were similar in both groups. Procedural success was 91.9% and 91.2% in the TR and TF groups, respectively (p=0.53). At 30days, there was 2 intra-hospital death (1 in TF and 1 in TR), 1 major stroke in the TF group and 1 coronary artery dissection in the TR group. Vascular complications were less frequent in the TR group (0.58% vs. 7.3%; p=0.002). The mean length of follow-up was 4.56±4.34years (IQR 0.69-8.2; median 2.92years; maximum: 15.5years). By Kaplan-Meier estimate, the observed survival in the overall cohort was comparable to the expected survival for a sex and age-matched comparable general French population at 10years (86.9 vs. 83.6%, p=0.88). Survival was similar between the TR and TF group (92.1% vs. 89.7% at 6years, respectively; p=0.71).Alcohol septal ablation from the radial approach can be performed with similar acute and long-term success, but with lower vascular complications compared to the femoral approach.

Aortic valve calcification has been shown to be associated with short and long term adverse outcomes in small observational datasets of patients undergoing transcatheter aortic valve replacement (TAVR). We sought to examine the associations between aortic valve calcification patterns and other

A 56-year-old man with a history of chest radiation and severe aortic stenosis was transferred to our institution for percutaneous aortic valve replacement. The multislice computed tomography scan showed an aortic annulus measuring 482 cm2 with an area-derived diameter of 24.8 mm and prominent

Aims Transcatheter mitral valve replacement (TMVR) is an emerging technology with the potential to treat patients with mitral regurgitation at excessive risk for mitral valve surgery. Geometrical measurements of the mitral valvular complex may have implications for the design of TMVR devices and for patient selection. This study sought to quantify the dynamic geometry of the mitral valvular complex in patients with significant functional mitral regurgitation (FMR) using multi-slice computed tomography (MSCT). Methods and results MSCT images were acquired in 32 patients with symptomatic, significant FMR. Two independent observers analysed image sets using a dedicated software package and a standard measurement methodology. In patients with FMR, the mean mitral annulus intercommissural and aorto-mural diameters were, respectively, 41.5±5.2 mm and 38.7±5.9 mm in systole, and were 41.5±4.4 mm and 40.0±4.7 mm in diastole. In patients without MR, the diameters were, respectively, 33.6±5.1 mm and 28.8±8.0 mm in systole, and 36.2±4.5 mm and 31.6±7.9 mm in diastole. The obstacle-free zone below the mitral annulus averaged more than 20.0 mm and varied by less than 1 mm between systole and diastole, which is not statistically significant. The aorto-mitral angle was 129.7±10.5° in systole and 131.0±9.4° in diastole. Conclusions The mitral annulus is larger in dimension, more circular, and less dynamic in patients with FMR. The obstacle-free zone below the mitral annulus is relatively constant during the cardiac cycle. Measurements of the mitral valvular apparatus vary considerably between patients, which suggests that tridimensional imaging will play an important role in the sizing of TMVR devices.

AIMS Transcatheter mitral valve replacement (TMVR) is an emerging technology with the potential to treat patients with severe mitral regurgitation at excessive risk for surgical mitral valve surgery. Multimodal imaging of the mitral valvular complex and surrounding structures will be an important component for patient selection for TMVR. Our aim was to describe and evaluate a systematic multi-slice computed tomography (MSCT) image analysis methodology that provides measurements relevant for transcatheter mitral valve replacement. METHODS AND RESULTS A systematic step-by-step measurement methodology is described for structures of the mitral valvular complex including: the mitral valve annulus, left ventricle, left atrium, papillary muscles and left ventricular outflow tract. To evaluate reproducibility, two observers applied this methodology to a retrospective series of 49 cardiac MSCT scans in patients with heart failure and significant mitral regurgitation. For each of 25 geometrical metrics, we evaluated inter-observer difference and intra-class correlation. The inter-observer difference was below 10% and the intra-class correlation was above 0.81 for measurements of critical importance in the sizing of TMVR devices: the mitral valve annulus diameters, area, perimeter, the inter-trigone distance, and the aorto-mitral angle. CONCLUSIONS MSCT can provide measurements that are important for patient selection and sizing of TMVR devices. These measurements have excellent inter-observer reproducibility in patients with functional mitral regurgitation.

Aims The accuracy of transcatheter aortic valve replacement (TAVR) sizing using three-dimensional transoesophageal echocardiography (3D-TEE) compared with the gold-standard multi-slice computed tomography (MSCT) remains unclear. We compare aortic annulus measurements assessed using these two imaging modalities. Methods and results We performed a single-centre prospective cohort study, including 53 consecutive patients undergoing TAVR, who had both MSCT and 3D-TEE for aortic annulus sizing. Aortic annular dimensions, expected transcatheter heart valve (THV) oversizing, and hypothetical valve size selection based on CT and TEE were compared. 3D-TEE and CT cross-sectional mean diameter (r = 0.69), perimeter (r = 0.70), and area (r = 0.67) were moderately to highly correlated (all P-values

Background Transcatheter interventions are currently undertaken using "generic" fluoroscopic viewing angles. However, the position and orientation of heart structures may vary across patients and disease-specific remodeling processes. Objective This study uses multislice computed tomography to determine optimal fluoroscopic viewing angles of the aortic and mitral annuli, the left atrial appendage and the atrial septum. We explored differences between patients with severe aortic stenosis (AS) and severe mitral regurgitation (MR). Methods and results The multislice computed tomographies of 28 patients with severe aortic stenosis (AS) and 32 patients with severe functional mitral regurgitation (MR) were analyzed. For each patient, we evaluated the optimal fluoroscopic viewing angles of the aortic and mitral annuli ( en face , maximal and minimal diameters, aortic root with right, left and non coronary sinus in center), left atrial appendage orifice ( en face , maximal and minimal diameters), and atrial septum (fossa ovalis) en face . The TAVR implantation view with right coronary sinus in center was LAO 9 – CRA 0 in the AS group and LAO 6 – CAU 5 in the MR group (p = NS). AS and MR patients differed significantly with respect to the fluoroscopic angulation of the aortic annulus en face (8.3°), the aortic annulus maximal (17.7°) and minimal (18.5°) diameters, the mitral annulus aorto-mural diameter (11.3°), and the left atrial appendage orifice en face (11.1°) (all p-values Conclusion Optimal fluoroscopic viewing angles of left-sided structures vary considerably between patients. Multislice computed tomography is a valuable tool to determine the most procedurally relevant angulations, with the potential to optimize procedural safety, efficacy and duration.

The classic Hoffman and Rigler (HR) sign, originally described in 1965, suggests that left ventricular (LV) dilatation is present if the left ventricle extends more than 18 mm posterior to the inferior vena cava at a level 2 cm above their crossing on a lateral chest radiograph. This sign is still widely used by radiologists but has not been well evaluated against modern methods of noninvasive assessment. This study investigated the sensitivity and specificity of the HR sign in a modern population.A sample of 145 patients with LV dilatation based on current echocardiographic criteria was matched for age and sex with 145 patients without LV dilatation. Patients were required to have undergone a lateral chest radiograph in the 3 months before or after undergoing echocardiography; the HR sign and the cardiothoracic index were assessed on the radiograph independently by 2 blinded physicians.Using the threshold value of 18 mm, sensitivity, specificity, and positive and negative likelihood ratios of the HR sign were 54.9%, 59.2%, 1.34, and 0.76, respectively (area under the curve [AUC], 0.58). In comparison, the cardiothoracic index provided better prediction of LV dilatation (sensitivity, 87.9%; specificity, 47.5%; AUC, 0.72).The HR sign is a poor marker of LV enlargement when compared with echocardiography and should not be used as a radiologic index of LV enlargement.

We read with great interest the paper by De Torres-Alba [(1)][1] on changes in the rate of pacemaker implantation after transition from the SAPIEN XT to the SAPIEN S3 transcatheter aortic valve (Edwards Lifesciences, Irvine, California). The investigators showed, in agreement with other reports

Background We sought to determine if preprocedural CT can predict appropriate fluoroscopic angulations to achieve a coplanar view during transcatheter mitral valve implantation (TMVI) and to assess the relationship of the mitral annulus and the coronary sinus to determine the feasibility of using this as an additional landmark on fluoroscopy. Methods With CT, the mitral annulus was segmented in 25 patients with functional mitral regurgitation. After this, optimal projection curves were plotted and the necessary angulations for specific views parallel to the trigone-to-trigone line (TT view) and septal-to-lateral distance (SL view) were noted. The outer contour of the coronary sinus and great cardiac vein were segmented to simulate a guide wire, and its relation to the annular plane was assessed. Employed angulations and coplanarity of device depiction were investigated in 4 patients who underwent TMVI. Results The mitral annulus is oriented in an anterior superior fashion with tilting to the right. SL and TT views were found at 29.4 ± 9.0° right anterior oblique (RAO), 20.1 ± 8.7° cranial (CAU) and 81.6 ± 18.9° RAO, 56.7 ± 8.0° caudal (CAU). The optimal projection curve and the relationship of coronary sinus to the mitral annular plane showed a wide intersubject variability. Commonly, the coronary sinus passed along the atrial wall with a mean distance of 13.2 ± 3.7 mm toward the mitral annular plane at P2 and 1.4 ± 3.1 mm anteriorly in alignment with the TT line. Coplanar depiction of the TMVI prosthesis was achieved in all 4 patients, with a compromise view chosen on the optimal projection curve between the TT view and SL view. Conclusion CT allows for prediction of optimal fluoroscopic angulations to achieve a coplanar view of the mitral annulus. The relationship of the coronary sinus to the mitral annulus is variable and preprocedural CT segmentation may allow for a more patient-specific approach to the use of a coronary sinus guide wire as a fluoroscopic landmark.

Background: After a review of the evidence, our cardiology evaluation unit recommended to the Quebec Ministry of Health that transcatheter aortic valve implantation (TAVI) should be used in carefully selected patients and that use and outcomes be independently monitored. Herein, we describe the first results of our province-wide field evaluation of patient and procedural characteristics and clinical outcomes and compare them with the STS/ACC TVT registry. Methods: Our trained data abstractors conducted a retrospective review of medical charts of all TAVI cases (n=96) in 6 hospitals during April-July 2013. Variables, outcomes and definitions were chosen to enable valid comparison with other registries in Canada and the USA. The evaluation protocol was created in collaboration with a scientific committee of representative interventionists and surgeons. Results: During the 4-month period, the number of TAVI patients varied from 4 to 37 across the 6 centers. Median age was 83 years (interquartile range [IQR]: 78-86) vs 84 years (IQR: 78-88) in the TVT registry. Half of Quebec TAVI patients were women, as in TVT. Documentation of an evaluation by a surgeon was found for only 58% of patients and the STS predicted risk of operative mortality was documented for only 54%. Of these, the median STS score was 6% (IQR: 4-10) compared to 7% (IQR: 5-11) in TVT where 91% of patients were evaluated by 2 surgeons. The most common vascular access approach in Quebec was transfemoral (70% vs. 64% in TVT); the transapical approach was used less in Quebec than in TVT (16% vs. 29%). While all TAVI in the TVT registry used Edwards SAPIEN XT valves, in Quebec 71% of TAVI used Edwards SAPIEN XT valves, 26% were Medtronic Corevalve and 3% were Portico valves. In-hospital mortality in Quebec was 6.3% (95% CI: 1.3-11.2) compared with 5.5% (95% CI: 5.0-6.1) in TVT. Conversion to surgery (3% vs 1%) and insertion of a new permanent pacemaker (13% vs 7%) were higher in Quebec than in TVT. TAVI patients in Quebec spent less time in intensive care (median 31 hours (IQR: 23-70) vs 46 hours (IQR: 25-77) and in hospital after TAVI (median 5 days (IQR: 3-8) vs 6 (IQR: 4-10). They were also more likely to be discharged home than patients in the TVT registry (80% vs 63%). Conclusions: Preliminary results from a province-wide TAVI registry in Quebec suggest that practice and outcomes are similar to those observed in the TVT registry. Compared with TVT, notable differences in practice were less documentation of surgical evaluation and of STS predicted mortality, less use of the transapical approach and more frequent need for a permanent pacemaker. Some differences may relate to use of a greater variety of valve types in Quebec. In-hospital mortality was similar. These results will be discussed with each TAVI team. Continued monitoring and long-term follow-up in collaboration with clinical experts are essential to promote an optimal quality of care.

Transcatheter aortic valve implantation (TAVI) has been increasingly recognized as a curative treatment for severe aortic stenosis (AS). Despite important improvements in current device technology and implantation techniques, specific complications still remain and warrant consideration. Vascular complications and peri-procedural neurological events were the first concerns to emerge with this new technology. Recently, significant post procedural para-valvular leak has been shown to be more frequent after TAVI than after surgical aortic valve replacement (SAVR), and its potential association with worse long-term prognostic has raised concerns. In moving toward treatment of lower risk populations, structural integrity and long-term durability of heat valve prosthesis are becoming of central importance. Emerging technologies and newer generations of devices seem promising in dealing with these matters.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is an emerging treatment for frequently elderly patients with severe symptomatic aortic stenosis considered at too high risk for conventional surgery. However, this less invasive treatment has important implications in a universal public payer healthcare system with limited resources. In early 2011, the province of Quebec’s Ministry of Health requested an evaluation of TAVR by INESSS, a government-funded independent body that assists evidence-based policy-making with literature reviews, field evaluations and outcomes research. The Ministry also asked INESSS to be involved in the creation of a provincial registry. At the time of the request, 4 centers were already performing TAVR and others were developing programs. METHODS: We conducted a systematic literature review (2008-2011) on effectiveness, safety, economic, and ethical issues, in collaboration with a committee of independent clinical experts (4 interventional cardiologists, 4 cardiac surgeons). The committee’s role was to help interpret and contextualize existing evidence and to collaborate in the development of a provincial registry. We proposed clinical, process of care and economic variables for a registry based on the literature review and the clinicians’ perspectives. RESULTS: According to the literature, outcomes of TAVR are promising for carefully selected patients with respect to 1-year survival, functional improvement, and quality of life. Limitations in the evidence base include uncertain longer-term benefits and device durability due to a lack of studies with lengthy follow-up; an important risk of stroke and high rates of hospitalization post-intervention in the one available randomized controlled trial; lack of standardization of data definitions across studies; and insufficient evidence on cost-effectiveness and cost-utility. We recommended that: (1) TAVR be offered only to patients declined for surgery and who would likely have improved quality of life as a result of the procedure; (2) patients be fully informed of the relative novelty of the procedure and uncertainty about associated risks and longer-term benefits; (3) selection of patients involve a multi-disciplinary team and be uniform in terms of criteria and process across centers to ensure equal access; (4) the patient selection process be documented; (5) TAVR programs receive specific funding that includes financing of a registry; (6) a mandatory registry be used to collect data on baseline patient characteristics, procedures, outcomes, and costs, to inform both participating centres and the Ministry; and (7) TAVR be performed by a limited number of expert centers to maintain a sufficient volume of procedures. CONCLUSIONS: The practice of TAVR in the province of Quebec will be guided by the results of a systematic review of existing evidence and future evidence from a provincial registry developed by an independent body in collaboration with clinical experts. We believe that this evaluation model will meet the challenges posed by the introduction of innovative technology in a universal healthcare system with limited resources.

Surgical aortic valve replacement (SAVR) is currently the standard of care to treat patients with severe symptomatic aortic stenosis (AS) and is generally accepted to alleviate symptoms and prolong survival. Based on the results of randomized trials, transcatheter aortic valve implantation (TAVI) is the new standard of care for patients with symptomatic AS who are deemed 'inoperable'. Debatably, TAVI is also an alternative to SAVR in selected patients who are at high risk but operable. As we approach 10 years of clinical experience with TAVI, with over 50 000 implantations in 40 countries, a review of the current literature and clinical outcomes with this rapidly evolving technology is appropriate.

The purpose of this investigation was to evaluate both long-term functional status and quality of life (QoL) following valvular replacement surgery in octogenarians. The influence of gender and discharge location was also examined.A total of 133 patients (age range: 80-89 years) who underwent surgical valve replacement between January 2003 and December 2006 was identified. Two questionnaires evaluating QoL (SF-12v2 and MLHFQ), as well as a demographic questionnaire, were sent to these patients.The response rate was 64.4%. Among the participants, the mean NYHA functional class improved from 2.7 to 1.4 after surgery. Men showed results similar to those of the age-matched general Canadian population on the mental and physical component scales of the SF-12v2. The data on women were similar to those of the general population on the physical component scale, but their scores were significantly lower on the mental component scale of the SF-12v2. Further analysis of the results comparing discharge location for each gender revealed that women discharged to a convalescence resource had significantly better QoL scores than those discharged to home with regards to the physical component scale of the SF-12v2, the total score of the MLHFQ, and the physical dimension score of the MLHFQ.Patients agedor = 80 years benefit from heart valve replacement surgery in terms of both QoL and functional status. Women may be at increased risk of a decline in their emotional well-being and, postoperatively, may benefit more from convalescence than from discharge to home.

AIM To investigate the clinical outcomes of transcatheter aortic valve implantation (TAVI) with the SAPIEN 3 transcatheter heart valve (S3-THV) vs the SAPIEN XT valve (XT-THV). METHODS We retrospectively analyzed 507 patients that underwent TAVI with the XT-THV and 283 patients that received the S3-THV at our institution between March 2010 and December 2015. RESULTS Thirty-day mortality (3.5% vs 8.7%; OR = 0.44, P = 0.21) and 1-year mortality (25.7% vs 20.1%, P = 0.55) were similar in the S3-THV and the XT-THV groups. The rates of both major vascular complication and paravalvular regurgitation (PVR) > 1 were almost 4 times lower in the S3-THV group than the XT-THV group (major vascular complication: 2.8% vs 9.9%, P < 0.0001; PVR > 1: 2.4% vs 9.7%, P < 0.0001). However, the rate of new pacemaker implantation was almost twice as high in the S3-THV group (17.3% vs 9.8%, P = 0.03). In the S3 group, independent predictors of new permanent pacemaker were pre-procedural RBBB (OR = 4.9; P = 0.001), pre-procedural PR duration (OR = 1.14, P = 0.05) and device lack of coaxiality (OR = 1.13; P = 0.05) during deployment. CONCLUSION The S3-THV is associated to lower rates of major vascular complications and PVR but higher rates of new pacemaker compared to the XT-THV. Sub-optimal visualization of the S3-THV in relation to the aortic valvular complex during deployment is a predictor of new permanent pacemaker.

Transcatheter cardiac interventions are a fast evolving field. The past decade has seen the development of transcatheter aortic valve replacement, transcatheter mitral valve repair and replacement, septal defect closure devices and left atrial appendage closure devices for thromboprophylaxis. More than ever, medical imaging is taking a central role in the care of patients with structural heart disease. In this review article we outline the use of MSCT as a tool for diagnosis of structural heart interventions, as well as patient selection, preprocedural planning, device sizing and post-procedural assessment. We focus on procedures targeting the aortic valve, the mitral valve, the inter-atrial septum and the left atrial appendage.

s S245 promote the mineralization of valve interstitial cells (VICs), the main cellular component of the aortic valve. We hypothesized that the expression of NPP1, which generates adenosine monophosphate (AMP), and 5’nucleotidase, an enzyme using AMP as a substrate to produce adenosine, may co-regulate the mineralization of the aortic valve. METHODS: We have investigated the expression of NPP1 and 5’nucleotidase in CAVD tissues and determined the role of these ecto-nucleotidases on the mineralization of isolated VICs. RESULTS: In CAVD tissues, we documented that NPP1 and 5’nucleotidase enzyme activities were increased. NPP1 and 5’nucleotidase were co-expressed by VICs. In cell culture we found that mineralization induced by ATP was decreased by silencing NPP1 and 5’nucleotidase, suggesting a role for adenosine. Adenosine and specific A2a receptor agonist increased the calcification of VICs. Silencing of A2a receptor and the use of A2a-/receptor mouse VICs abrogated adenosine-induced mineralization. Also, A2a receptor-mediated mineralization of VICs was negated by the transfection of a mutant dominant negative Gas vector. Inhibition of the protein kinase A (PKA) pathway prevented adenosine-induced mineralization of VICs and expression of NPP1. We next showed that activation of PKA promoted in luciferase assay the activity of the NPP1 promoter. By using chromatin immunoprecipitation assay (ChIP) we documented that the cAMP response element binding protein (CREB), downstream of PKA, physically interacted with the NPP1 promoter region. Furthermore, the transfection of a mutant dominant active CREBDIEDML in isolated cells increased the NPP1 promoter activity by 6.5-fold. CONCLUSION: The overexpression of NPP1 and 5’nucleotidase in CAVD promotes the mineralization of the aortic valve through A2a adenosine receptor, which signals through Gas and the cAMP/PKA/CREB pathway. CREB is a positive regulator of NPP1 promoter activity in a positive feedback loop. The ecto-nucleotidases and/or A2a adenosine receptor could represent potential novel pharmaceutical targets in CAVD. 372 ROLE OF LONG NON-CODING RNAS IN THE REGULATION OF THE NOTCH PATHWAY: IMPLICATION FOR CALCIFIC AORTIC VALVE STENOSIS F Hadji, M Boulanger, S Guauque-Olarte, R Bouchareb, Y Bosse, P Mathieu

Cerebrovascular events can occur in up to 7% of patients following transcatheter aortic valve replacement (TAVR), increasing dementia and mortality. Neuro-embolic events on post-TAVR diffusion-weighted (DW) MRI are nearly universal, and have been associated with cognitive decline. Embolic protection