Identification of Periprocedural Myocardial Infarction Using a High-Sensitivity Troponin I Assay in Patients Who Underwent Transcatheter Aortic Valve Implantation.

Periprocedural myocardial infarction (MI), a rare complication after transcatheter aortic valve implantation (TAVI), is associated with worse outcome. According to the Valve Academic Research Consortium (VARC-2), MI is defined by an increase in cardiac troponin (cTn) and creatine kinase MB (CK-MB) levels; however, many patients show periprocedurally elevated cTn without clinical evidence of MI. The aims of this study were to establish reference values of cardiac troponin I measured with a high-sensitivity assay (hs-cTnI) and to assess the periprocedural diagnostic value of this biomarker in patients who underwent TAVI. Hs-cTnI and CK-MB levels were assessed before and up to 3 days after transfemoral (TF) or transapical (TA) TAVI in 515 patients. A high proportion (61.2%) of patients had elevated hs-cTnI at baseline. According to VARC-2 criteria, almost all TA-patients (99.5%) showed an MI based on hs-cTnI compared with 4.2% based on CK-MB. In TF-patients, 81.1% had an MI based on hs-cTnI compared with 9.0% based on CK-MB. Only 10 patients (2%), however, had a type 1 MI. The ninety-ninth percentile for hs-cTnI was 285 ng/L in the TAVI cohort. After applying a TAVI-specific cutoff the frequency of MI was lower and more realistic (TF: 5% vs 81.1%; p <0.001; TA: 22.2% vs 99.5%; p <0.001). In conclusion, the VARC-2 definition leads to an overestimation of periprocedural MI. Our new TAVI-specific reference values yield a more realistic estimation of the myocardial ischemic risk. hs-cTnI, however, does not seem to be the biomarker of choice for MI detection in this setting.

DynaCT-guided anatomical rotation of the SAPIEN XT valve during transapical aortic valve implantation: proof of concept.

BACKGROUND: Transcatheter aortic valve implantation (T-AVI) by using the Edwards SAPIEN (Edwards Lifesciences LLC, Irvine, California, United States) prosthesis is currently being performed by the implantation of valved stent into the aortic annulus without respecting the native commissural (rotational) orientation. Anatomical orientation may, however, be beneficial regarding optimal physiological valve performance, optimal coronary flow, and avoidance of the fully covered commissural stent part in front of the coronary ostia. With the recently introduced SAPIEN XT, transcatheter valve identification of the commissures during fluoroscopy is feasible. The aim of this study was to evaluate the concept of Dynamic-CT (DynaCT)-guided anatomical rotation of the SAPIEN XT valve during transapical-AVI (TA-AVI). METHODS: Intraoperatively, an automatically segmented DynaCT was performed using the Siemens Syngo Aortic ValveGuide (Siemens AG, Forchheim, Germany) software prototype. Commissures of SAPIEN XT could be identified with a high-quality fluoroscopic system. Before standard TA implantation, one radiopaque stent commissure of the crimped SAPIEN XT prosthesis was aligned with the native aortic valve commissure visualized by DynaCT. Resulting rotational orientation of the valve after implantation was assessed by transesophageal echocardiography. RESULTS: Feasibility of anatomical rotation was evaluated in 10 patients scheduled for TA-AVI by an interdisciplinary heart team. Mean logistic EuroSCOREs and Society of Thoracic Surgeons scores were 23.7 ± 4.9% and 8.6 ± 2.1%, mean aortic gradient improved from 46.0 ± 21.9 to 9.6 ± 3.1 mm Hg, and there was no death within 30 days. All valves were implanted successfully with none or trivial paravalvular regurgitation in seven patients, mild (1 + ) in two patients, and moderate (2 + ) in one patient. An optimal anatomical position could be achieved in six patients, minor rotational deviation (< 10 degrees) in three patients, and moderate deviation (10 to 20 degrees) in one patient only. CONCLUSIONS: DynaCT-guided anatomical rotation of the SAPIEN XT valve is feasible during TA-AVI, avoiding implantation of the fully covered commissural posts in front of the coronary ostia. This might reduce the risk of coronary obstruction. In addition, the technique provides the potential benefit of physiological valve position and performance.

Minimally invasive off-pump valve-in-a-valve implantation: the atrial transcatheter approach for re-operative mitral valve replacement.

AIMS: This study was designed to evaluate the feasibility and haemodynamic performance of transcatheter valve-in-a-valve (VinV) implantation for failed mitral xenografts using a minimally invasive, transatrial, off-pump approach. METHODS AND RESULTS: Nine adult sheep (71.1 +/- 3.4 kg) underwent mitral valve replacement with a 25 mm bioprosthesis using standard conventional techniques. After weaning from cardiopulmonary bypass, a transcatheter 23 mm pericardial prosthesis mounted on a balloon-inflatable steel stent was deployed within the conventional xenograft. The VinV implantation (10.1 +/- 0.9 min) was performed off-pump using an antegrade transatrial approach under fluoroscopic guidance successfully in all nine sheep. Mean transvalvular gradient was 4.6 +/- 1.0 mmHg, and five of nine sheep had no paravalvular leak with two sheep each having mild and moderate one. All transcatheter prostheses were confirmed in good position on post-mortem analysis. In an in vitro model, the minimum force required to dislodge the valve was 22.5 +/- 3.0 N, which was well above the normal estimated forces generated by the left ventricle (LV). When this model was attached to a LV assist device, the VinV withstood pressure loops of 300 mmHg, without dislocation or embolization. CONCLUSION: Transatrial, transcatheter mitral VinV implantation is feasible off pump. This is a truly minimally invasive concept to treat patients with failed xenografts using a right lateral minithoracotomy.