Cerebrovascular Events after Transcatheter Aortic Valve Replacement: The Difficulty in Predicting the Unpredictable.

Background: Cerebrovascular events (CVE) are feared complications following transcatheter aortic valve replacement (TAVR). We aimed to develop a new risk model for CVE prediction with the application of multimodal imaging. Methods: From May 2011 to August 2019, a total of 2015 patients underwent TAVR at our institution. The study cohort was subdivided into a derivation cohort (n = 1365) and a validation cohort (n = 650) for risk model development. Results: Of 2015 patients, 72 (3.6%) developed TAVR-related CVE. Pre-procedural factors of our risk model were history of prior CVE, a larger aortic valve area (≥0.55 cm2), a large aortic angulation (≥48.5°), and enhanced calcification of the right coronary cusp (≥447.2 AU), left ventricular outflow tract (≥262.4 AU), and ascending thoracic aorta (≥116.4 AU). Our risk model was superior for in-hospital CVE prediction following TAVR in the establishment cohort (AUC 0.73, 95% CI 0.66−0.80; p < 0.001) compared to other risk scores, such as the EuroSCORE II or the CHA2DS2-VASc score. Conclusions: Although CVE prediction in patients undergoing TAVR is challenging due to the complex nature of the TAVR procedure, our study highlights that multimodal imaging is a promising approach to generate a more accurate risk model for CVE prediction.

Predictors of calcification distribution in severe tricuspid aortic valve stenosis.

We investigated aortic valve calcification (AVC) distribution and predictors for leaflet calcification patterns in patients with severe tricuspid aortic valve stenosis undergoing transcatheter aortic valve replacement (TAVR). Patients undergoing routine multi-sliced computed tomography (MSCT) for procedural planning were enrolled. MSCT data were transferred to a dedicated workstation for evaluation (3mensio Structural Heart™, Pie Medical Imaging BV, Maastricht, The Netherlands) and analyzed. Participants were separated into asymmetrical (AC) and symmetrical (SC) leaflet calcification and potential predictors for calcification distribution were identified with univariate and multivariate regression analysis. 567 Participants with severe tricuspid AS were divided into asymmetrical (AC, n = 443; 78.1%) and symmetrical (SC, n = 124; 21.9%) AVC. In AC, the non-coronary cusp was the most calcified cusp (n = 238; 57.7%). SC is more common in females (AC/SC: 49.2% vs. 67.7%; p < 0.0001). AVC was more severe in patients with AC, who also have larger aortic root dimensions. Multivariate analysis depicted, inter alia, left ventricular outflow tract (LVOT) calcification < 25 Agatston units (OR 1.81 [1.09-3.00], p = 0.021), a mean pressure gradient < 36 mmHg (OR 1.77 [1.03-3.05], p = 0.039), and an annulo-apical angle > 67° (OR 1.68 [1.00-2.80], p = 0.049) as predictors for SC, although with only moderate predictive value. Data from this retrospective analysis indicate that SC occurs more frequently in females. The cumulative leaflet calcification burden is higher in patients with AC, who also present with larger aortic root dimensions. The predictive value for prominent calcification of different aortic valve cusps in AC patients was only low to moderate.Trial registration number: NCT01805739.

Aortic valve calcification is subject to aortic stenosis severity and the underlying flow pattern.

Sex- and flow-related aortic valve calcification (AVC) studies are still limited in number, and data on the exact calcium quantity and distribution are scarce. Therefore, we aimed to (1) re-define the best threshold of AVC load to distinguish severe from moderate aortic stenosis (AS) in common AS entities and to (2) evaluate differences in the aortic annulus and left ventricular outflow tract (LVOT) calcium load. Nine hundred and thirty-eight patients with contrast-enhanced cardiac MSCT and moderate-to-severe aortic stenosis (AS) were retrospectively enrolled. Patients with severe AS ≤ 1.0 cm2 (n = 841) were further separated into three AS entities: high gradient (HGAS, n = 370, 44.0%), paradoxical low gradient (pLGAS, n = 333, 39.6%), and classical low gradient (LGAS, n = 138, 16.4%). AVC, leaflet, and LVOT calcification were quantified. Aortic valve calcification scores were highest in severe HGAS, and lower in severe pLGAS and classical LGAS. In all severity and AS entities, the non-coronary cusp (NCC) was the most calcified one. LVOT calcification was consistently comparable between gender and AS entities. Accuracy of logistic regression was the highest in HGAS (male vs. female: AVC > 2156 Agatston units (AU), c-index 0.76; vs. AVC > 1292 AU, c-index 0.85; or AVC density > 406 AU/cm2, c-index 0.82; vs. > 259 AU/cm2, c-index 0.86; each p < 0.0001*) to diagnose severe AS. AVC could only be used in men to differentiate between severe LGAS and moderate AS. Data from this retrospective analysis indicate that the NCC is subject to pre-dominant degeneration throughout gender, AS severity, and several AS entities. AVC was consistently comparable in severe pLGAS and classical LGAS, but only AVC in severe LGAS could sufficiently distinguish from moderate AS in men. LVOT calcification failed to be a reliable indicator of accelerating AS.

Impact of Combined "CHADS-BLED" Score to Predict Short-Term Outcomes in Transfemoral and Transapical Aortic Valve Replacement.

BACKGROUND: High CHA2DS2-VASC and HAS-BLED scores are linked to increased mortality in structural and nonstructural cardiovascular interventions irrespective of the presence of atrial fibrillation (AF) or oral anticoagulation. We aimed to use the aforementioned scores to quantify the risk of 30-day mortality, major vascular and bleeding events (MVASC/BARC), and cerebrovascular insults (CVI) in patients undergoing different access routes in transcatheter aortic valve replacement (TAVR). METHODS: Out of 1329 patients, 980 transfemoral (TF) TAVR (73.7%) and 349 transapical (TA) TAVR (26.3%) were included. CHA2DS2-VASC, HAS-BLED, and combined "CHADS-BLED" scores were calculated and compared to the predictive value of the established EuroSCORE and STS score. RESULTS: In all-comers TF TAVR patients, the applied risk models showed only poor association with 30-day mortality while, in patients with concomitant AF, a strong association was observed using the combined CHADS-BLED score (c-index: 0.83; 95% CI: 0.76-0.91; p < 0.0001). Concerning 30-day mortality, only the STS score for TF TAVR (c-index: 0.68; 95% CI: 0.59-0.76; p = 0.001) and EuroSCORE for TA TAVR (c-index: 0.66; 95% CI: 0.56-0.76; p = 0.005) could show some predictive value. High CHADS-BLED was associated with enhanced CVI (3.0% vs. 7.2%;p=0.0039 ∗ ) and more frequent MVASC/BARC (3.2% vs. 6.3%; p = 0.0362) in the all-comers TAVR cohort. All risk models failed in the prediction of CVI and MVASC/BARC for TA TAVR patients. CONCLUSION: The combined CHADS-BLED score was a strong predictor for 30-day mortality in TF TAVR patients with AF. A high CHADS-BLED score showed a good predictive value for major vascular and bleeding events as well as CVI in TF TAVR patients. This study is registered at clinical trials (NCT01805739).

Novel insights on outcome in horizontal aorta with self-expandable new-generation transcatheter aortic valve replacement devices.

BACKGROUND: The impact of a horizontal aorta (HA) on adverse events (AE) following in transcatheter aortic valve replacement (TAVR) is dealt controversially. Using new-generation self-expandable devices, we aimed to reevaluate an appropriate threshold of the aortic root angulation (ARA) in terms of HA and its impact on outcome. METHODS: The 466 consecutive patients, who underwent transfemoral TAVR with self-expandable new-generation devices, were analyzed. Patients were classified into cases with HA (ARA ≥ 51°; n = 225; 48%) and without HA (ARA <51°; n = 241; 52%). Primary endpoints were device success and 30-day mortality. Secondary endpoints were specific AE according to VARC-2 definitions. RESULTS: Contrast use (107.6 ± 50.1 vs. 94.1 ± 46.1 ml; p = .033) and radiation dose (3,176 [1,928-5,596] vs. 2,651 [1,643-4,394] Gyxcm2 ; p = .016) were higher in HA. Primary device success was comparable (97.1 vs. 97.8%; p = .773). A 30-day mortality (3.3 vs. 0.4%; p = .038, plogrank = 0.025), stroke (7.1 vs. 2.7%; p = .033), and major vascular complications (MVASC) (6.6 vs. 2.7%; p = .050) were more frequent in HA. Pronounced calcification of the noncoronary cusp and left ventricular outflow tract, the condition of HA, as well as repositioning maneuvers were independent predictors for overall specific AE. CONCLUSION: An HA above 51° is associated with an increased rate of stroke, MVASC, and 30-day mortality. Valve size and asymmetric calcification affect the incidence of repositioning maneuvers and subsequent VARC-2 AE, indicating that an HA-together with specific anatomic features-remains a crucial factor for TAVR-related outcome with self-expandable new-generation devices.