Baseline NT-proBNP predicts acute kidney injury following transcatheter aortic valve implantation.

BACKGROUND/PURPOSE: Acute kidney injury (AKI) after transcatheter aortic valve implantation (TAVI) increases morbidity and mortality. Our study aimed to investigate the role of baseline N-terminal pro B-type natriuretic peptide (NT-proBNP) as a predictor of AKI following TAVI. METHODS: All consecutive TAVI patients were included in the analysis, except patients with dialysis and those with a GFR < 15 ml/min/1.73 m2 at baseline. Rates of AKI after TAVI were assessed according to the updated valve academic research consortium definitions using AKIN classification in three stages. NT-proBNP was measured at baseline. One-year mortality rates were assessed. RESULTS: We included 1973 patients treated with TAVI between January 2006 and December 2016. Median [IQR] age was 81.0 [77.0;84.0] years, the STS score was 6.2 [3.9;9.0], and the logEuroScore was 14.5 [9.0;23.0]. 30-day and one-year mortality was 5.1 % and 16.1 % for all patients, respectively. Multivariate analysis revealed that patients with NT-proBNP levels higher than two times above the upper level of normal (ULN) had an increased risk for AKI after TAVI compared to patients with NT-proBNP levels < 2× ULN (OR 1.40 [1.03-1.91]). CONCLUSIONS: Routine assessment of baseline NT-proBNP levels might be an additional tool to identify patients at increased risk for AKI after TAVI.

Mid-term results of "off-label" use of the Endurant stentgraft in patients with infrarenal abdominal aortic aneurysms.

OBJECTIVES: EVAR is the preferred treatment modality for patients with an infrarenal abdominal aortic aneurysm with suitable anatomy. Each manufacturer of aortic stentgrafts has specific anatomic requirements. In some patients, it is not possible to adhere to the instructions for use, but alternative treatment is also not possible. In these patients, EVAR can be performed outside instructions for use. METHODS: In this study, all consecutive patients in whom an Endurant II or IIS stentgraft was used between 1 January and 31 December were reviewed. We compared the two patient groups in whom this stentgrafts was used outside and inside instructions for use. Patients with planned adjuvant therapy, for example, chimney procedure or iliac side branches, were excluded. RESULTS: In 74 of 178 (41.6%) patients, the instructions for use were not adhered. The main reason was pathology of the aortic neck. There were more patients with type IA endoleak, this difference was borderline significant (p = .06). There were more patients with limb occlusion in the early postoperative period, but at the end of the follow-up period, the incidence was comparable. Aneurysm-related mortality and all-cause mortality were comparable in both groups. CONCLUSION: In this study, real-life experience with the Endurant II and IIS stentgraft is described. Non-adherence with instructions for use was associated with a higher risk of endoleak type IA (p = .06). In the early postoperative period, there were more patients with limb occlusion; this finding was not observed anymore at the end of the follow-up period.

Predictors of Crossing Failure in Femoropopliteal Lesions: The Importance of Length of the Lesion and Calcification.

BACKGROUND: Endovascular therapy is nowadays the first choice for most patients with peripheral artery disease. The most important cause of technical failure is failure to cross the lesion with a wire. In this retrospective study, we explore possible risk factors of crossing failure. METHODS: We included all consecutive patients in whom the lesion could not be crossed in the period of the January 1, 2017-January 1, 2022. The lesions of these patients were compared with patients in whom the lesion could be crossed (2:1). The following potential anatomical risk factors were compared: location of the lesion, occlusion length, lesion length, Peripheral Arterial Calcium Scoring Scale, Peripheral Academic Research Consortium, circumferential characterization classification, and the Trans-Atlantic Inter-Society Consensus II classification. RESULTS: In 71 patients, the lesion could not be crossed; these patients were compared with 142 patients. There were significantly more patients with hypertension and hyperlipidemia in the group with crossing failure. The following factors were risk factors for crossing failure: occlusion length, lesion length, Peripheral Arterial Calcium Scoring Scale, Peripheral Academic Research Consortium, and circumferential characterization classification. CONCLUSIONS: Although conclusions should be carefully drawn from this retrospective study, calcification and length of the lesion are associated with crossing failure in the femoropopliteal segment. The Trans-Atlantic Inter-Society Consensus II classification was the best predictor of crossing failure.

VARC-3 defined outcome of valve-in-valve transcatheter aortic valve implantation in stentless compared with stented aortic bioprostheses.

BACKGROUND: Valve-in-valve (ViV) transcatheter aortic valve implantation (TAVI) is a viable alternative to redo surgery in selected patients with bioprosthetic valve dysfunction. Most ViV-TAVI procedures have been performed in stented bioprosthetic valves (ST); stentless bioprostheses (SL) lack fluoroscopic markers and could be more challenging for ViV-TAVI. Data on more recent patients applying Valve Academic Research Consortium (VARC)-3 defined outcomes are scarce. We compared patient characteristics, procedural outcomes, and 5-year mortality of patients with SL versus ST aortic bioprosthetic valve failure undergoing ViV-TAVI. METHODS: Patients undergoing ViV-TAVI between 2007 and 2022 (52.5% of cases after 2015) at 3 German centers were included in this analysis. The co-primary outcome measures were technical success, device success, and early safety defined by VARC-3. Mortality was assessed up to 5 years. RESULTS: Overall, 43 (11.8%) SL and 313 (88.2%) ST ViV-TAVI were included. Patients were comparable with regard to age, sex, clinically relevant baseline comorbidities, and surgical risk. Technical success (SL: 83.7% versus ST: 79.9%, p = 0.552), device success (SL: 67.4% versus ST: 54.3%, p = 0.105), and early safety (SL: 74.4% versus ST: 66.5%, p = 0.296) were comparable between groups. The 30-day mortality (SL: 7.0% versus ST: 2.6%, p = 0.136) and 5-year mortality rates (SL: 23.3% versus ST: 24.6%, p = 0.874) were not significantly different between groups. CONCLUSION: SL and ST ViV-TAVI led to comparable short-term outcomes according to VARC-3- defined endpoints and similar mortality rates up to 5 years of follow-up. VARC-3 defined technical success, device success, and early safety as well as 5-year all-cause mortality in patients undergoing valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) into stentless (SL) compared with stented (ST) failed aortic bioprostheses.

Sex-Related Differences in Proximal Neck Anatomy and Their Consequences in Patients after EVAR: A Matched Cohort Analysis.

INTRODUCTION: Studies comparing male and female patients with abdominal aortic aneurysms have shown that female patients are generally older and more often experience postoperative complications after endovascular and open repair. There are also indications that female patients have more extensive neck pathologies and that they more often have postoperative complications related to proximal neck pathology. MATERIAL AND METHODS: This retrospective study describes all consecutive female patients who underwent EVAR between 1 January 2012 and 31 December 2021. Propensity-score matching was used to obtain a matched control male cohort. Propensity scores were generated with the following anatomic parameters: infrarenal and suprarenal angulation, proximal and distal neck diameter and neck length. 1 Female patient was matched with 3 male patients. RESULTS: A total of 160 patients were included, namely 120 male patients and 40 female patients. Due to matching, there were no significant differences regarding infrarenal and suprarenal angulation and proximal and distal neck diameter and length. All-cause and aneurysm-related mortality were comparable (p = 0.19 and p = 0.98). The necessity of neck-related secondary procedures was significantly higher in female patients (p = 0.02). In the multivariate analysis, the female sex was a significant predictor of endoleak type IA within 30 days. However, there was no significant association between intraoperative endoleak type IA and endoleak type IA at the end of follow-up. CONCLUSIONS: This study suggests that there was a higher initial incidence of endoleak type IA in female patients, despite thematched preoperative anatomic parameter. Due to the relatively low number of included female patients, conclusions should be drawn carefully.

An analytical, mathematical annuloplasty ring curvature model for planning of valve-in-ring transcatheter mitral valve replacement.

Objectives: An increasing number of high-risk patients with previous mitral valve annuloplasty require transcatheter mitral valve replacement due to recurrent regurgitation. Annulus dilation with a transcatheter balloon is often performed before valve-in-ring transcatheter mitral valve replacement, which is believed to reduce misalignment and paravalvular leakage, yet little evidence exists to support this practice. Our objective was to generate intuitive annuloplasty ring analyses for improved valve-in-ring transcatheter mitral valve replacement planning. Methods: We generated a mathematical model that calculates image-tracked differential ring curvature to build quantifications for improved planning for valve-in-ring procedures. Carpentier-Edwards Physio M24 and M30 (n = 2 each), Physio II M24 and M26 (n = 3 each), LivaNova AnnuloFlex M26 (n = 2), and Edwards Geoform M28 (n = 2) rings were tested with a 30-mm Toray Inoue balloon inflated to maximum rated pressures. Results: Curvature variance reduces with larger ring sizes, indicating that larger rings are initially more circular than smaller ones. Evaluated semi-rigid and rigid rings showed little to no difference between pre- and post-dilation states. Annuloflex rings (flexible band) showed a postdilation variance reduction of 32.83% (P < .001) followed by an increase after 10 minutes of relaxation that was still reduced by 19.62% relative to the initial state (P < .001). Conclusions: We discovered that balloon dilation does not significantly deform evaluated semi-rigid or rigid rings at maximum rated balloon pressures. This may mean that dilation for these conditions before valve-in-ring transcatheter mitral valve replacement is unnecessary. Our mathematical approach creates a foundation for extended classification of this practice, providing meaningful quantification of ring geometry.

Factors Influencing Compliance to Follow-Up After Endovascular Aneurysm Repair.

OBJECTIVES: Regular follow-up after endovascular repair of aortic aneurysm is necessary to detect endoleak and/or migration of the stentgraft. However, absence or incomplete compliance to follow-up is common in this patient population. In this study we will analyse the frequency of non-compliance to post-EVAR follow-up and explore the underlying reasons. METHODS: All patients undergoing EVAR for infrarenal aortic aneurysm between 1st January 2011 and 31st December 2020 were included in this retrospective study. Absence of compliance to FU was defined as not showing up at the out-patient clinic; incomplete FU was defined as a surveillance gap of >18 months. RESULTS AND CONCLUSION: Non-compliance to follow-up was 35.9% (175 patients). In the multivariate analysis the patients who came with a ruptured aneurysm and patients who needed secondary therapy in the first 30 days more often did not comply with the FU protocol (P = .03 and P < .01). Other studies have confirmed the low attendance to follow-up after EVAR.

Incidence and outcomes of emergency intraprocedural surgical conversion during transcatheter aortic valve implantation: Insights from a large tertiary care centre.

OBJECTIVE: During a transcatheter aortic valve implant (TAVI) procedure, intraprocedural complications that are manageable only by conversion to emergency open-heart surgery (E-OHS) occasionally occur. Contemporary data on the incidence and outcome of TAVI patients undergoing E-OHS are scarce. This study aimed to evaluate early and midterm outcomes following E-OHS of patients undergoing TAVI in a large tertiary care centre with immediate surgical backup availability for all TAVI procedures over a 15-year period. METHODS: Data from all patients undergoing transfemoral TAVI between 2006 and 2020 at the Heart Centre Leipzig were analysed. The study time was divided into 3 periods: 2006-2010 (P1), 2011-2015 (P2) and 2016-2020 (P3). Patients were grouped according to their surgical risk (high risk: EuroSCORE II ≥ 6%; low/intermediate risk: EuroSCORE II <6%). Primary outcomes were intraprocedural and in-hospital death and 1-year survival. RESULTS: During the study period, a total of 6903 patients underwent transfemoral TAVI. Among them, 74 (1.1%) required E-OHS [high risk, n = 66 (89.2%); low/intermediate risk, n = 8 (10.8%)]. The rate of patients requiring E-OHS was 3.5% (20/577 patients), 1.8% (35/1967 patients) and 0.4% (19/4359 patients) in study periods P1 to P3, respectively (P < 0.001). The proportion of patients who had E-OHS who were low/intermediate risk increased considerably over time (P1:0%; P28.6%; P3:26.3%; P = 0.077). Intraprocedural deaths occurred in 10 patients (13.5%), all of whom were high-risk. In-hospital mortality was 62.1% in high-risk patients and 12.5% in low/intermediate risk patients (P = 0.007). One-year survival was 37.8% in all patients undergoing E-OHS, 31.8% in high-risk patients and 87.5% in low/intermediate risk patients (log-rank P = 0.002). CONCLUSIONS: In-hospital and 1-year survival rates following E-OHS are higher in low/intermediate risk than in high-risk patients undergoing TAVI. An on-site cardiac surgical department with immediately available E-OHS capabilities is an important component of the TAVI team.

Impact of Enterococci vs. Staphylococci Induced Infective Endocarditis after Transcatheter Aortic Valve Implantation.

BACKGROUND: The two most common organisms found in infective endocarditis following transcatheter aortic valve implantation (TAVI-IE) are enterococci (EC-IE) and staphylococci (SC-IE). We aimed to compare clinical characteristics and outcomes of patients with EC-IE and SC-IE. METHODS: TAVI-IE patients from 2007 to 2021 were included in this analysis. The 1-year mortality was the primary outcome measure of this retrospective multi-center analysis. RESULTS: Out of 163 patients, 53 (32.5%) EC-IE and 69 (42.3%) SC-IE patients were included. Subjects were comparable with regard to age, sex, and clinically relevant baseline comorbidities. Symptoms at admission were not significantly different between groups, except for a lower risk for presenting with septic shock in EC-IE than SC-IE. Treatment was performed in 78% by antibiotics alone and in 22% of patients by surgery and antibiotics, with no significant differences between groups. The rate of any complication, in particular heart failure, renal failure, and septic shock during treatment for IE, was lower in EC-IE compared with SC-IE (p < 0.05). In-hospital (EC-IE: 36% vs. SC-IE: 56%, p = 0.035) and 1-year mortality (EC-IE: 51% vs. SC-IE: 70%, p = 0.009) were significantly lower in EC-IE compared with SC-IE. CONCLUSIONS: EC-IE, compared with SC-IE, was associated with a lower morbidity and mortality. However, absolute numbers are high, a finding that should trigger further research in appropriate perioperative antibiotic management and improvement of early IE diagnosis in the case of clinical suspicion.

Twenty-year outcomes of minimally invasive direct coronary artery bypass surgery: The Leipzig experience.

OBJECTIVE: Minimally invasive direct coronary artery bypass (MIDCAB) surgery involving left anterior descending coronary artery grafting with the left internal thoracic artery through a left anterior small thoracotomy is being routinely performed in some specified centers for patients with isolated complex left anterior descending coronary artery disease, but very few reports regarding long-term outcomes exist in literature. Our study was aimed at assessing and analyzing the early and long-term outcomes of a large cohort of patients who underwent MIDCAB procedures and identifying the effects of changing trends in patient characteristics on early mortality. METHODS: A total of 2667 patients, who underwent MIDCAB procedures between 1996 and 2018, were divided into 3 groups on the basis of the year of surgery: group A, 1996-2003 (n = 1333); group B, 2004-2010 (n = 627) and group C, 2011-2018 (n = 707). Groupwise characteristics and early postoperative outcomes were compared. Long-term survival for all patients was analyzed and predictors for late mortality were identified using Cox proportional hazards methods. RESULTS: The mean age was 64.5 ± 10.9 years and 691 (25.9%) patients were female. Group C patients (log EuroSCORE I = 4.9 ± 6.9) were older with more cardiac risk factors and comorbidities than groups A (log EuroSCORE I = 3.1 ± 4.5) and B (log EuroSCORE I = 3.5 ± 4.7). Overall and groupwise in-hospital mortality was 0.9%, 1.0%, 0.6%, and 1.0% (P = .7), respectively. Overall 10-, 15-, and 20-year survival estimates for all patients were 77.7 ± 0.9%, 66.1 ± 1.2%, and 55.6 ± 1.6%, respectively. CONCLUSIONS: MIDCAB can be safely performed with very good early and long-term outcomes. In-hospital mortality remained constant over the 22-year period of the study despite worsening demographic profile of patients.

Incidence, Clinical Characteristics, and Impact of Absent Echocardiographic Signs in Patients With Infective Endocarditis After Transcatheter Aortic Valve Implantation.

BACKGROUND: Echocardiography is the primary imaging modality for diagnosis of infective endocarditis (IE) in prosthetic valve endocarditis (PVE) including IE after transcatheter aortic valve implantation (TAVI). This study aimed to evaluate the characteristics and clinical outcomes of patients with absent compared with evident echocardiographic signs of TAVI-IE. METHODS: Patients with definite TAVI-IE derived from the Infectious Endocarditis after TAVI International Registry were investigated comparing those with absent and evident echocardiographic signs of IE defined as vegetation, abscess, pseudo-aneurysm, intracardiac fistula, or valvular perforation or aneurysm. RESULTS: Among 578 patients, 87 (15.1%) and 491 (84.9%) had absent (IE-neg) and evident (IE-pos) echocardiographic signs of IE, respectively. IE-neg were more often treated via a transfemoral access with a self-expanding device and had higher rates of peri-interventional complications (eg, stroke, major vascular complications) during the TAVI procedure (P < .05 for all). IE-neg had higher rates of IE caused by Staphylococcus aureus (33.7% vs 23.2%; P = .038) and enterococci (37.2% vs 23.8%; P = .009) but lower rates of coagulase-negative staphylococci (4.7% vs 20.0%, P = .001). IE-neg was associated with the same dismal prognosis for in-hospital mortality in a multivariate binary regression analysis (odds ratio: 1.51; 95% confidence interval [CI]: .55-4.12) as well as a for 1-year mortality in Cox regression analysis (hazard ratio: 1.10; 95% CI: .67-1.80). CONCLUSIONS: Even with negative echocardiographic imaging, patients who have undergone TAVI and presenting with positive blood cultures and symptoms of infection are a high-risk patient group having a reasonable suspicion of IE and the need for an early treatment initiation.

Valve-in-Valve Transcatheter Aortic Valve Replacement Versus Redo Surgical Aortic Valve Replacement for Failed Surgical Aortic Bioprostheses: A Systematic Review and Meta-Analysis.

Background In the absence of randomized controlled trials, reports from nonrandomized studies comparing valve-in-valve implantation (ViV) to redo surgical aortic valve replacement (rAVR) have shown inconsistent results. Methods and Results PubMed/MEDLINE, Google Scholar, and CENTRAL (Cochrane Central Register of Controlled Trials) were searched through December 2021. Meta-Analysis of Observational Studies in Epidemiology guidelines were followed. The protocol was registered at the International Prospective Register of Systematic Reviews. Random effects models were applied. The primary outcomes of interest were short-term and midterm mortality. Secondary outcomes included stroke, myocardial infarction, acute renal failure, and permanent pacemaker implantation, as well as prosthetic aortic valve regurgitation, mean transvalvular gradient, and severe prosthesis-patient mismatch. Of 8881 patients included in 15 studies, 4458 (50.2%) underwent ViV and 4423 (49.8%) rAVR. Short-term mortality was 2.8% in patients undergoing ViV compared with 5.0% in patients undergoing rAVR (risk ratio [RR] 0.55 [95% CI, 0.34-0.91], P=0.02). Midterm mortality did not differ in patients undergoing ViV compared with patients undergoing rAVR (hazard ratio, 1.27 [95% CI, 0.72-2.25]). The rate of acute kidney failure was lower following ViV, (RR, 0.54 [95% CI, 0.33-0.88], P=0.02), whereas prosthetic aortic valve regurgitation (RR, 4.18 [95% CI, 1.88-9.3], P=0.003) as well as severe patient-prothesis mismatch (RR, 3.12 [95% CI, 2.35-4.1], P<0.001) occurred more frequently. The mean transvalvular gradient was higher following ViV (standard mean difference, 0.44 [95% CI, 0.15-0.72], P=0.008). There were no significant differences between groups with respect to stroke (P=0.26), myocardial infarction (P=0.93), or pacemaker implantation (P=0.21). Conclusions Results of this meta-analysis demonstrate better short-term mortality after ViV compared with rAVR. Midterm mortality was similar between groups. Given the likely selection bias in these individual reports, an adequately powered multicenter randomized clinical trial with sufficiently long follow-up in patients with low-to-intermediate surgical risk is warranted. Registration URL: crd.york.ac.uk/prospero/. Unique identifier: CRD42021228752.

Impact of Initial Operative Urgency on Short-Term Outcomes in Patients Treated with ECMO Due to Postcardiotomy Cardiogenic Shock.

The outcomes of patients with PCS and following ECMO therapy are associated with several preoperative risk factors. Our aim was to compare clinical presentation, ECMO-related data and in-hospital outcomes of patients treated with ECMO due to PCS after cardiac surgery, in regard to elective or emergent cardiac surgery procedures. Between April 2006 and October 2016, 164 consecutive patients that received VA-ECMO therapy due to PCS were identified and included in this retrospective cohort study. The patients were divided into groups based on the urgency of the initial procedures performed: elective group (ELG; n = 95) and an emergency group (EMG; n = 69). To compare the unequal patient groups, a propensity score-based matching (PSM) was applied (ELG, n = 56 vs. EMG, n = 56). The EMG primarily received ECMO intraoperatively (p ≤ 0.001). In contrast, the ELG were needed ECMO support more frequently postoperatively (p < 0.001). In-hospital mortality accounted for 71% (n = 40) in the ELG and 76% (n = 43) in the EMG (p = 0.518). Outcome data showed no major differences in the (abdominal ischemia (p = 0.371); septic shock (p = 0.393): rhythm disturbances (p = 0.575); emergency re-thoracotomy (p = 0.418)) between the groups. The urgency of the initial procedures performed is secondary in patients suffering PCS and following ECMO. In this regard, PCS itself seems to trigger outcomes in cardiac surgery ECMO patients substantially.

Impact of moderate or severe left ventricular outflow tract calcification on clinical outcomes of patients with severe aortic stenosis undergoing transcatheter aortic valve implantation with self- and balloon-expandable valves: a post hoc analysis from the SOLVE-TAVI trial.

BACKGROUND: Left ventricular outflow tract (LVOT) calcification has been associated with worse outcomes in patients undergoing transcatheter aortic valve implantation (TAVI) and may influence the selection of prosthetic valve type. AIMS: We aimed to evaluate the impact of LVOT calcification on outcomes after TAVI with a self-expanding valve (SEV) versus a balloon-expandable valve (BEV). METHODS: Patients of the SOLVE-TAVI trial, randomised to Edwards SAPIEN 3 or Medtronic Evolut R, were divided according to LVOT calcification into no/mild (≤1 calcium nodule extending <5 mm and covering <10% of the LVOT perimeter) and moderate/severe LVOT calcification groups. The primary endpoint was a composite of death, stroke, moderate/severe paravalvular regurgitation, permanent pacemaker implantation and annulus rupture at 30 days. Additional endpoints included all-cause and cardiovascular mortality at 1 year. RESULTS: Out of 416 eligible patients, moderate/severe LVOT calcification was present in 143 (34.4%). Moderate/severe LVOT calcification was associated with significantly longer fluoroscopy time and higher rates of pre- and post-dilation. Regardless of the LVOT calcification group, there was no significant difference in the primary endpoint associated with the valve type (no/mild LVOT calcification group: SEV 25.0% vs BEV 27.0%; hazard ratio [HR] 1.10, 95% confidence interval [95% CI]: 0.68-1.73; p=0.73 and moderate/severe LVOT calcification group: SEV 25.0% vs BEV 19.4%; HR 0.76, 95% CI: 0.38-1.61; p=0.49), no significant interaction between LVOT calcification and valve type (pint=0.29) and no differences between SEV vs BEV within LVOT calcification groups regarding 1-year all-cause and cardiovascular mortality. CONCLUSIONS: Moderate/severe LVOT calcification was associated with longer fluoroscopy time and an increased need for pre- and post-dilation, but not with a higher incidence of early and mid-term adverse clinical outcomes, regardless of valve type. (ClinicalTrials.gov: NCT02737150).

Early- and mid-term outcomes following redo surgical aortic valve replacement in patients with previous transcatheter aortic valve implantation.

OBJECTIVES: The aim of this study was to analyse the early- and mid-term outcomes after redo surgical aortic valve replacement (SAVR) in patients with previous transcatheter aortic valve implantation (TAVI). METHODS: Retrospective single-centre analysis of early- and mid-term outcomes following redo SAVR in patients with previous TAVI between 2013 and 2020. Primary outcomes were in-hospital mortality and mid-term survival. RESULTS: During the study period, a total of 5756 patients underwent TAVI. Among them, 28 (0.5%) patients required redo SAVR after TAVI. During periods 2013-2016 and 2017-2020, 4/2184 (0.2%) patients and 24/3572 (0.7%) patients required SAVR after TAVI, respectively. The median logistic EuroSCORE was significantly higher at the time of SAVR than at the time of the index TAVI (5.9% vs 11.6%; P < 0.001). The median elapsed time between TAVI and redo SAVR was 7 months (3.5-14 months). Infective endocarditis (IE) was the most frequent indication for surgery [19 (67.8%) patients]. A total of 11 (39.3%) patients underwent isolated SAVR and 17 (60.7%) SAVR + additional cardiac surgical procedures. The overall in-hospital mortality was 14.3% (4/28). In-hospital mortality was 15.8% (3/19) among IE patients and 11.1% (1/9) among non-IE patients (P = 0.7). Overall estimated survival was 66.5%, 59.9% and 48.0% at 12, 18 and 24 months, respectively. Patients with IE showed a trend towards a lower estimated mid-term survival compared to non-IE patients [41.6% (95% confidence interval: 22.0-78.0%) vs 58.3% (95% confidence interval: 30.0-100%) survival at 24 months (P = 0.3)]. CONCLUSIONS: SAVR can be successfully performed in patients with prior TAVI despite the increased surgical risk and technical difficulty. IE is associated with decreased mid-term survival.

Sex Differences in Infective Endocarditis After Transcatheter Aortic Valve Replacement.

BACKGROUND: Outcomes after transcatheter aortic valve replacement (TAVR) and infectious diseases may vary according to sex. METHODS: This multicentre study aimed to determine the sex differences in clinical characteristics, management, and outcomes of infective endocarditis (IE) after TAVR. A total of 579 patients (217 women, 37.5%) who had the diagnosis of definite IE following TAVR were included retrospectively from the Infectious Endocarditis After TAVR International Registry. RESULTS: Women were older (80 ± 8 vs 78 ± 8 years; P = 0.001) and exhibited a lower comorbidity burden. Clinical characteristics and microbiological profiles were similar between men and women, but culture-negative IE was more frequent in women (9.9% vs 4.3%; P = 0.009). A high proportion of patients had a clinical indication for surgery (54.4% in both groups; P = 0.99), but a surgical intervention was performed in a minority of patients (women 15.2%, men 20.3%; P = 0.13). The mortality rate at index IE hospitalisation was similar in both groups (women 35.4%, men 31.7%; P = 0.37), but women exhibited a higher mortality rate at 2-year follow-up (63% vs 52.1%; P = 0.021). Female sex remained an independent risk factor for cumulative mortality in the multivariable analysis (adjusted HR 1.28, 95% CI 1.02-1.62; P = 0.035). After adjustment for in-hospital events, surgery was not associated with better outcomes in women. CONCLUSIONS: There were no significant sex-related differences in the clinical characteristics and management of IE after TAVR. However, female sex was associated with increased 2-year mortality risk.

Risk Assessment of Coronary Obstruction During Transcatheter Aortic Valve Replacement: Insights From Post-BASILICA Computed Tomography.

OBJECTIVES: The aim of this study was to examine the predictive value of preprocedural computed tomography (CT)-based risk stratification of coronary obstruction during transcatheter aortic valve replacement (TAVR) on the basis of geometric measurements on postprocedural CT. BACKGROUND: Proper patient selection for additional procedures to prevent coronary obstruction during TAVR has not been adequately evaluated. METHODS: Pre- and postprocedural computed tomographic scans of 28 patients treated using bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA) and TAVR were analyzed. Using the postprocedural computed tomographic images, threatened coronary obstruction (TCO) was defined as: 1) ostial obstruction (adherence of the transcatheter heart valve [THV] to the coronary ostium with leaflet extension above the ostium); and/or 2) sinus sequestration (THV adherence to the sinotubular junction [STJ] with leaflet extension above the STJ) and was substratified into complete and incomplete types. RESULTS: A total of 51 leaflets were evaluated (88% surgical tissue valves) after excluding leaflets not visible on CT (n = 5). On postprocedural CT, complete TCO was observed in 25.4% (13 of 51 leaflets). On preprocedural CT, leaflets were at high risk for complete TCO (incidence 53%) if the virtual THV-to-coronary distance (VTC) was <3.0 mm, or if the virtual THV-to-STJ distance (VTSTJ) was <1.0 mm with STJ height - leaflet length <0 mm (leaflet-STJ mismatch). Leaflets were at low risk (incidence 0%) if the VTC was ≥3 mm and VTSTJ was ≥3.0 mm or STJ height - leaflet length was ≥+2.0 mm. Of 28 leaflets treated using BASILICA, complete TCO was seen in 35.7% (n = 10), due to sinus sequestration (100%) with coexisting ostial obstruction (30%). Actual coronary events occurred in 7.1% (n = 2) because of leaflet prolapse, corresponding to an absolute risk reduction by BASILICA of 29% (P = 0.021). CONCLUSIONS: Risk assessment of coronary obstruction after TAVR may improve with a multiparametric approach incorporating VTC, VTSTJ, and leaflet-STJ mismatch. BASILICA appeared to reduce actual coronary events even in leaflets with anticipated coronary obstruction.

Very early infective endocarditis after transcatheter aortic valve replacement.

BACKGROUND: Scarce data exist about early infective endocarditis (IE) after trans-catheter aortic valve replacement (TAVR). OBJECTIVE: The objective was to evaluate the characteristics, management, and outcomes of very early (VE) IE (≤ 30 days) after TAVR. METHODS: This multicenter study included a total of 579 patients from the Infectious Endocarditis after TAVR International Registry who had the diagnosis of definite IE following TAVR. RESULTS: Ninety-one patients (15.7%) had VE-IE. Factors associated with VE-IE (vs. delayed IE (D-IE)) were female gender (p = 0.047), the use of self-expanding valves (p < 0.001), stroke (p = 0.019), and sepsis (p < 0.001) after TAVR. Staphylococcus aureus was the main pathogen among VE-IE patients (35.2% vs. 22.7% in the D-IE group, p = 0.012), and 31.2% of Staphylococcus aureus infections in the VE-IE group were methicillin-resistant (vs. 14.3% in the D-IE group, p = 0.001). The second-most common germ was enterococci (34.1% vs. 24.4% in D-IE cases, p = 0.05). VE-IE was associated with very high in-hospital (44%) and 1-year (54%) mortality rates. Acute renal failure following TAVR (p = 0.001) and the presence of a non-enterococci pathogen (p < 0.001) were associated with an increased risk of death. CONCLUSION: A significant proportion of IE episodes following TAVR occurs within a few weeks following the procedure and are associated with dismal outcomes. Some baseline and TAVR procedural factors were associated with VE-IE, and Staphylococcus aureus and enterococci were the main causative pathogens. These results may help to select the more appropriate antibiotic prophylaxis in TAVR procedures and guide the initial antibiotic therapy in those cases with a clinical suspicion of IE. Very early infective endocarditis after trans-catheter aortic valve replacement. VE-IE indicates very early infective endocarditis (≤30 days post TAVR). D-IE indicates delayed infective endocarditis.