Multidimensional Prognostic Index and Outcomes in Older Patients Undergoing Transcatheter Aortic Valve Implantation: Survival of the Fittest.

Selecting patients with a high chance of endured benefit from transcatheter aortic valve implantation (TAVI) is becoming relevant with changing indications and increasing number of TAVI being performed. The aim of our study was to investigate the association of the multidimensional prognostic index (MPI) based on a comprehensive geriatric assessment (CGA) on survival. The TAVI Care & Cure program is a prospective, observational registry of patients referred for TAVI at the Erasmus MC University Medical Center. Consecutive patients who underwent a complete CGA and TAVI were included. CGA components were used to calculate the MPI score. The impact of the MPI score on survival was evaluated using Cox regression. Furthermore, 376 patients were included, 143 (38.0%) patients belonged to the MPI-1 group and 233 (61.9%) patients to the MPI-2-3 group. After 3 years, 14.9% of the patients in the MPI-1 group and 30.5% of the patients in the MPI-2-3 group died (p = 0.001). Patients in MPI-1 had increased chances of overall survival in comparison with patients in MPI group 2-3 Hazard Ratio (HR) 0.57, (95% Confidence Interval (CI) 0.33-0.98)). In this study we found that the MPI tool could be useful to assess frailty and to predict which patient will have a higher chance of enduring benefit from a TAVI procedure.

Heterogeneity of debris captured by cerebral embolic protection filters during TAVI.

AIMS: The aim of this study was to investigate the total amount, size and heterogeneity of debris captured among different transcatheter valve types and while repositioning. METHODS AND RESULTS: A total of 328 patients who underwent transcatheter aortic valve implantation (TAVI) with the SENTINEL cerebral embolic protection (CEP) at our centre were eligible. Histopathological and semiquantitative analysis of captured debris was performed and data were entered into our prospective database. TAVI was performed with either the Evolut R/PRO (N=123), SAPIEN 3 (N=113) or Lotus valve (N=92). Capture of debris occurred in 98% of patients. Lotus TAVI resulted in more frequent foreign body material (62% vs 40% vs 47%, p=0.006), endothelium (49% vs 30% vs 16%, p<0.0005), calcified material (33% vs 12% vs 24%, p=0.001) and myocardial tissue (19% vs 11% vs 2%, p<0.0005) compared to SAPIEN 3 or Evolut R/PRO. Native (functional) bicuspid valves (OR 2.91, 95% CI: 1.20-7.03, p=0.02) and Lotus (OR 2.44, 95% CI: 1.14-5.24, p=0.02) were associated with the highest risk for dislodging particles ≥1,000 um. Valve repositioning was independently associated with larger amounts of debris (OR 2.96, 95% CI: 1.42-6.16, p=0.004). CONCLUSIONS: All THV platforms had similar amounts of captured debris. THV repositioning seemed to be associated with a higher risk for dislodging greater amounts of debris to the brain.

The digital heart-lung unit: applications of exponential technology.

Exponential technologies such as virtual reality (VR), computational modelling, and additive manufacturing have emerged in the field of cardiology and cardiothoracic surgery. An increasing number of publications that evaluate the clinical role of these technologies are becoming available. Moreover, there is an increase in the number of hospitals and departments that have implemented digital and exponential solutions in clinical workflow. In our centre, we have adopted various exponential technologies in order to improve clinical pre-procedural workflow, patient care, and training and education. In order to provide our view and approach on the implementation of these technologies, in this article, we provide an overview of the currently applied modalities including immersive VR, three-dimensional (3D) computational modelling, VR-based simulations, and additive manufacturing (3D printing). Moreover, we present the potential of these applications in cardiovascular and cardiothoracic medicine, and additionally, we will provide key facilitators, challenges, and recommendations to adopting these technologies in clinical practice.

Impact of frailty on health-related quality of life 1 year after transcatheter aortic valve implantation.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) brings symptom relief and improvement in health-related quality of life (HRQoL) in the majority of patients treated for symptomatic, severe aortic stenosis. However, there is a substantial group of patients that do not benefit from TAVI. The aim of this study is to investigate the impact of frailty on HRQoL 1 year after TAVI. METHODS: The TAVI Care & Cure Program is an ongoing, prospective, observational study including patients referred for TAVI to our institution. A comprehensive geriatric assessment was performed to evaluate existence of frailty using the Erasmus Frailty Score (EFS). HRQoL was assessed using the EQ-5D-5 L at baseline and 1 year after TAVI. RESULTS: 239 patients underwent TAVI and completed HRQoL assessment 1 year after TAVI. Seventy (29.3%) patients were classified as frail (EFS ≥ 3). In non-frail patients, the EQ-5D-5 L index did not change (0.71(± 0.22) to 0.68(± 0.33) points, P = 0.22); in frail patients, the EQ-5D-5 L index decreased from 0.55(±0.26) to 0.44 points (±0.33) (P = 0.022). Frailty was an independent predictor of deteriorated HRQoL 1 year after TAVI (OR 2.24, 95% CI 1.07-4.70, P = 0.003). In frail patients, the absence of peripheral artery disease (OR 0.17, 95% 0.05-0.50, P = 0.001) and renal dysfunction (OR 0.13, 95% CI 0.04-0.41, P = <0.001) at baseline was associated with improved HRQoL 1 year after TAVI. CONCLUSION: Frailty is associated with deterioration of HRQoL 1 year after TAVI. Notably, HRQoL did improve in frail patients with no peripheral arterial disease or renal impairment at baseline.

Association between pulmonary vein orientation and atrial fibrillation-free survival in patients undergoing endoscopic laser balloon ablation.

AIMS: Obtaining optimal pulmonary vein (PV) occlusion with the endoscopic laser balloon ablation system (EAS) can be difficult, hypothetically influenced by PV geometry. The aim of this study was to determine the impact of PV orientation on atrial fibrillation (AF)-free survival after PV isolation (PVI) using the EAS. METHODS AND RESULTS: Forty-three patients undergoing a single EAS PVI were included. Left atrial electrocardiogram -triggered computed tomography was performed in all patients prior to PVI. Of all four PVs, the orientation at the insertion in the left atrium was measured in both the transverse and frontal plane and assigned to one of the four orientation groups: ventral-caudal, dorsal-caudal, ventral-cranial, and dorsal-cranial. Mean age was 56 years; 86% had paroxysmal AF. Overall, AF-free survival after a median follow-up of 18.2 months was 51.2%. AF-free survival varied between 21 and 88% depending on left upper PV orientation (P = 0.045). Furthermore, AF-free survival varied between 21 and 86% depending on left lower PV orientation (P = 0.010) and AF-free survival varied between 29 and 88% depending on right lower PV orientation (P = 0.053). No association was found between right upper PV orientation and AF-free survival after EAS PVI (P = 0.794). In multivariate analysis, only left lower PV orientation was associated with AF-free survival [hazards ratio (HR) 10.4, P = 0.019]. CONCLUSION: PV orientation is associated with AF-free survival after EAS PVI. PV orientation assessment may be useful for selecting the most suitable patients for EAS PVI.

Pulmonary vein orientation assessment: Is it necessary in patients undergoing contact force sensing guided radiofrequency catheter ablation of atrial fibrillation.

PURPOSE: We hypothesized that pulmonary vein (PV) orientation influences tissue contact of the contact force (CF) sensing radiofrequency ablation catheter (CFC) and therefore atrial fibrillation (AF) free survival after pulmonary vein isolation (PVI). The aim of this study was to determine the association between PV orientation, CF and AF free survival in patients undergoing CFC PVI. METHODS: Sixty consecutive patients undergoing CFC PVI were included. ECG-triggered cardiac CT scans were obtained in all patients before PVI, and the PV orientation was measured at the insertion in the LA for all PVs in both the transverse and frontal plane. PVs were assigned to 1 of 4 orientation groups: ventral-caudal, dorsal-caudal, ventral-cranial and dorsal-cranial. RESULTS: Mean age was 59 years, 88% had paroxysmal AF. AF free survival off anti-arrhythmic drugs after a median follow-up of 12 months was 58% after a single PVI procedure. No association was found between PV orientation and CF. Furthermore, no association was found between PV orientation and AF free survival. In univariate analysis, the number of lesions with a mean CF of 10 g was associated with AF free survival. However, in multivariate analysis, only the AF duration was significantly associated with AF free survival. CONCLUSIONS: This study shows that in patients undergoing PVI with the CFC ablation system, PV orientation does not affect CF and is not associated with AF free survival. PV orientation assessment does not appear to be necessary in patients undergoing CFC PVI.