Changes of Right Ventricular Function After Transcatheter Aortic Valve Replacement and Association With Outcomes.

BACKGROUND: Baseline right ventricular (RV) dysfunction represents a predictor for poor outcome in patients undergoing transcatheter aortic valve replacement (TAVR). However, RV function may improve after TAVR, which could have important implications on outcomes. The aim of the present study was to assess changes in RV function after TAVR and its prognostic value regarding clinical outcome. METHODS AND RESULTS: Patients undergoing TAVR at our institution were consecutively enrolled and categorized into 4 groups according to changes in RV function during echocardiographic follow-up at 6 months. A total of 188 patients were included. Of those showing normal function at baseline, 87% (130/149) had preserved RV function at follow-up (group 1), whereas 13% (19/149) developed new RV dysfunction (group 2). Of those with RV dysfunction at baseline (39 patients), RV function normalized in 46% (18/39) (group 3) and remained impaired in 54% (21/39) (group 4). The Kaplan-Meier estimated survival at 3 years was highest in patients in group 1 (83%), intermediate in group 2 (65%) and 3 (69%), whereas group 4 had the worst survival (37%; P < .001). Furthermore, new or persistent RV dysfunction was identified to be independently associated with mortality during follow-up (hazard ratio 2.55; interquartile range 1.03-6.47, P = .004). CONCLUSIONS: Patients with preserved RV function have a high 3-year survival. Normalization of RV function showed improved survival compared with patients with persistent RV dysfunction, who had a dismal prognosis despite TAVR.

Impact of sinus rhythm versus atrial fibrillation on left ventricular remodeling after transcatheter aortic valve replacement.

AIMS: Atrial fibrillation (AF) is associated with increased mortality after transcatheter aortic valve replacement (TAVR). Cerebrovascular complications and bleeding events associated with anticoagulation therapy are discussed to be possible causes for this increased mortality. The present study sought to assess whether AF is associated with impaired left ventricular (LV) reverse remodeling representing another possible mechanism for poor outcome. METHODS: All patients who underwent TAVR in our institution and had 1-year echocardiography follow-up were included. LV mass index (LVMI) at baseline and follow-up as well as LVMI change at 1 year were assessed with respect to the presence of AF (either at baseline or during hospitalization after TAVR) and sinus rhythm (SR). RESULTS: A total of 213 patients (n = 95 in AF; n = 118 in SR) were enrolled in the present study. Patients with AF had higher LVMI at 1 year compared to those with SR (173 ± 61 g/m2 vs. 154 ± 55 g/m2; p = 0.02) and they showed lower relative LVMI change at 1 year (- 2 ± 28% vs. - 9 ± 29%; p = 0.04). In linear regression analysis, AF was independently associated with relative LVMI change (regression coefficient ß 0.076 [95% CI 0.001-0.150]; p = 0.04). With respect to clinical outcome depending on AF and LVMI regression, the Kaplan-Meier estimated event-free of death or cardiac rehospitalization at 3 years was lowest among patients with AF and no LVMI regression. CONCLUSIONS: The present study identified a significant association of AF with changes in LVMI after TAVR, which was also shown to be associated with clinical outcome.

Dose-Dependent Effect of Renin-Angiotensin System Blockade Following Transcatheter Aortic Valve Replacement.

BACKGROUND: There is growing body of evidence from retrospective studies that renin-angiotensin system (RAS) blockade is associated with improved outcome after transcatheter aortic valve replacement (TAVR). However, it remains unknown whether the effect of RAS blockade is dose dependent. The current study sought to assess the dose-dependent effect of RAS blockade on survival and left-ventricular (LV) remodelling after TAVR. METHODS: Patients who were enrolled into our observational TAVR study at our institution were retrospectively assessed according to different doses of RAS blockade: group 1 (no RAS blockade), group 2 (25% of maximum daily dose), group 3 (50% of maximum daily dose), and group 4 (full daily dose). RESULTS: A total of 323 patients between January 2015 and September 2019 were included. Patients with higher doses of RAS blockade showed a trend toward higher overall survival at 3-year follow-up (56% with no RAS blockade vs 66% with the 25% dose vs 79% with the 50% dose vs 78% with the full dose; P = 0.063). After adjustment for baseline characteristics, the difference in survival was significant (P = 0.042). Besides New York Heart Association class and left-ventricular ejection fraction (LVEF), RAS blockade dose was identified as independent predictor for all-cause mortality (hazard ratio [HR] 0.72; 95% confidence interval [CI], 0.54-0.97; P = 0.03). With respect to LV remodelling, a significantly larger reduction of LV mass index was observed during the follow-up with higher doses of RAS blockade. CONCLUSIONS: The current study showed that the impact of RAS blockade treatment on clinical outcome and LV remodelling after TAVR is dose dependent.

Prognostic Impact of Left Atrial Function Following Transcatheter Mitral Valve Repair.

Background Left atrial ( LA ) function predicts clinical outcome in a variety of cardiovascular diseases. However, limited data are available in the setting of mitral regurgitation. The aim of the present study was to assess potential changes in LA ejection fraction (LAEF) and its prognostic value in patients following transcatheter mitral valve repair using the MitraClip. Methods and Results A total of 88 consecutive patients undergoing MitraClip implantation with complete echocardiography at baseline and follow-up between 3 and 6 months postprocedure were enrolled. LAEF improved in 58% of the population. Change in LAEF was associated with residual mitral regurgitation, residual transmitral gradient and left ventricular ejection fraction changes. Compared with their counterparts, patients with residual mitral regurgitation ≥grade 2 (change in LAEF, -6% [Interquartile [IQR], -9-1%] versus 4% [IQR, -5-15%]; P=0.05) and with residual transmitral gradient ≥5 mm Hg (change in LAEF, -2% [IQR, -9-9%] versus 5% [IQR, -4-16%]; P=0.03) showed a decline in LAEF , respectively. Furthermore, LAEF significantly correlated with changes in left ventricular ejection fraction ( r=0.40; P=0.001). With regards to clinical outcome, heart failure symptoms as assessed by New York Heart Association class were more severe in patients with worsened LAEF at follow-up. Finally, LAEF change was identified as an independent predictor of all-cause mortality (hazard ratio, 0.94; 95% CI, 0.90-0.98 [ P=0.008]). Conclusions The present analysis showed that changes in LA function in patients undergoing MitraClip implantation are associated with important measures including residual mitral regurgitation, elevated transmitral gradient, and left ventricular function. Importantly, LA function alterations represent a strong predictor for all-cause mortality.

Reverse Cardiac Remodeling After Transcatheter Treatment of Severe Tricuspid Regurgitation Using the Edge-to-Edge MitraClip Technique.

OBJECTIVES: In recent years, transcatheter treatment techniques for tricuspid regurgitation (TR) have rapidly evolved. Cardiac remodeling analysis beyond clinical outcome assessment following transcatheter tricuspid repair is still lacking. The aim of the present case series was to analyze cardiac remodeling after tricuspid valve repair using the edge-to-edge MitraClip technique. METHODS: Echocardiographic analysis was performed prior to MitraClip implantation and at 3-month and 6-month follow-up exams. RESULTS: Six consecutive patients undergoing MitraClip implantation between April 2017 and March 2018 at our institution were enrolled. During follow-up, TR reduction was durable in all patients, without recurrence of severe TR. Compared to baseline, right ventricular function improved in 5 out of 6 patients. Reduction in right ventricular area was observed in the majority of patients and reduction in right atrial volume was observed in all subjects. Patients also experienced beneficial left cardiac remodeling. CONCLUSION: The present series indicates that transcatheter treatment of severe TR using the edge-to-edge MitraClip technique can lead to reverse cardiac remodeling, which is not commonly seen in surgically treated patients.

Emergency treatment of decompensated aortic stenosis.

OBJECTIVE: The optimal treatment of patients with acute and severe decompensation of aortic stenosis is unclear due to recent advances in transcatheter interventions and supportive therapies. Our aim was to assess the early outcome of emergency transcatheter aortic valve implantation (eTAVI) versus emergency balloon aortic valvuloplasty (eBAV) followed by TAVI under elective circumstances. METHODS: Emergency conditions were defined as: cardiogenic shock with requirement of catecholamine therapy, severe acute dyspnoea (NYHA IV), cardiac resuscitation or mechanic respiratory support. The data were collected according to the Valve Academic Research Consortium 2 (VARC-2) criteria. RESULTS: In five German centres, 23 patients (logistic Euroscore 37.7%±18.1) underwent eTAVI and 118 patients underwent eBAV (logistic Euroscore 35.3%±20.8). In the eTAVI group, immediate procedural mortality was 8.7%, compared with 20.3% for the eBAV group (p=0.19). After 30 days, cardiovascular mortality for the eTAVI group was 23.8% and for the eBAV group 33.0% (p=0.40). Analyses adjusting for potential confounders did not provide evidence of a difference between groups. Of note, the elective TAVI performed after eBAV (n=32, logistic Euroscore 25.9%±13.9) displayed an immediate procedural mortality of 9.4% and a cardiovascular mortality after 30 days of 15.6%. Major vascular complications were significantly more likely to occur after eTAVI (p=0.01) as well as stroke (p=0.01). CONCLUSION: In this multicentre cohort, immediate procedural and 30-day mortality of eTAVI and eBAV were high, and mortality of secondary TAVI subsequent to eBAV was higher than expected. Randomised study data are required to define the role of emergency TAVI in tertiary care centres with current device generations.