Impact of the Clinical Frailty Scale on Long-term Outcomes After Transcatheter Aortic Valve Implantation.

BACKGROUND: The semiquantitative Clinical Frailty Scale (CFS) is reportedly a useful marker for predicting short- and mid-term mortality after transcatheter aortic valve implantation (TAVI). We assessed the long-term prognostic impact of CFS in patients with severe aortic stenosis undergoing TAVI. METHODS: We prospectively assessed patients undergoing TAVI in Kokura Memorial Hospital using a 9-level CFS and enrolled 1594 patients after excluding patients with CFS 8-9. The patients were divided into the low (CFS level, 1-3; N = 842), intermediate (4; N = 469), and high (5-7; N = 283) groups according to their CFS levels. RESULTS: In the low, intermediate, and high groups, 3-year all-cause mortality rates were 17.4%, 29.4%, and 41.7% (P <0.001) and composite rates of cardiovascular mortality and heart failure hospitalization were 12.1%, 19.1%, and 23.9% (P <0.001), respectively. Multivariable analysis showed that higher frailty was independently associated with all-cause mortality (intermediate group: adjusted hazard ratio [HR], 1.63, 95% confidence interval [CI], 1.24-2.15, P <0.001; high group: adjusted HR, 2.18, 95% CI, 1.59-2.99, P <0.001) and composite of cardiovascular mortality and heart failure hospitalization (intermediate group: adjusted HR, 1.47, 95% CI, 1.04-2.08, P = 0.030; high group: adjusted HR, 1.66, 95% CI, 1.09-2.51, P = 0.018) and this result was consistent, irrespective of stratification based on age, sex, body mass index, left ventricular ejection fraction, Society of Thoracic Surgeons score, and New York Heart Association functional class without significant interaction. CONCLUSIONS: The simple CFS tool predicts the long-term adverse outcomes post-TAVI.

Successful Balloon-Expandable Transcatheter Aortic Valve Replacement for Extremely Large Annulus (>1,000 mm2).

Transcatheter aortic valve replacement in extra-large annulus is challenging because of the limited sizes and data of the current commercial prosthesis sizes available. We present a case of successful transcatheter aortic valve replacement with a new balloon-expandable SAPIEN 3 Ultra RESILIA valve for an aortic annulus area >1,000 mm2 on computed tomography.

Association between left atrial low-voltage area and induction and recurrence of macroreentrant atrial tachycardia in pulmonary vein isolation for atrial fibrillation.

BACKGROUND: The relationship between induction and recurrence due to atrial tachycardia (AT) and left atrial (LA) matrix progression after atrial fibrillation (AF) ablation remains unclear. METHODS: One hundred fifty-two consecutive patients with paroxysmal and persistent AF who underwent pulmonary vein isolation (PVI) and cavo-tricuspid isthmus (CTI) ablation and achieved sinus rhythm before the procedure were classified into three groups according to the AT pattern induced after the procedure: group N (non-induced), F (focal pattern), and M (macroreentrant pattern) in 3D mapping. RESULTS: The total rate of AT induction was 19.7% (30/152) in groups F (n = 13) and M (n = 17). Patients in group M were older than those in groups N and F, with higher CHADS2/CHA2DS2-VASc values, left atrial enlargement, and low-voltage area (LVA) size of LA. The receiver operating characteristic curve determined that the cut-off LVA for macroreentrant AT induction was 8.8 cm2 (area under the curve [AUC]: 0.86, 95% confidence interval [CI]: 0.75-0.97). The recurrence of AT at 36 months in group N was 4.1% (5/122), and at the second ablation, all patients had macroreentrant AT. Patients with AT recurrence in group N had a wide LVA at the first ablation, and the cut-off LVA for AT recurrence was 6.5 cm2 (AUC 0.94, 95%CI 0.88-0.99). Adjusted multivariate analysis showed that only LVA size was associated with the recurrence of macroreentrant AT (odds ratio 1.21, 95%CI 1.04-1.51). CONCLUSIONS: It is important to develop a therapeutic strategy based on the LVA size to suppress the recurrence of AT in these patients.

Assessing Potential Risks of Future Redo Transcatheter Aortic Valve Replacement in Asian Patients.

Background: In the Asian cohort, data are limited on the risk for coronary obstruction due to sinus of Valsalva (SOV) sequestration in redo transcatheter aortic valve replacement (TAVR) procedures. Objectives: The aim of this study was to assess the potential risk for coronary obstruction in simulated redo TAVR in Asian patients. Methods: Post-TAVR computed tomographic data from 788 patients who received balloon-expandable (BE) SAPIEN 3 transcatheter aortic valves (TAVs) and 334 patients who received self-expanding (SE) Evolut R or Evolut PRO TAVs were analyzed. The risk for coronary obstruction due to SOV sequestration in redo TAVR, defined as the TAV commissure level above the sinotubular junction (STJ) and a TAV-to-STJ distance <2.0 mm in each coronary sinus, was retrospectively evaluated. Results: The potential risks for coronary obstruction due to SOV sequestration at 1 or both coronary arteries were identified in 52.1% of the BE TAV group and 71.3% of the SE TAV group (P < 0.001). After adjusting for multiple covariates, STJ diameter, STJ height, TAV oversizing degree by area, and implantation depth were independently associated with SOV sequestration risk in the BE TAV group, whereas STJ diameter and implantation depth were independently associated with SOV sequestration risk in the SE TAV group. Conclusions: Coronary obstruction due to SOV sequestration in redo TAVR may occur in a substantial number of Asian patients. This finding suggests the importance of considering the structural feasibility of future redo TAVR when implanting the first TAV, especially in Asian patients with long life expectancy.

Impact of Transjugular Intracardiac Echocardiography-Guided Self-Expandable Transcatheter Aortic Valve Implantation on Reduction of Conduction Disturbances.

BACKGROUND: A high permanent pacemaker implantation (PPI) risk remains a concern of self-expandable transcatheter aortic valve implantation, despite the continued improvements in implantation methodology. We aimed to assess the impact of real-time direct visualization of the membranous septum using transjugular intracardiac echocardiography (ICE) during transcatheter aortic valve implantation on reducing the rates of conduction disturbances including the need for PPI. METHODS: Consecutive patients treated with Evolut R and Evolut PRO/PRO+ from February 2017 to September 2022 were included in this study. We compared outcomes between the conventional implantation method using the 3-cusps view (3 cusps without ICE group), the recent method using cusp-overlap view (cusp overlap without ICE group), and our novel method using ICE (cusp overlap with ICE group). RESULTS: Of the 446 patients eligible for analysis, 211 (47.3%) were categorized as the 3 cusps without ICE group, 129 (28.9%) were in the cusp overlap without ICE group, and 106 (23.8%) comprised the cusp overlap with ICE group. Compared with the 3 cusps without ICE group, the cusp overlap without ICE group had a smaller implantation depth (2.2 [interquartile range, 1.0-3.5] mm versus 4.3 [interquartile range, 3.3-5.4] mm; P<0.001) and lower 30-day PPI rates (7.0% versus 14.2%; P=0.035). Compared with the cusp overlap without ICE group, the cusp overlap with ICE group had lower 30-day PPI rates (0.9%; P=0.014), albeit with comparable implantation depths (1.9 [interquartile range, 0.9-2.9] mm; P=0.150). Multivariable analysis showed that our novel method using ICE with the cusp-overlap view was independently associated with a 30-day PPI rate reduction. There were no group differences in 30-day all-cause mortality (1.4% versus 1.6% versus 0%; P=0.608). CONCLUSIONS: Our novel implantation method using transjugular ICE, which enable real-time direct visualization of the membranous septum, achieved a predictably high position of prostheses, resulting in a substantial reduction of conduction disturbances requiring PPI after transcatheter aortic valve implantation.

Zero-Contrast Left Atrial Appendage Closure in Patients With Chronic Kidney Disease.

BACKGROUND: Left atrial appendage closure (LAAC) usually requires contrast medium during the procedure. However, patients with chronic kidney disease (CKD) are at high risk of developing contrast nephropathy. This study aimed to assess the safety and feasibility of zero-contrast LAAC in patients with CKD.Methods and Results: Zero-contrast LAAC was attempted in 15 patients with CKD Stages 3b-5 who were not on hemodialysis. All procedures were performed successfully, without any periprocedural complications. At the 45-day follow-up, no device-related complications or acute kidney disease were observed. CONCLUSIONS: The strategy of zero-contrast LAAC in patients with CKD can be an acceptable option.