Improved Screening Reduces Transesophageal Study Cancellations at a Large Tertiary Israeli Medical Center.

BACKGROUND: Cancellation of transesophageal echocardiography (TEE) tests leads to inefficient use of echocardiography laboratory (echo lab) time and wastes resources. OBJECTIVES: To identify the causes of same-day TEE cancellations in hospitalized patients, to formulate a TEE order screening protocol, and to evaluate its efficacy at implementation. METHODS: We performed a prospective analysis of inpatients referred to a single tertiary hospital echo lab for TEE study by inpatient wards. A comprehensive screening protocol emphasizing active participation of all links directly involved in the chain of inpatient TEE referral was developed and implemented. Comparison of pre- and post-implementation of the new screening protocol on two consecutive periods of 6 months on TEE cancellation rates out of total ordered TEEs stratified by cause categories was performed. RESULTS: : In total, 304 inpatient TEE procedures were ordered during the initial observation period; 54(17.8%) were canceled on the same day. The most common cancellation reasons were equally respiratory distress and patient not in fasted state (20.4% of total cancellations and 3.6% of all scheduled TEEs for each cause). Following implementation of the new screening process, total TEEs ordered (192) and cancelled (16) dropped significantly. A decrease in the rate of each cancellation category was observed, with statistical significance achieved for the overall cancellation rate (8.3% vs. 17.8%, P = 0.003), but not for the individual cancellation categories in split analysis. CONCLUSIONS: A concerted effort to implement a comprehensive screening questionnaire significantly reduced same-day cancellations of scheduled TEEs.

Tricuspid Structural Valve Deterioration Treated with a Transcatheter Valve-in-Valve Implantation: A Single-Center Prospective Registry.

The valve-in-valve (ViV) technique is an emerging alternative for the treatment of bioprosthetic structural valve deterioration (SVD) in the tricuspid position. We report on the outcomes of patients treated by a transcatheter tricuspid valve-in-valve (TT-ViV) implantation for symptomatic SVD in the tricuspid position during the years 2010-2019 at our center. Three main outcomes were examined during the follow-up period: TT-ViV hemodynamic data per echocardiography, mortality and NYHA functional class. Our cohort consisted of 12 patients with a mean age 65.4 ± 11.9 years, 83.3% male. The mean time from initial valve intervention to TT-ViV was 17.4 ± 8.7 years. The indications for TT-ViV were varied (41.7% for predominant regurgitation, 33.3% for predominant stenosis and 25.0% with a mixed pathology). All patients were treated with a balloon-expandable device. The mean follow-up was 3.4 ± 1.3 years. Tricuspid regurgitation was ≥ moderate in 57.2% of patients prior to the procedure and this decreased to 0% following the procedure. The mean transtricuspid valve gradients mildly decreased from the mean pre-procedural values of 9.0 mmHg to 7.0 mmHg at one month following the procedure (p = 0.36). Mortality at one year was 8.0% (95% CI 0-23). At the baseline, 4 patients (33.3%) were in NYHA functional class III/IV; this was reduced to 2 patients (18.2%) at the one year follow-up and both were in NYHA III. The TT-ViV procedure offered a safe, feasible and less invasive treatment option for patients with SVD in our detailed cohort.

Five-Year Outcomes of Patients With Mitral Structural Valve Deterioration Treated With Transcatheter Valve in Valve Implantation - A Single Center Prospective Registry.

The Valve-in-Valve (ViV) technique is an emerging alternative for the treatment of bioprosthetic structural valve deterioration (SVD) in the mitral position. We report on intermediate-term outcomes of patients with symptomatic SVD in the mitral position who were treated by transcatheter mitral valve-in-valve (TM-ViV) implantation during the years 2010-2019 in our center. Three main outcomes were examined during the follow-up period: NYHA functional class, TM-ViV hemodynamic data per echocardiography, and mortality. Our cohort consisted of 49 patients (mean age 77.4 ± 10.5 years, 65.3% female). The indications for TM-ViV were mainly for regurgitant pathology (77.6%). All 49 patients were treated with a balloon-expandable device. The procedure was performed via transapical access in 17 cases (34.7%) and transfemoral vein/trans-atrial septal puncture in 32 cases (65.3%). Mean follow-up was 4.4 ± 2.0 years. 98% and 91% of patients were in NYHA I/II at 1 and 5 years, respectively. Mitral regurgitation was ≥moderate in 86.3% of patients prior to the procedure and this decreased to 0% (p < 0.001) following the procedure and was maintained over 2 years follow-up. The mean trans-mitral valve gradients decreased from pre-procedural values of 10.1 ± 5.1 mmHg to 7.0 ± 2.4 mmHg at 1 month following the procedure (p = 0.03). Mortality at 1 year was 16% (95%, CI 5-26) and 35% (95%, CI 18-49) at 5 years. ViV in the mitral position offers an effective and durable treatment option for patients with SVD at high surgical risk.

The clinical value of the endocarditis team: insights from before and after guidelines implementation strategy.

PURPOSE: To evaluate the impact of a multidisciplinary the "Endocarditis Team" (ET) on the course and outcome of infective endocarditis (IE) patients. METHODS: A retrospective before-after study, including hospitalized patients with definite IE, managed before (01.2013-12.2015) and after (01.2016-07.2019) the introduction of an ET. The primary outcomes were defined as 30-day and 1-year mortality and the secondary as conservative vs. invasive strategy, the interval from clinical suspicion of IE to the performance of echocardiography, utilization of multimodality evaluation, time to an invasive procedure, and the duration of hospitalization. RESULTS: Study population included 92 pre-ET and 128 post-ET implementation patients. Baseline characteristics were similar. During the post-ET period compared with pre-ET, we found higher rates of abscesses and extra-cardiac emboli (27.8% vs. 16.3%, p = 0.048); and a higher invasive procedures rate, including lead extraction (15.6% vs. 6.5%, p = 0.035) and noncardiac surgeries (14.8% vs. 6.5%, p = 0.05). Patients managed during the post-ET period had reduced short (8.5% vs. 17.4%, p = 0.048) and long-term mortality (Log-rank = 0.001). In multivariate analysis of risk factors for long-term mortality, period (pre- or post-ET) was not found to be significantly associated with the mortality. CONCLUSION: Establishment of an ET was associated with faster and more intensive evaluation of patients with IE. During the period of an ET activity, mortality rates were reduced compared with the previous period.

Comparison of Simultaneous Transthoracic Versus Transesophageal Echocardiography for Assessment of Aortic Stenosis.

Transthoracic echocardiography (TTE) is the gold standard for aortic stenosis (AS) assessment. Transesophageal echocardiography (TEE) provides better resolution, but its effect on AS assessment is unclear. To answer this question, we studied 56 patients with ≥moderate AS. Initial TTE (TTE1) was followed by conscious sedation with simultaneous TEE and TTE2. Based on conservative versus actionable implication, AS types were dichotomized into group A, comprising moderate and normal-flow low-gradient, and group B, comprising high gradient, low ejection fraction low-flow low-gradient, and paradoxical low-flow low-gradient AS. Paired analysis of echocardiographic variables and AS types measured by TEE versus TTE2 and by TEE versus TTE1 was performed. TEE versus simultaneous TTE2 comparison demonstrated higher mean gradients (31.7 ± 10.5 vs 27.4 ± 10.5 mm Hg) and velocities (359 ± 60.6 vs 332 ± 63.1 cm/s) with TEE, but lower left ventricular outflow velocity-time-integral (VTI1) (18.6 ± 5.1 vs 20.2 ± 6.1 cm), all p <0.001. This resulted in a lower aortic valve area (0.8 ± 0.21 vs 0.87 ± 0.28 cm2), p <0.001, and a net relative risk of 1.86 of group A to B upgrade. TEE versus (awake state) TTE1 comparison revealed a larger decrease in VTI1 because of a higher initial awake state VTI1 (22 ± 5.6 cm), resulting in similar Doppler-velocity-index and aortic valve area decrease with TEE, despite a slight increase in mean gradients of 0.8 mm Hg (confidence interval -1.44 to 3.04) and velocities of 10 cm/s (confidence interval -1.5 to 23.4). This translated into a net relative risk of 1.92 of group A to B upgrade versus TTE1. In conclusion, TEE under conscious sedation overestimates AS severity compared with both awake state TTE and simultaneous sedation state TTE, accounted for by different Doppler insonation angles obtained in transapical versus transgastric position.

Severe aortic stenosis echocardiographic thresholds revisited.

BACKGROUND: In view of inconsistencies in threshold values of severe aortic stenosis (AS) hemodynamic indices, it is unclear what is the relative contribution of each variable in a binary classification of AS based on aortic valve replacement (AVR) indication. We aimed to assess relative discriminative value and optimal threshold of each constituent hemodynamic parameter for this classification and confirm additional prognostic value. METHODS: Echocardiography studies of 168 patients with ≥ moderate AS were included. AS types were dichotomized into Group-A, comprising moderate and Normal-Flow Low-Gradient (NFLG), and Group-B, comprising High-Gradient(HG), Low Ejection Fraction Low-Flow Low-Gradient(Low EF-LFLG), and Paradoxical Low-Flow Low-Gradient(PLFLG) AS. Aortic valve area (AVA), Doppler velocity index (DVI), peak aortic velocity, mean gradient, stroke volume index and transaortic flow rate(TFR) were assessed for A/B Group discrimination value and optimal thresholds were determined. Dichotomized values were assessed for predictive value for AVR or death. RESULTS: C-statistic values for binary AS classification was .74-.9 for the tested variables. AVA and DVI featured the highest score, and SVI the lowest one. AVA≤.81 cm2 and DVI≤.249 had 87.6% and 86% respective sensitivity for Group B patients, and a similar specificity of 80.9%. During a mean follow-up of 9.1±10.1 months, each of the tested dichotomized variables except for SVI predicted AVR or death on multivariate analysis. CONCLUSION: An AVA value ≤.81 cm2 or a DVI ≤ .249 threshold carry the highest discriminative value for severe AS in patients with aortic stenosis, translating into an independent prognostic value, and can be helpful in making clinical decisions.

Myocardial extracellular volume quantification by computed tomography predicts outcomes in patients with severe aortic stenosis.

BACKGROUND: The extent of myocardial fibrosis in patients with severe aortic stenosis might have an important prognostic value. Non-invasive imaging to quantify myocardial fibrosis by measuring extracellular volume fraction might have an important clinical utility prior to aortic valve intervention. METHODS: Seventy-five consecutive patients with severe aortic stenosis, and 19 normal subjects were prospectively recruited and underwent pre- and post-contrast computed tomography for estimating myocardial extracellular volume fraction. Serum level of galectin-3 was measured and 2-dimensional echocardiography was performed to characterize the extent of cardiac damage using a recently published aortic stenosis staging classification. RESULTS: Extracellular volume fraction was higher in patients with aortic stenosis compared to normal subjects (40.0±11% vs. 21.6±5.6%; respectively, p<0.001). In patients with aortic stenosis, extracellular volume fraction correlated with markers of left ventricular decompensation including New York Heart Association functional class, left atrial volume, staging classification of aortic stenosis and lower left ventricular ejection fraction. Out of 75 patients in the AS group, 49 underwent TAVI, 6 surgical AVR, 2 balloon valvuloplasty, and 18 did not undergo any type of intervention. At 12-months after aortic valve intervention, extracellular volume fraction predicted the combined outcomes of stroke and hospitalization for heart failure with an area under the curve of 0.77 (95% confidence interval: 0.65-0.88). A trend for correlation between serum galectin-3 and extracellular volume was noted. CONCLUSION: In patients with severe aortic stenosis undergoing computed tomography before aortic valve intervention, quantification of extracellular volume fraction correlated with functional status and markers of left ventricular decompensation, and predicted the 12-months composite adverse clinical outcomes. Implementation of this novel technique might aid in the risk stratification process before aortic valve interventions.

Long-term outcomes of catheter-based intervention for clinically significant paravalvular leak.

BACKGROUND: In most centres, clinically significant percutaneous paravalvular leak (PVL) closure following valve replacement surgery is reserved for those considered high-risk for surgery. There is a paucity of data regarding the long-term outcomes of these patients. AIMS: Our goals were to assess the long-term outcomes of patients undergoing percutaneous PVL closure. METHODS: A total of 100 consecutive transcatheter PVL closure procedures (74 mitral, 26 aortic) were performed in 95 patients between February 2005 and August 2019 at our hospital. Data collected included procedural success rates, indication-specific outcomes and mortality. RESULTS: Mean follow-up was 5.6±6.1 years, mean age 62.6±15.2 years, and 45.4% were female. The device was successfully implanted in 88 procedures (88.0%). Patients who presented with heart failure (n=57) had a significant improvement in NYHA classification (29.2% Class III/IV versus 100.0%, p<0.001). For patients who presented with haemolytic anaemia (n=38), haemoglobin increased (11.94±1.634 vs 9.72±1.49, p<0.001) and LDH levels were reduced (1,354.90±1,225.55 vs 2,039.40±1,347.20, p<0.001) following the procedure. Rates of mortality were 3.8% at 90 days, 15.6% after 1 year, and 27.2% after 5 years. CONCLUSIONS: For patients who are deemed intermediate- to high-risk for repeat surgery, transcatheter PVL closure shows reasonable clinical success rates, with a significant improvement in symptoms, and a relatively low rate of periprocedural complications.

Trends in Ischemic Mitral Regurgitation Following ST-Elevation Myocardial Infarction Over a 20-Year Period.

Background: Ischemic mitral regurgitation (IMR) is a common complication of acute ST-elevation myocardial infarction (STEMI). Little is known regarding the impact of IMR over a long period of follow up. Methods: Of 3,208 consecutive STEMI patients from a prospective registry, full echocardiographic information was available for 2,985 patients between the years 2000 and 2020. We compared the two decades- 2001 to 2010 and 2011 to 2020, and assessed for the presence of IMR at baseline, 3 (range 2-6) months and 12 (range 10-14) months after the index event. Results: One thousand six hundred and sixty six patients were included in the first decade, 1,319 in the second. Mean patient age was 61.3 ± 12.3 years, 21.1% female patients in the first decade vs. 60.9 ± 12.0 years and 22.2% female in the second (p = 0.40 and p = 0.212, respectively). Rates of moderate IMR or above during the index admission were 17.2% in the first period and 9.3% in the second one (p < 0.001). After 3 months, the rate of IMR was 48.5% for those who suffered from IMR at baseline, vs. 9.5% for those without IMR at baseline (HR- 4.2, p < 0.001). Death rates for those with moderate IMR or above were 14.7% and 17.8% after 1 and 2 years, respectively, vs. 7.3 and 9.6% for those without (p < 0.001 for both). IMR was associated with 1 year mortality in multivariate analysis (HR-1.37; 1.09-2.20, p = 0.009), as well as in propensity score matched analysis (HR 1.29; CI: 1.07-1.91; p < 0.001). Conclusions: IMR is a common complication following acute STEMI, impacting prognosis. Rates of IMR have declined significantly over the years.

[DIFFERENT ANESTHESIA APPROACHES IN THE TRANSCATHETER AORTIC VALVE IMPLANTATION (TAVI) PROCEDURE AND THEIR POSSIBLE EFFECT ON MORBIDITY AND MORTALITY].

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is used in patients with severe aortic stenosis (AS) who are at high surgical risk. Pre- and post-operative management is challenging as these patients are older, have significant comorbidities and a very high expected mortality rate in conventional surgery. There is no consensus in the literature about the preferred form of anesthesia, however, currently most centers perform the procedure using local anesthesia with sedation (LA-S). OBJECTIVES: To compare general anesthesia (GA) and LA-S in patients undergoing TAVI. METHODS: A retrospective review of the first 100 patients who underwent TAVI (11/2008-6/2011) at the Rabin Medical Center, due to severe and symptomatic AS and a counter-indication for conventional valve replacement surgery. RESULTS: A total of 46 patients underwent the procedure with GA and 54 with LA-S. In 63 patients, the transfemoral approach was used, transapical in 23, and transaxillary in 11. There were no significant differences in short- and long-term mortality, but average hospitalization was longer in the GA group. A larger proportion of patients needed norepinephrine and blood transfusions during the procedure in the GA group. In the LA-S group, more conduction, vascular complications and postoperative fever were observed. In comparisons between anesthesia methods with the transfemoral approach, most of the differences lost their significance. Therefore, these differences are most likely attributed to the surgical approach and not to the anesthesia method. CONCLUSIONS: There is no clear preference for GA in TAVI. LA-S appears to be an effective and safe option for eligible patients.

Long-Term Functional and Structural Durability of Bioprosthetic Valves Placed in the Aortic Valve Position via Percutaneous Rout in Israel.

There is limited organized "real life" data regarding the long-term structural and functional durability of transcatheter aortic valve implants, a topic of major importance. We assessed the 5-year structural and functional integrity outcomes following trans-catheter aortic valve implantation (TAVI) with both self-expandable and balloon-expandable prosthetic valve devices. This study included 450 consecutive patients who underwent TAVI for severe symptomatic aortic stenosis (AS) between September 2008 and December 2011. Data were acquired from a multicenter Israeli registry and the median follow up time was 5.6 years. In 184 patients (40.9%) who survived 5 years, prostheses displayed sustained hemodynamic performance, with average peak and mean aortic valve gradients of 16.2 ± 8.9 and 9.2 ± 6.6 mm Hg, respectively. Late structural valve deterioration was found in 22 (12.3%) patients. Of these, 16 (8.9%) experienced valve deterioration and 6 (3.3%) experienced valve failure. Among the 6 patients with bioprosthetic valve failure, only 3 underwent re-interventions. Bioprosthetic valve dysfunction occurred more frequently in patients with small valves (23 mm) and high peak and mean transvalvular gradients at baseline. In conclusion, a relatively low rate of valve deterioration or failure was noted in our long-term follow-up study after TAVI procedures with both the catheter-based self-expandable and balloon-expandable prosthetic valves.

Echocardiographic Assessment of Aortic Stenosis under Sedation Underestimates Stenosis Severity.

BACKGROUND: Sedation can impact aortic stenosis (AS) classification, which depends on left ventricular ejection fraction (<≥ [less than or greater than and/or equal to] 50%), aortic valve area (AVA<≥ 1 cm2), mean pressure gradient (<≥ 40 mm Hg), peak velocity <≥ 400 cm/sec, and stroke volume index (SVI <≥35 mL/m2). We compared AS classification by transthoracic echo (TTE) during wakefulness versus sedation. METHODS: Immediately following a baseline TTE performed during wakefulness, another TTE was done during sedation delivered for a concomitant transesophageal study in 69 consecutive patients with AS (mean age 78 ± 7 years, 32 males). AVA was calculated through the continuity equation using the relevant hemodynamic parameters measured by each TTE study and same left ventricular outflow tract. AS class was defined as moderate, severe high gradient (HG), low ejection fraction low flow low gradient (LF-LG), paradoxical LF-LG (PLFLG), and normal flow low gradient (NF-LG). Based on conservative versus invasive treatment implication, AS classes were aggregated into group A (moderate AS and NFLG) and group B (HG, low-EF LF-LG, and PLFLG). RESULTS: During sedation, systolic and diastolic blood pressure decreased by 14.3 ± 29 and 8 ± 22 mm Hg, respectively, mean pressure gradient from 30.4 ± 10.9 to 27.2 ± 10.8 mm Hg, peak velocity from 345.3 ± 57.7 to 329.3 ± 64.8 cm/m2, and SVI from 41.5 ± 11.3 to 38.3 ± 11.8 mL/m2 (all P < .05). Calculated AVA was similar (delta = -0.009 ± 0.15 cm2). Individual discrepancies in hemodynamic parameters between the paired TTE studies resulted in an overall 17.4% rate of AS intergroup misclassification with sedation, with a relative risk of 1.09 of downgrade misclassification from group B to A versus upgrade misclassification (P < .001). CONCLUSIONS: Sedation TTE assessment downgrades AS severity in a significant proportion of patients, with a conversely smaller proportion of patients being upgraded, and therefore cannot be a substitute for wakefulness assessment.

Long-term Israeli Single-Center Experience with the Percutaneous MitraClip Procedure.

BACKGROUND: The MitraClip procedure is becoming an acceptable alternative for high-risk patients with mitral regurgitation (MR) due to functional (FMR) or degenerative (DMR) disease and suitable mitral anatomy. OBJECTIVES: To evaluate the results of MitraClip at our institute in carefully selected patients. METHODS: We conducted a retrospective analysis of medical records and echocardiography data from January 2012 to December 2017. RESULTS: A total of 39 MitraClip procedures in 37 patients (aged 75 ± 12 years, 9 women) was performed. Twenty-four patients presented with FMR, 12 with DMR, and 1 with combined pathology. One-day post-procedure MR was moderate to low in 86.1% of patients, with immediate device success in 88.8%. MR at 1 year was moderate to low in 79% at 1 year. Survival at 1 year was 86% and at 2 years 69.4%. Peri-procedural (< 1 week) death and MitraClip failure occurred in one and three patients, respectively. New York Heart Association score improved to class 1 or 2 in 37% of patients at 1 year vs. one patient at baseline. Post-procedural systolic pulmonary pressure was reduced from 53 (range 48-65) to 43 (range 36-52) mmHg at 1 month with a subsequent plateau at follow-up, to 41 (34-57) mmHg at 6 months, and to 47 (38-50) at 12 months. CONCLUSIONS: MitraClip in severe MR resulted in modest improvement in functional status and pulmonary pressure with a small risk of immediate procedural complications. Outcomes are encouraging considering the natural course of MR and the risks of surgical intervention.

Prevalence, Echocardiographic Correlations, and Clinical Outcome of Tricuspid Regurgitation in Patients with Significant Left Ventricular Dysfunction.

PURPOSE: We initiated this study to evaluate the prevalence and clinical significance of tricuspid regurgitation in patients with left ventricular dysfunction. METHODS: A single-center analysis of all echocardiographic studies between 2000 and 2013 was performed. Patients with ejection fraction <35% were included, and those with mechanical valves, mitral stenosis, or significant aortic valve pathology were excluded. Patients were grouped based on tricuspid regurgitation severity (nonsignificant, moderate, and severe). Demographic and echocardiographic findings and survival were compared. RESULTS: The study included 3943 patients (74% male, age 69 ± 14 years); 70% had nonsignificant, 24% had moderate, and 6% had severe tricuspid regurgitation. In a multivariate model, tricuspid regurgitation was independently associated with older age (odds ratio [OR] 1.009; 95% confidence interval [CI], 1.001-1.017; P = .022), female sex (OR 1.644; 95% CI, 1.329-2.035; P < .001), atrial fibrillation (OR 1.764; 95% CI, 1.429-2.134; P < .001), tricuspid regurgitation gradient (OR 1.051; 95% CI, 1.045-1.058; P < .001 per mm Hg), right ventricular dysfunction (OR 3.492; 95% CI, 2.870-4.248; P < .001), left atrial area (cm2, OR 1.031; 95% CI, 1.013-1.049; P < .001), mitral regurgitation severity (P < .001), and lack of hypertension (OR 0.760; 95% CI, 0.616-0.936; P = .010) or obesity (OR 0.583; 95% CI, 0.427-0.796; P < .001). Patients were followed for a median of 8.15 years (interquartile range 4.75-11.42). Median survival was 4.88 years for nonsignificant, 2.3 years for moderate, and 1.6 years for patients with severe tricuspid regurgitation, significantly associated with tricuspid regurgitation severity (hazard ratio 1.513; 95% CI, 1.383-1.656 for moderate, hazard ratio 1.857; 95% CI, 1.606-2.148 for severe tricuspid regurgitation; P < .001), the association persisted after multiple adjustments. CONCLUSIONS: Significant tricuspid regurgitation is common in patients with left ventricular dysfunction. It is linked to various cardiac pathologies and independently associated with increased mortality.

Transcatheter aortic valve implantation versus conservative treatment in chronic kidney disease patients.

AIMS: There are no studies comparing transcatheter aortic valve implantation (TAVI) to conservative management in patients with chronic kidney disease stage 3-5 and severe aortic stenosis. We sought to compare the mortality rate and change in renal function in this patient population. METHODS AND RESULTS: This was a single-centre retrospective cohort study that included all patients with chronic kidney disease stage 3-5 and severe aortic stenosis who underwent TAVI or were treated conservatively between 2010 and 2015. Three hundred and sixty patients were included (162 TAVI and 198 conservatively treated patients). Several statistical methods were used, including propensity score matching and inverse probability weighting. Mean follow-up was 1.9 years. Conservative management was associated with a hazard ratio of 3.95 (95% CI: 2.59-6.02) for mortality compared with TAVI. After one year there was a significant decrease in renal function in the control group (39.6±13.9 ml/min to 34.4±15.3 ml/min), but not in the TAVI group (41.7±13 ml/min to 42.9±14.5 ml/min) (p-value=0.001). CONCLUSIONS: TAVI is associated with improved survival in patients with aortic stenosis and chronic kidney disease stage 3-5 compared to conservative management and protects from further decline in renal function up to one-year follow-up.

MitraClip-induced systolic anterior motion complicated by pericardial effusion: A case report.

Systolic anterior motion (SAM) of the anterior mitral leaflet is a well reported complication of surgical mitral valve repair (MVR). In the current report, we present a case of SAM with left ventricular outflow tract obstruction (LVOTO) which occurred after transcatheter mitral valve repair (TMVR) using the MitraClip device. LVOTO was caused by the combination of protrusion of the MitraClip device into the LVOT and underfilling of the left ventricle due to pericardial effusion and atrial fibrillation. Rapid clinical resolution and marked decline in LVOT pressure gradient occurred following surgical drainage and windowing of the pericardium. We conclude that SAM and LVOTO could occur after TMVR. Seeking and addressing reversible aggravators of LVOTO including pericardial effusion is essential and could potentially make the difference between a successful procedure and a failed one. © 2016 Wiley Periodicals, Inc.

Transcatheter aortic valve implantation in degenerative sutureless perceval aortic bioprosthesis.

Sutureless aortic bioprostheses (SAB) are increasingly being used to provide shorter cross-clamp time. Valve-in-valve transcatheter aortic valve replacement (VIV-A) is shown to be effective and safe in the vast majority of patients with degenerated bioprosthetics, yet its' use in SAB failure is infrequent. We present a case of balloon-expandable VIV-A in an 80-year-old woman who suffered severe symptomatic aortic regurgitation in a failed Perceval S 21-mm valve. Computed tomography scan demonstrated a deformed valve. Our heart team favored a percutaneous VIV-A over reoperation due to the patients' high surgical risk. An Edwards-Sapien XT 23 mm was successfully deployed with excellent results. The patient remained asymptomatic following 6 months. As other bioprosthesis, some sutureless valves are condemned to structural valve degeneration. Because VIV-A is being established for managing degenerative bioprosthesis in high risk patients, it is cardinal to identify its role in novel degenerative sutureless valves. SAB were introduced to the clinical market only 5-7 years ago. The absence of sutures may theoretically impose risk for valve instability when adding a transcatheter sutureless valve inside the first one. Our successful experience was very reassuring. We report its feasibility because we believe it should provide support for further investigation on VIV-A within novel SAV. © 2016 Wiley Periodicals, Inc.

Usefulness of the CHA2DS2-VASc Score to Predict Outcome in Patients Who Underwent Transcatheter Aortic Valve Implantation.

Risk assessment for transcatheter aortic valve implantation (TAVI) patients remains challenging, especially in elderly and high-risk candidates. Although several risk factors contribute to increased morbidity and mortality after TAVI, simple risk scores for routine use are lacking. Applying the CHA2DS2-VASC (congestive heart failure, hypertension, age ≥ 75 years, diabetes, prior stroke, vascular disease, age 65-74 years, sex [female] category) score as a novel risk stratification tool for conditions other than atrial fibrillation and stroke prevention has been previously examined; however, its usefulness in a population of patients with aortic stenosis after TAVI has not been established. Thus, we investigated 633 consecutive patients who underwent TAVI between November 2008 and May 2017, and calculated the CHA2DS2-VASC score. Patients were stratified according to their CHA2DS2-VASC score into 3 categories (0 to 3, 4 to 6, 7 to 9), and the association between CHA2DS2-VASC score and 1-year clinical outcomes (stroke, all-cause mortality, and combined outcome of stroke or mortality) was evaluated. We found that both stroke and mortality at 1 year were significantly more frequent with increasing CHA2DS2-VASC score (p = 0.012 and p = 0.025, respectively). Each single-point rise in CHA2DS2-VASC score was associated with a 38% increase in the 1-year combined outcome of mortality or stroke (p = 0.022; C index 0.615). In conclusion, CHA2DS2-VASC score can be used as a simple and effective tool to predict 1-year clinical outcomes including death and stroke in patients who underwent TAVI.

Transcatheter Aortic Valve Implantation Futility Risk Model Development and Validation Among Treated Patients With Aortic Stenosis.

Risk-benefit assessment for transcatheter aortic valve implantation (TAVI) is still evolving. A sizeable group of patients do not fully benefit from intervention despite a technically successful procedure. All patients who underwent TAVI with device success and with no Valve Academic Research Consortium (VARC)-2 defined complications were included. Various demographic data, clinical details, and echocardiographic findings were examined. The outcome was defined as 1-year composite of mortality, stroke, lack of functional-class improvement (by New York Heart Association class), and readmissions (≥1 month after the procedure). Logistic regression was used to fit the prediction model. We used a 10-fold cross-validation to validate our results. Of 543 patients, 435 met the inclusion criteria. The mean age was 82 (±6.5) years, 43% were men, and the mean Society of Thoracic Surgeons score was 6.6 (±4.7). At 1 year, 66 of 435 patients (15%) experienced the study end point. The final logistic regression model included diabetes, baseline New York Heart Association functional class, diastolic dysfunction, need for diuretics, mean gradient, hemoglobin level, and creatinine level. The area under the curve was 0.73 and was reduced to 0.71 after validation, with a 97% specificity using a single cutoff. Dividing to low-, medium-, and high-risk groups for futility produced a corresponding prevalence of 6%, 19%, and 59% futility. A web application for the prediction model was developed and provided. In conclusion, this prediction score may provide an important insight and may facilitate identification of patients who, despite a technically successful and uncomplicated procedure, have risk that may outweigh the benefit of a contemplated TAVI.

Prognostic significance of aortic valve gradient in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement.

OBJECTIVE: To evaluate the effect of baseline aortic valve gradient (AVG) both as a continuous and a categorical variable on mortality in patients undergoing transcatheter aortic valve replacement (TAVR), focusing on the high-gradient severe aortic stenosis (AS) patients. BACKGROUND: Identifying new predictors of mortality in the TAVR population can help refine risk stratification and improve the patient selection process for this procedure. So far, AVG has mainly been studied as a categorical variable and there is a paucity of data on its prognostic value as a continuous variable, especially in patients with high AVG AS, who constitute the majority of patients referred for TAVR. METHODS: We analyzed data on 1,224 consecutive symptomatic severe AS patients, who underwent TAVR at 3 centers. The relation between pre-TAVR AVG and mortality was evaluated among all patients and in patients with high AVGs (mean AVG ≥40 mm Hg) using the Cox proportional hazard model adjusting for multiple variables. RESULTS: During a mean follow-up of 1.8 years, baseline AVG was inversely associated with mortality in the entire cohort and in patients with high AVG AS. By multivariable analysis, patients with mean AVG 40-60 mm Hg and >60 mm Hg had a respective 38% (P = 0.010) and 61% (P < 0.001) reduction in mortality compared to patients with mean AVG <40 mm Hg. Every 10 mm Hg increase in mean AVG was associated with 20% reduction in mortality (P < 0.001). Analyses among patients with high (mean AVG >40 mm Hg) and very high AVG AS (mean AVG >60 mm Hg) yielded similar results (HR = 0.88, P = 0.031, and HR = 0.80, P = 0.019, per 10 mm Hg increase in AVG, respectively). Using peak AVGs and an analysis restricted to patients without reduced ejection fraction yielded consistent results. CONCLUSIONS: Baseline AVGs show an inverse association with mortality post-TAVR. These results were consistent also in patients with high-gradient AS, suggesting that AVG can be used to identify patients most likely to benefit from TAVR.