Feasibility of Transcatheter Aortic Valve Implantation in Patients With Very Severe Aortic Stenosis.

Background: Very severe aortic stenosis (AS) has a poor prognosis even in asymptomatic patients, and asymptomatic very severe AS is a Class IIa indication for aortic valve replacement, although the safety and effectiveness of transcatheter aortic valve implantation (TAVI) for very severe AS is not well-established. Methods and Results: This study included 366 patients undergoing TAVI at a single center, with 85 and 281 patients in the very severe AS (peak velocity ≥5 m/s or mean pressure gradient (PG) ≥60 mmHg) and severe AS groups, respectively. Procedural and clinical outcomes at 1-year follow-up were compared between groups. The calcium scores were significantly higher in the very severe AS group (2,864.5 vs. 1,405.8 arbitrary units [AU] (P<0.001). Although the patient-prosthesis mismatch rate was higher in the very severe AS group (38.3% vs. 25.7%; P=0.029), there was no significant difference in the early safety and clinical efficacy between the groups (16.5% vs. 17.1% and 12.0% vs. 18.9%, respectively). Similarly, there was no significant difference in all-cause mortality at 1 year (4.8% vs. 9.8%). Conclusions: Despite a higher incidence of prosthesis-patient mismatch in those with very severe AS, the procedural and clinical outcomes were comparable to those in patients with severe AS. TAVI may be a reasonable treatment option for very severe AS.

Additive value of the right parasternal view for the assessment of aortic stenosis.

BACKGROUND: Although Doppler evaluation using a multiplanar method is recommended to assess the severity of aortic stenosis (AS) with transthoracic echocardiography, evidence on the diagnostic significance of a non-apical method is limited. This study aimed to compare the use of the apical with the use of the right parasternal view (RPV) method to evaluate AS severity and to examine the diagnostic significance of performing the RPV method in addition to the apical method during the evaluation. METHODS: This retrospective observational study included 276 consecutive patients (mean age: 79 ± 10 years; women, 56%) with severe AS (aortic valve area [AVA] ≤1.0cm2 ). The severity of AS according to the apical method and that according to the RPV for all subjects were compared, and the significance of performing the RPV method in addition to the apical method was examined. Furthermore, we compared the concordance group, in which the apical and RPV methods indicated matching in severity, and the discordant group, in which the apical and RPV methods did not indicate matching severity. RESULTS: Peak velocity (Vmax ), mean pressure gradient (MG) were significantly higher and the AVA, AVAi, and Doppler velocity index (DVI) were significantly smaller when the RPV was added to the apical view. Performing the RPV method in addition to the apical method significantly decreased the number of low PG AS cases (MG < 40 mmHg) from 69.9% to 65.0% and it increased the number of very severe AS cases (Vmax ≥ 5 m/s) from 8.7% to 14.5%. Deviation of Doppler angle was significantly greater in the discordant group compared to the concordant group (22.5 ± .6 vs. 31.8 ± 1.7, p < .001). CONCLUSIONS: By performing the RPV method in addition to the apical method to determine AS severity, the diagnosis of AS to be resolved in approximately 10% of cases. These results suggest that AS severity may be underestimated by using the apical method alone.