Determinants of success and hemodynamic impact of balloon postdilatation of self-expanding transcatheter aortic valves

OBJECTIVES: To explore the rate, the determinants of success, and the hemodynamic impact of balloon postdilatation (BPD) of self-expanding transcatheter heart valves (SE-THVs) Background: BPD is commonly used to optimize valve expansion and reduce paravalvular leakage (PVL) after transcatheter aortic valve implantation (TAVI) without clearly knowing its hemodynamic benefits. METHODS: Patients (n 5 307) who received a SE-THV were stratified according to whether a BPD was performed or not. Patients who received BPD were stratified according to the severity of PVL remaining after BPD into two groups: Successful BPD ( mild PVL 1 BPD) and Failed BPD (moderate-severe PVL 1 BPD). RESULTS: BPD was performed in 121 patients (39.4%) and was successful in 106 patients (87.6% of attempts). A ratio of the postdilatation balloon diameter to the annulus diameter 0.95 was an independent predictor of BPD failure (OR: 10.72 [2.02-56.76], P 5 .005). Peak transvalvular pressure gradient (PG) was lower in the Successful BPD group (14[12-22] mm Hg) than in the Failed BPD group (18[16-23] mm Hg, P 5 .029), and did not rise in either group during follow-up (median [IQR], 364[161-739] days). CONCLUSION: BPD was performed in 39% of patients who received a SE-THV, and was successful in the majority of attempts. BPD failure was more likely in patients with a small postdilatation balloon-to-annulus diameter ratio. Effective BPD improved THV hemodynamic performance, and this was maintained in the intermediate-term post-TAVI.

Angiographic assessment of aortic regurgitation by video-densitometry in the setting of TAVI: echocardiographic and clinical correlates

We sought to investigate a new angiographic method for aortic regurgitation (AR) severity assessment in the setting of transcatheter aortic valve implantation (TAVI). AR after TAVI is common but challenging to quantitate, especially in the cath-lab. In 228 patients, AR was quantitated before and after TAVI by echocardiography and by video-densitometric analysis of aortograms. Contrast time– density curves for the aortic root (the reference region) and the left ventricular outflow tract, LVOT were generated. LVOT-AR was calculated as the area under the curve of the LVOT as a fraction of the area under the curve of the reference region. LVOT-AR was 0.10 6 0.08, 0.13 6 0.10 and 0.28 6 0.14 in none-trace, mild and moderate-severe post-TAVI AR as defined by echocardiography (P 0.17 corresponded to moderate-severe AR on echocardiography (area under the curve 5 0.84). At follow-up (median, 496 days), patients with LVOT-AR 0.17 showed a significant reduction of LV mass index (LVMi; 121 [95–148] vs. 140 [112– 169] g/m2 , P 5 0.009) and the prevalence of LV hypertrophy (LVH; 64 vs. 88%, P 5 0.001) compared to baseline. In patients with LVOT-AR > 0.17, LVMi (149 [121–178] vs. 166 [144–188] g/m2 , P 5 0.14) and the prevalence of LVH (74 vs. 87%, P 5 0.23) did not show a significant change. Compared to patients with LVOT-AR 0.17, those with LVOT-AR > 0.17 had an increased 30-day (16.4% vs. 7.1%, P 5 0.035) and one year mortality (32.9 vs. 14.2%, log rank P value 5 0.001; HR: 2.690 [1.461–4.953], P 5 0.001). LVOT-AR > 0.17 corresponds to greater than mild AR as defined by echocardiography and predicts impaired LV reverse remodeling and increased early and midterm mortality after TAVI.

Prevalence, predictors, and prognostic implications of residual impairment of functional capacity after transcatheter aortic valve implantation

Background Patients with degenerative aortic stenosis(AS) referred for transcatheter aortic valve implantation(TAVI) typically have advanced cardiac and vascular adverse remodeling and multiple comorbidities and,therefore, might not recover a normal functional capacity after valve replacement. We sought to investigate the prevalence, the predictors, and the prognostic impact of residual impairment of functional capacity after TAVI. Methods and results Out of 790 patients undergoing TAVI with impaired functional capacity (NYHA II–IV) at baseline, NYHA functional class improved in 592 (86.5%) andremained unchanged/worsened in 92 (13.5%) at follow-up[median (IQR): 419 (208–807) days] after TAVI. Normal functional capacity (NYHA I) was recovered in 65.5%(n = 448) of patients, while the rest had variable degrees of residual impairment. On multivariable regression analysis,atrial fibrillation [odds ratio-OR, 2.08 (1.21–3.58), p = 0.008],low-flow–low-gradient AS [OR, 1.97 (1.09–3.57),p = 0.026], chronic obstructive pulmonary disease [OR, 1.92(1.19–3.12), p = 0.008], and lower hemoglobin at baseline[OR, 1.11 (1.01–1.21) for each g% decrement, p = 0.036]were independently associated with residual impairment offunctional capacity. All-cause and cardiac mortality weresignificantly higher in those with residual impairment of functional capacity than in those in NYHA I class [hazard ratioHR:2.37 (95% CI: 1.51–3.72), p/0.001 and 2.16 (95% CI:1.08–4.35), p = 0.030, respectively]. Even mild residual functional impairment (NYHA II) was associated with a higherall-cause [HR: 2.02 (95% CI: 1.10–3.72), p = 0.023] andcardiac [HR: 2.08 (95% CI: 1.42–3.07), p/0.001] mortality. Conclusion Residual impairment of functional capacity iscommon after TAVI and is independently associated with increased mortality. Predictors of residual impairment of functional status are predominantly patient-rather than procedure-related.

Transcatheter aortic valve implantation for mixed versus pure stenotic aortic valve disease

In addition to patients with pure/predominant aortic stenosis (PAS), real-world transcatheter aortic valve implantation(TAVI) referrals include patients with mixed aortic valve disease (MAVD; severe stenosis+moderate-severe regurgitation). We sought to compare TAVI outcomes in patients with MAVD vs. PAS. Out of 793 consecutive patients undergoing TAVI, 106 (13.4%) had MAVD. Patients with MAVD were younger and had a higher operative risk, a more severe adverse cardiac remodelling, and a worse functional status than patients with PAS. Moderate-severe prosthetic valve regurgitation (PVR) was significantly more frequent in patients with MAVD than in patients with PAS (15.7% vs. 3.6%, p=0.003), even after propensity-score and multivariable adjustments. Moderate-severe PVR was associated with increased one-year mortality in patients with PAS (log-rank p=0.002), but not in patients with MAVD (log-rank p=0.27). Eventually, all-cause and cardiac mortality as well as the functional capacity were similar in the two study groups up to one year. A significant proportion of patients referred for TAVI in a real-world registry has MAVD. Moderate-severe AR at baseline can influence the rate and modify the clinical sequelae of post-TAVI PVR. Eventually, clinical outcomes in patients with MAVD are comparable to those in patients with PAS in the acute and midterm phases, in spite of a baseline higher risk. MAVD should not be considered a contraindication for TAVI.

Estrategias de tratamiento y estratificación del riesgo en los síndromes coronarios agudos: ¿cómo identificar a los pacientes que se pueden beneficiar de un abordaje invasivo temprano? / Treatment strategies and risk stratification in acute coronary syndrome: how do we identify patients who would benefit from early invasive treatment?

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