Prognostic Value of Shock Index Creatinine in Patients With Severe Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement.

INTRODUCTION:   Shock index (SI) and its derivatives have been reported to have prognostic value in various cardiovascular diseases. This study aims to ascertain the utility of shock index creatinine (SIC) in predicting mid-term mortality among patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR). METHODS: We conducted a retrospective analysis of 555 patients with severe AS who underwent TAVR from April 2016 to March 2023. SIC was calculated as (SI × 100) - estimated creatinine clearance (CCr). The primary endpoint was all-cause mortality during the follow-up period, and secondary endpoints included in-hospital complications as defined by the Valve Academic Research Consortium-3 (VARC-3) criteria. Patients were stratified into two groups based on the optimal cut-off value determined by the receiver operating characteristic (ROC) curve. Cox regression analysis was employed to identify independent predictors of all-cause mortality. Additionally, restricted cubic spline (RCS) was deployed to illustrate the relationship between SIC and mortality risk. The predictive performance of risk scores was evaluated using the area under the ROC curve (AUC). RESULTS: Over a mean follow-up period of 21.5 months, there were 51 cases of all-cause mortality. Patients with a high SIC, identified by a cut-off of 16.5, exhibited a significantly higher cumulative all-cause mortality compared to those with a low SIC (18.3% vs. 5.2%, p < 0.001; adjusted HR=2.188; 95% CI 1.103-4.341, p = 0.025). Patients with a high SIC were older (p = 0.002) and exhibited a higher prevalence of frailty (p<0.001). Furthermore, they exhibited a heightened probability of moderate or severe mitral regurgitation (p < 0.001), tricuspid regurgitation (p < 0.001), and pulmonary hypertension (p < 0.001) compared to those with a low SIC. In terms of perioperative complications, acute kidney injury (10.1% vs. 3.9%, p = 0.008) and bleeding (13.6% vs. 6.7%, p = 0.014) were more prevalent in patients with a high SIC. The RCS demonstrated a positive correlation between SIC and all-cause mortality rate. Furthermore, incorporating high SIC into the STS score improved its predictive value for 1-year all-cause mortality (AUC: 0.731 vs. 0.649, p=0.01). CONCLUSION: Patients with a high SIC are more likely to experience frailty and cardiac damage and exhibit an increased in-hospital and mid-term mortality rate. SIC may provide additional information for risk stratification of patients undergoing TAVR.

Gender-Dependent Association of Pulmonary Hypertension with Adverse Outcomes in Patients Undergoing Transcatheter Aortic Valve Replacement.

Background: The relationship between pulmonary hypertension (PH) and outcomes after transcatheter aortic valve replacement (TAVR) has been shown to be unfavorable. The impact of gender on TAVR outcomes remains controversial. There have been no studies evaluating the simultaneous effects of both factors on TAVR outcomes. Methods: We retrospectively analyzed a prospective cohort of patients who underwent TAVR between January 2016 and December 2022. The patients were stratified by gender and the presence of PH. The primary outcome of the study was all-cause mortality. Secondary outcome was a composite of all-cause mortality and heart failure hospitalization. Results: We identified a total of 133 female patients without PH, 179 males without PH, 87 females with PH, and 122 males with PH. The median follow-up period was 18 months. Female patients without PH demonstrated a lower cumulative mortality rate compared to those with male gender and/or PH. Adjusted multivariate Cox proportional hazard analyses revealed that male gender and PH status, either individually or in combination, were independently associated with long-term mortality when compared to female patients without PH. Specifically, females with PH (HR 6.80, 95% confidence interval (CI): 1.49-31.12, P=0.013), males without PH (HR 6.45, 95% CI: 1.47-28.22, P=0.013), and males with PH (HR 7.2, 95% CI: 1.63-31.81, P=0.009) demonstrated significantly higher risk for mortality. Conclusion: Patients who were male or had PH status had a higher risk of mortality. However, there was no synergistic effect between being male and having PH on the prognosis after TAVR.

Assess the Outcomes of Transcatheter Aortic Valve Replacement in Bicuspid Valve with Mixed Disease versus Predominant Aortic Stenosis.

Purpose: In mixed aortic valve disease (MAVD), the results of transcatheter aortic valve replacement (TAVR) are conflicting. There is limited data on the outcomes of TAVR in patients with bicuspid aortic valve (BAV) and MAVD. The objective of this study is to compare outcomes after TAVR in BAV patients with MAVD and predominant aortic stenosis (PAS). Patients and Methods: Patients with BAV who underwent TAVR between January 2016 and April 2023 were included. The primary outcome was device success. The secondary endpoints were periprocedural mortality and other complications as defined by the Valve Academic Research Consortium-3 (VARC-3). Propensity score matching was used to minimize potential confounding. Results: A total of 262 patients were included in this study, 83 of whom had MAVD. The median age was 72 years, and 55.7% were male. The baseline comorbidity risk files were comparable between the two groups. Patients with MAVD had more mitral regurgitation, tricuspid regurgitation and pulmonary hypertension, larger annular and left ventricular outflow tract dimensions, and more severe calcification than PAS. In the unmatched population, MAVD patients had similar device success rate (69.9% vs 79.9%, P=0.075) and 30-day mortality (3.6% vs 3.4%, P=1) compared to PAS. Propensity score matching resulted in 66 patient pairs. Device success rate were still comparable in the matched population. Other clinical outcomes, including stroke, bleeding (type 2-4), major vascular complications, acute kidney injury (stage 2-4) and permanent pacemaker implantation, were comparable between the two groups. Multivariable logistic regression analysis did not show MAVD to be an independent negative predictor of device success. At one year, survival was similar between patients with MAVD and those with PAS. Conclusion: For the bicuspid valve, patients with MAVD had a more challenging anatomy. MAVD patients associated with comparable 30-day clinical outcomes after TAVR compared to PAS patients in patients with BAV.

Transcatheter aortic valve replacement with the VenusA-Pro and VenusA-Plus systems: preliminary experience in China.

Background: The outcomes of transcatheter aortic valve replacement (TAVR) employing the second-generation retrievable VenusA-Pro and VenusA-Plus delivery systems with the self-expanding VenusA-Valve have not been described yet. This study aims to report the outcomes of these two second-generation delivery systems. Methods: From January 2022 to April 2023, we prospectively enrolled patients with severe aortic stenosis undergoing TAVR with VenusA-Pro from three centers across China in this first-in-man study and retrospectively identified those undergoing TAVR with VenusA-Plus. All outcomes were reported according to the Valve Academic Research Consortium 3 definition. The primary outcome was 30-day all-cause mortality. Results: A total of 156 patients were included, of which 46 underwent TAVR with VenusA-Pro and 110 underwent TAVR with VenusA-Plus. The Society of Thoracic Surgeons median score was 2.1%, bicuspid anatomy prevalence rate was 55.1%, and the mean aortic root calcification volume was 693 mm3. The technical success rate was 91.7%, comparable between the VenusA-Pro and VenusA-Plus groups (87.0% vs. 93.6%, P = 0.169). The 30-day all-cause mortality was 2.6%, similar between the VenusA-Pro and VenusA-Plus groups (2.2% vs. 2.7%, P = 0.842). No myocardial infarction occurred. The incidences of stroke (0.6%), major bleeding (3.8%), major vascular complications (5.1%), acute kidney injury (9.0%), permanent pacemaker implantation (5.1%), new-onset atrial fibrillation (5.8%), and moderate-to-severe paravalvular aortic regurgitation (6.0%) were favorable and comparable between the two groups. The clinical outcomes were similar between the patients with bicuspid and tricuspid aortic valve, except that the incidence of permanent pacemaker implantation was lower in patients with bicuspid anatomy (1.2% vs. 10.6%, P = 0.010). Conclusions: The 30-day outcomes of TAVR with VenusA-Pro and VenusA-Plus were favorable and comparable.

Anatomical Predictors of Valve Malposition During Self-Expandable Transcatheter Aortic Valve Replacement.

Background: The consequence of valve malposition (VM) during transcatheter aortic valve replacement (TAVR) can be severe, but the determinants of VM with self-expandable TAVR have not been thoroughly evaluated. We aimed to investigate the anatomical predictors of VM during self-expandable TAVR. Methods: In this multicenter retrospective study, TAVR was performed using the Venus A-Valve. The baseline, computed tomography, and procedural characteristics along with clinical outcomes were collected. Multivariate logistic regression model and receiver operating characteristic (ROC) curve analyses were performed. Results: A total of 84 consecutive patients (23 with VM) were included. Stepwise regression showed that annulus perimeter/left ventricular outflow tract perimeter (AL ratio) and sinotubular junction (STJ) height were predictors of VM. The ROC curve indicated a moderate strength of AL ratio [area under the curve (AUC) 0.71, cutoff 0.96] and a weak strength of STJ height (AUC 0.69, cutoff 23.8 mm) to predict VM. The combination of both predictors revealed a higher predictive value of VM (AUC 0.77). In multivariate analysis, AL ratio <0.96 [odds ratio (OR) 3.98, p = 0.015] and STJ height ≥23.8 mm (OR 4.63, p = 0.008) were strong independent predictors of VM. The presence of both predictors was associated with a very high risk of VM (OR 10.67, p = 0.002). The rate of moderate-to-severe paravalvular regurgitation was higher in patients with VM at 30 days (26.1 vs. 4.9%, p = 0.011). Conclusions: A conical left ventricular outflow tract and tall aortic sinuses were strong anatomical predictors of VM during self-expandable TAVR.