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Introduction: New permanent pacemaker (PPM) requirement has been linked with left ventricular dysfunction after TAVR. Objective: We sought to study the impact of new PPM on echocardiographic outcomes after TAVR with SAPIEN-3 (S3) valve. Methods: We included consecutive patients who underwent TAVR with S3 valve at the Cleveland Clinic between April 2015 and December 2018. Patients with prior PPM were excluded. Echocardiograms were reviewed to determine left ventricular ejection fraction (LVEF), left ventricular end diastolic volume index (LVEDVi), left ventricular end systolic volume index (LVESVi), left ventricular dimension during diastole (LVDd), posterior wall thickness during diastole (PWTd), interventricular septum during diastole (IVSd), right ventricular systolic pressure (RVSP), inferior vena cava (IVC) diameter and tricuspid regurgitation (TR) grade. Results: Among 886 patients, the rate of 30-day PPM was 10.2%. Baseline LVEF was similar between new PPM and no PPM (55.4 ± 12.7% vs. 57.2 ± 11.2%; p = 0.188). There were no differences in the other studied echocardiographic parameters at baseline. Among patients with new PPM, LVEF was lower at both 30 days (54.4 ± 11.3% vs. 58.4 ± 10.1%; p = 0.001) and 1 year (54.2 ± 12% vs. 59.1 ± 11.3%; p = 0.009) compared to no PPM with Δ LVEF -0.9% vs. +1.4%; p = 0.023. There were no differences in LVEDVi (52 ± 20.8 vs. 48.3 ± 17.6; p = 0.186) at 1 year. LVESVi was higher with new PPM (24.8 ± 16.1 vs. 20.2 ± 10.9; p = 0.038). However, Δ LVESVi was similar between the 2 groups (-1.6 vs. -2.6; p = 0.517). There were no differences in RVSP (38.9 ± 14.1 vs. 40 ± 14; p = 0.58). LVIDd, PWTd, IVSd and IVC diameter also did not show variations whether patients were paced or not. Moderate to severe TR rates were similar as well (17.7% vs. 21.5%; p = 0.407). Conclusion: Among S3 TAVR recipients, new pacing requirement had a detrimental impact on LVEF at both 30 days and 1 year. However, it did not seem to affect the other studied echocardiographic outcomes after TAVR.

Introduction: Pre-existing atrial fibrillation has been linked with poor outcomes among patients undergoing transcatheter aortic valve replacement (TAVR). Objective: We sought to study the impact of baseline atrial fibrillation/flutter (AF) on outcomes after TAVR with SAPIEN-3 (S3) valve. Methods: All consecutive patients with severe symptomatic aortic stenosis who underwent TAVR with S3 valve at the Cleveland Clinic between April 2015 and December 2018 were included. Results: We included 1028 consecutive patients. Overall, the mean age of our study population was 81 ± 8.9 years, 58.8% were males, 95.8% were Caucasians. Pre-existing AF was present in 432 patients (42%). STS risk score was higher with AF compared to no AF (6.7 ± 3.8% vs. 5.4 ± 3.4%; p < 0.001). Baseline left ventricular ejection fraction (LVEF) was lower with AF (54% vs. 58%; p < 0.001). The rates of 30-day permanent pacemaker (PPM) implantation were similar between AF and no AF (11.4% vs. 9.4%; p = 0.326), as were the rates of new-onset left bundle branch block (LBBB) at discharge (9.6% vs. 9.4%; p = 0.901). There was also no difference in stroke rates at 30 days between the 2 groups (1.6% vs. 1%; p = 0.385). Post-TAVR mild or greater aortic regurgitation (AR) was higher with AF compared to no AF (21.5% vs. 16%; p = 0.022). LVEF was lower with AF at both 30 days (56% vs. 58.5%; p < 0.001) and 1 year (56% vs. 59%; p < 0.001). However, the change in LVEF (Δ) after TAVR was similar between AF and no AF (+1.1% vs. +1.4%; p = 0.624). At 2 years, all-cause death was higher with AF (22.9% vs. 12.8%; log-rank p = 0.011). There was no mortality difference between persistent versus paroxysmal AF (log-rank p = 0.714). Conclusions: Among our S3 TAVR patients, AF did not affect PPM, new-onset LBBB or stroke rates after the procedure. AF was associated with higher mild or greater AR at 30 days, as well as lower LVEF at both 30 days and 1 year compared to no AF. There was significantly higher all-cause mortality in the AF group at 2 years after TAVR.

Introduction: Both hereditary (hATTR) and wild-type (wtATTR) transthyretin amyloidosis are under-recognized causes of cardiomyopathy (CM) and heart failure. Certain findings on Transthoracic Echocardiography (TTE) and cardiac Magnetic Resonance Imaging (cMRI) are suggestive but not diagnostic of ATTR. Although biopsy historically has been the gold standard for diagnosis, patients can be diagnosed with the highly sensitive and specific technetium-99m pyrophosphate scan (Tc-99m PYP). Genetic testing is recommended to confirm hATTR in patients diagnosed with ATTR cardiac amyloidosis. Despite growing awareness of this condition, many cases remain undiagnosed. This study evaluated if patients with TTEs concerning for infiltrative CM received appropriate diagnostic testing for ATTR-CM. Methods: Our echocardiography registry was queried from January 2011 to March 2020 for patients with our echo lab’s embedded infiltrative CM code. Data on demographics, comorbidities, TTE variables, cMRI results, PYP scans, genetic testing and biopsy results were retrieved from electronic medical records. Thorough manual chart review excluded other causes of CM. Data was expressed as mean ± SD and n (%). Results: We retrieved 510 patients (mean age 64 ± 16 years; 43% female) with TTEs suspicious for infiltrative CM revealing a mean interventricular septal diameter (IVSd) of 1.6 ± 0.3 cm. Only 67 (13%) patients underwent cMRI with 11 (16%) suggestive of cardiac amyloidosis. Of the patients with suspicious TTEs, 16 (3.1%) had PYP scans and 24 (4.7%) had tissue biopsy, with positive results in 7 (44%) and 11 (46%), respectively. Genetic testing in 31 (6%) patients revealed known hATTR mutations in 2 (6.5%) patients. Cardiac amyloidosis was diagnosed in 23 (4.5%) with 11 ATTR (2 hATTR), 5 amyloid light chain, and 7 unknown subtype. Conclusion: Despite clinical and TTE findings suspicious for ATTR-CM, many patients did not undergo appropriate confirmatory testing (see Figure 1).