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Valve-in-valve (ViV) transcatheter aortic valve implantation (TAVI) emerged has a less invasive treatment than surgery for patients with degenerated bioprosthesis. However, few data are currently available regarding results of ViV versus TAVI in native aortic valve. We aimed to compare hemodynamic performances and 1-year outcomes between patients who underwent ViV procedure and patients who underwent non-ViV TAVI. This bicentric study included all patients who underwent aortic ViV procedure for surgical bioprosthetic aortic failure between 2013 and 2017. All patients who underwent TAVI were included in the analysis during the same period. ViV and non-ViV patients were matched with 1:2 ratio according to size, type of TAVI device, age (±5 years), sex, and STS score. Primary end point was hemodynamic performance including mean aortic gradient and aortic regurgitation at 1-year follow-up. A total of 132 patients were included, 49 in the ViV group and 83 in the non-ViV group. Mean age was 82.8 ± 5.9 years, 55.3% were female. Mean STS score was 5.2% ± 3.1%. Self-expandable valves were implanted in 78.8% of patients. At 1-year follow-up, aortic mean gradient was significantly higher in ViV group (18.1 ± 9.4 mm Hg vs 11.4 ± 5.4 mm Hg; p0.0001) and 17 (38.6%) patients had a mean aortic gradient ≥20 mm Hg vs 6 (7.8%) in the non-ViV group (p = 0.0001). Aortic regurgitationgrade 2 were similar in both groups (p = 0.71). In the ViV group, new pacemaker implantation was less frequent (p = 0.01) and coronary occlusions occurred only in ViV group (n = 2 [4.1%]). At 1-year follow-up, 3 patients (2.3%) died from cardiac cause, 1 (2.1%) in the ViV group vs 2 (2.4%) in the non-ViV group (p = 0.9). There was no stroke. In conclusion, compared with TAVI in native aortic stenosis, ViV appears as a safe and feasible strategy in patients with impaired bioprosthesis. As 1-year hemodynamic performances seem better in native TAVI procedure, long-term follow-up should be assessed to determinate the impact of residual stenosis on outcomes and durability.

Background Valve-in-valve (ViV) transcatheter aortic-valve implantation (TAVI) emerged has a less invasive treatment than repeated surgery for patients with degenerated bioprosthesis. However, few data are currently available regarding results of ViV vs. native valve TAVI. Purpose We aimed to compare hemodynamic performances and 1-year outcomes between patients undergoing ViV procedure and patients undergoing non-ViV TAVI. Methods This bicentric study included all patients undergoing aortic ViV procedure for surgical bioprosthetic aortic failure between 2013 and 2017. All patients undergoing TAVI were included in the analysis during the same period. ViV and non-ViV patients were matched with 1:2 ratio according to size, type of TAVI device, age (± 5 years), sex and STS score. Primary endpoint was hemodynamic performance including mean aortic gradient and aortic regurgitation at 1-year follow-up. Results A total of 132 patients were included, 49 in the ViV group and 83 in the non-ViV group. Mean age was 82.8 ± 5.9 years, 55.3% were female. Mean STS score was 5.2 ± 3.1%. Self-expandable valves were implanted in 78.8% of patients. At 1-year follow-up, aortic mean gradient was significantly higher in ViV group (18.1 ± 9.4 mmHg vs. 11.4 ± 5.4 mmHg; P 20 mmHg vs. 6 (7.8%) in the non-ViV group (P = 0.0001). Aortic regurgitations > grade 2 were similar in both groups (P = 0.71). In the ViV group new pacemaker implantation were less frequent (P = 0.01) and coronary occlusions occurred only in ViV group (n = 2 (4.1%)) ( Fig. 1 ). Conclusion ViV is a promising alternative to repeated cardiac surgery in patients with failed bioprosthesis. As 1-year hemodynamic performances seem better in native TAVI procedure, long-term follow-up should be assessed to determinate the impact of residual stenosis on outcomes and durability.

Background With the growing indications of trans-catheter aortic-valve implantation (TAVI) and beneficial results among lower risk patients, valve durability is become a crucial issue. Purpose To assess long-term evolution of different generations of percutaneous balloon-expandable prostheses, incidence and predictive factors of structural valve deterioration (SVD). Methods All consecutive patients undergoing TAVI for severe aortic stenosis with balloon-expandable prosthesis between 2009 and 2014 were included in this monocentric prospective study. All echocardiograms were reviewed by two independent experts. Clinical events were defined according to the Valve Academic Research Consortium. SVD was defined according to the 2017 EAPCI-ESC-EACTS international consensus at the longest follow-up. Results A total of 160 patients were included with a median follow-up of 3.4 [1.5–4.9] years and a maximum of 8 years. Patients were mostly implanted with the first generation Sapien XT valve (n = 138, 86.2%). Median age was 85 [79–86] years with a median logistic Euro-SCORE of 14.2% [10.6–23.2]. Immediately after TAVI, mean aortic gradient decreased dramatically from 51 ± 12 mmHg to 9 ± 2.6 mmHg (P Fig. 1 ). Conclusions Up to 8-year follow-up, SVD following balloon-expandable TAVI is very low. TAVI seems to be a safe alternative to surgery in severe aortic stenosis regardless of prosthesis generation.

Introduction Regarding the extent of TAVI's indication to patients with intermediary risks, it seems essential to lower its complication. Conduction disturbances after TAVI remains a major complication without any standardized guidelines to help with its treatment. Purpose The primary end-point of this study is to confirm that standard criterion for pacing are reliable in post-TAVI conduction disorders and to analyze the contribution of a systematic electrophysiological study. Method In TAVI patients, indications for pacing were persistent high-degree atrioventricular block or bundle branch block appearance associated to HV interval longer than 70 ms, 24 hours after the procedure. After a two-month follow-up, clinical and ECG evaluation and 24-hour ECG Holter monitoring were realized in patients without pacemaker and compared to data obtained from the devices in pacemaker implanted patients (% of ventricular pacing > 1%; presence of more than 1 AVB episode). Results A total of 165 consecutive patients who underwent TAVI were prospectively included. Out of the 165 patients included, 157 were sampled: 20 in the high grade persistent AV block, 5 in the persistent bundle branch heart block with HV interval > 70 ms, 13 with HV interval Conclusion From this experimental protocol it appears that an HV based algorithm has a good specificity but a poor sensibility. Conduction disorders are stable at day 3 and allow to decide if pacing is needed. Besides QRS duration, PR interval might be of interest in predicting risk of AV block after TAVI.

Summary Background The benefits of vascular closure devices (VCDs) in the prevention of vascular complications after femoral intervention remain controversial. Aim To evaluate the efficiency of collagen plug-based VCDs in the prevention of femoral access complications after balloon aortic valvuloplasty. Methods We conducted a prospective analysis of consecutive patients who underwent balloon aortic valvuloplasty by femoral retrograde technique in our centre between 2009 and 2012. Group 1 included 75 patients in whom femoral puncture haemostasis was obtained with the use of an 8F collagen plug-based VCD (Angio-Seal™; Saint-Jude Medical, Inc.); group 2 included 105 patients who had manual or mechanical groin compression (FemoStop™; RADI Medical Systems, Inc.). We did not use heparin during the procedure. We collected data on major in-hospital adverse events, major bleeding (Bleeding Academic Research Consortium classification ≥ 3) and vascular access complications. Results We included 180 patients with severe and symptomatic aortic stenosis. Indications for valvuloplasty were mainly bridge to transcatheter aortic valve implantation or palliative therapy (72%). The groups were similar in terms of median age, lower limb artery disease and body mass index. Vascular and bleeding complications occurred in 11.1% of patients and were not decreased with the use of VCDs (relative risk 2.60, 95% confidence interval 1.10–3.09; P = 0.05). These findings were consistent across all prespecified subgroups. Duration of hospital stay was not reduced by VCDs. Conclusions Based on the results of this study, performed with small-size sheaths and without heparin, collagen plug-based VCDs increase femoral access complications following aortic valvuloplasty. Systematic use of VCDs in elderly patients, with probable advanced limb atherosclerosis, is questionable.

Purpose and medical hypothesis: Rest is usually recommended in acute pericarditis, as it could help to lower heart rate (HR) and contribute to limit ‘‘mechanical inflammation’’. Whether HR on admission could be correlated and perhaps participate to inflammation has not been reported. Methods: Between March 2007 and February 2010, we conducted a retrospective study on all patients admitted to our center for acute pericarditis. Diagnosis criteria included two of the following ones: typical chest pain, friction rub, pericardial effusion on cardiac echography, or typical electrocardiogram (ECG) findings. Primary endpoint was biology: CRP on admission, on days 1, 2, 3, and especially peak. Results: We included 73 patients. Median age was 38 years (interquartiles 28–51) and median hospitalization duration was 2.0 days (1.5–3.0). Median heart rate was 88.0 beats per minute (bpm) on admission (interquartiles 76.0–100.0) and 72.0 on discharge (65.0–80.0). Heart rate on admission was significantly correlated with CRP peak (p < 0.001), independently of temperature on admission, hospitalization duration and age. Recurrences occurred within 1 month in 32% of patients. Heart rate on hospital discharge was correlated with recurrence, independently of age. Conclusion: In acute pericarditis, heart rate on admission is independently correlated with CRP levels and heart rate on discharge seems to be independently correlated to recurrence. This could suggest a link between heart rate and pericardial inflammation.

Balloon predilatation of the aortic valve has been regarded as an essential step during the transcatheter aortic valve implantation (TAVI) procedure but recent evidence has suggested that aortic valvuloplasty may induce complications. The purpose of the DIRECTAVI study was to evaluate the efficacy

Purpose There is good evidence that adherence to medical treatment is enhanced by knowledge and understanding of the drug, its benefits and its side-effects. Objectives To investigate knowledge and perceptions of antithrombotic therapy among a population of patients receiving chronic anticoagulation therapy with vitamine k antagonists (VKA) or direct oral anticoagulants (DOA). Methods We conducted a prospective study among 122 patients admitted in our cardiology unit and receiving anticoagulant therapy for more than 3 months. Atrial fibrillation was the main indication of therapy (n=63, 51.6%) and VKA concerned 87% of patients. All patients were invited to fill in a questionnaire (11 questions), which was handed out by a nurse in a face-to-face interview. None of the patients refused to fill in the questionnaire, which was completed at once and independently. Results While the vast majority of patients know that they have anticoagulant therapy (96,7%), patients presented a clear lack of knowledge concerning mainly food and drug interaction (table 1), the possible consequences of under- or over-anticoagulation (n=31; 25,4%), the reason why they have this therapy (n=39; 32,7%) and how to control their treatment. Comparing the two therapies, we observed a non significant difference in knowledge concerning VKA and DOA except knowledge of risks of therapy which was superior in the DOA group (p In conclusion Patients’ anticoagulant therapy knowledge, either vitamin K antagonists or DOA, is poor. With the increasing use of DOA, from which we have no more biologic control to assess compliance, improved patient education and physician involvement in therapeutic education, is crucial. Download : Download full-size image Abstract 0507 – Figure: Lack of knowledge concerning anticoagluant therapy

Objectives The aim of the study was to evaluate feasibility and safety of transcatheter aortic valve implantation (TAVI) performed without subsequent intensive care unit (ICU) admission using simple clinical, ECG and echocardiographic criteria. Methods We included prospectively 177 consecutive patients who underwent TAVI in our center. Low-risk patients, admitted to conventional cardiology unit, had stable clinical state, LVEF > 40%, transfemoral access, no right bundle branch block (RBBB), permanent pacing with self-expandable valve and no complication during the procedure. High-risk group included other patients who were transferred to ICU. The primary endpoint concerned in-hospital events (VARC-2 criteria). Results Mean age of patients was 83.5±6.5 years and mean logistic Euroscore was 14.6±9.7%. The balloon expandable SAPIENS 3 valve was mainly used (n=148; 83.6%), mostly with transfemoral access (n=167; 94,4%). Among the 61 patients (34.5%) included in the low-risk group, only 1 (1.6%) had a minor complication (NPV: 98.4%; 95% CI: 0.91-0.99). Conversely, 47 patients (40.5%) from the high-risk group had clinical events (PPV: 40.5%; 95% CI: 0.31-0.50), mainly conductive disorders requiring pacemaker (n=26; 22.4%). In multivariate analysis, RBBB (OR: 14.1; 95% CI: 3.5-56.3), use of self-expandable valve without pacemaker (OR: 5.5; 95% CI: 2-16.3), vitamin K antagonist treatment (OR: 3.8; 95% CI: 1.1-12.6) and female gender (OR: 2.6; 95% CI 1.003-6.9) were pre-procedural predictive factors of in-hospital adverse events. Conclusions Our results suggested that TAVI can be performed safely without ICU admission in selected patients. This strategy may optimize efficiency and cost-effectiveness of the procedure. The author hereby declares no conflict of interest Table . In hospital major adverse events in the two groups of patients. Post TAVI adverse events Low risk group (n=61; 34.5%) High risk group (n=116: 65.5%) Death (n=1; 0.6%) 0 1 (0.9%) Acute pulmonary oedema (n=1; 0.6%) 0 1 (0.9%) New high conductive disorder (n=36; 20.2%) 0 36 (31%) Permanent pacing requiring (n=26; 14.7%) 0 26 (22.4%) Major vascular complication (n=1; 0.6%) 0 1 (0.9%) Pericardial effusion requiring medical intervention (n=2; 1.2%) 0 2 (1.8%) Acute kidney injury (Akin 2 or 3) (n=3; 1.8%) 0 3 (2.7%) Secondary transfer to ICU (n=1) (pericardial effusion) 1 (1.6%) Total of patient with at least one complication (n=48; 27.1%) 1 (1.6%) 47 (40.5%)

Bleeding and femoral access complications which occurred after balloon aortic valvuloplasty (BAV) may be enhanced by the systematic use of heparin during the procedure. We assessed the hypothesis that BAV performed without heparin may be associated with lower complications rates. Methods We conducted a retrospective analysis of all consecutive patients who had undergone BAV in our center between 2008 and 2011. We evaluated 3 groups: group 1 included patients whose BAV was performed with large sheaths (10 to 12 F) and use of unfractionated heparin (UH) (50IU/kg bolus IV); patients whose BAV was performed with use of smaller size sheaths (8 or 9 F) who were divided into group 2 (with UH bolus) and group 3 (without UH bolus). We collected all major in-hospital adverse events, bleeding (≥BARC 3), vascular complications (including pseudoanerysm or arterio venous fistula) and acute limb ischemia. Results Overall, 132 patients were included in this study. The 3 groups had similar median age (84 years) or previous lower extremity artery disease (overall n= 36, 27%, p=0.79). Vascular and bleeding complications were observed in 17 patients (12.8%) and were significantly higher when UH was used (table 1) with a relative risk of 2.89 (1.18-6.1). Conversely, absence of heparin did not increase ischemic complications or major in-hospital adverse events (p=0.5). Vascular complications were similar among patients who received heparin whatever the size of the used sheath (table 1). Conclusion Balloon aortic valvuloplasty performed without heparin appears to be safe and is associated with a dramatic reduction of vascular and bleeding events. Although randomization was not used, this marked difference is difficult to explain by confounding factors. Table 1 . Vascular and bleeding complications. group 1 (UH+, LS) n=23 group 2 (UH+, SS) n=46 group 3 (UH-, SS) n=63 p value Femoral access and/or bleeding n=17 (12.8%) 4 (17.3%) 9 (19.5.%) 4 (6.3%)* 0.007 Bleeding n=15 (11.3%) 4 (17.3%) 8 (17.3%) 3 (4.7%)* 0.004 Acute limb ischemia n=4 (2.2%) 0 2 (4.3%) 2 (3.1%) 0.82 UH+: unfractionated heparin bolus 50 ui/kg; UH-: no heparin bolus; LS: large sheath; SS: small sheath