Search

Background: The use of oversizing in mitral valve-in-valve (MViV) procedures can lead to non-uniform expansion of transcatheter heart valves (THV). This may have implications for THV durability., Aims: The objective of this study was to assess the extent and predictors of THV deformation in MViV procedures., Methods: We examined 33 patients who underwent MViV with SAPIEN prostheses. The extent of THV deformation (deformation index, eccentricity, neosinus volume, asymmetric leaflet expansion and vertical deformation) and hypoattenuating leaflet thickening (HALT) were assessed using cardiac computed tomography (CT), performed prospectively at 30 days post-procedure. For descriptive purposes, the THV deformation index was calculated, with values >1.00 representing a more hourglass shape., Results: Non-uniform underexpansion of THV was common after MViV implantation, with a median expansion area of 74.0% (interquartile range 68.1-84.1) at the narrowest level and a THV deformation index of 1.21 (1.13-1.29), but circularity was maintained with eccentricity ranging from 0.24 to 0.28. The degree of oversizing was a key factor associated with greater underexpansion and a higher deformation index (β=-0.634; p<0.001; β=0.594; p<0.001, respectively). Overall, the incidence of HALT on the 30-day postprocedural CT was 27.3% (9 of 33). Most patients (32 of 33) were on anticoagulation therapy, but the prothrombin time and international normalised ratio (PT-INR) at the time of the CT scan was <2.5 in 23 of 32 patients. Among patients with a PT-INR of <2.5, HALT was predominantly observed with a high THV deformation index of ≥1.18., Conclusions: THV deformation, i.e., underexpansion and an hourglass shape, commonly occurs after MViV implantation and is negatively affected by excessive oversizing. Optimising THV expansion during MViV could potentially prevent HALT.

Background: The natural history of patients with moderate aortic stenosis (AS) is poorly understood. We aimed to determine the long-term outcomes of patients with moderate AS., Methods: We examined patients with moderate AS defined by echocardiography in our healthcare system, and performed survival analyses for occurrence of death, heart failure (HF) hospitalization, and progression of AS, with accounting for symptoms, left ventricular dysfunction, and comorbidities., Results: We examined 729 patients with moderate AS (median age, 76 years; 59.9 % men) with a median follow-up of 5.0 years (interquartile range: 2.0 to 8.1 years). The 5-year overall survival was 52.3 % (95 % confidence interval [CI]: 48.6 % to 56.0 %) and survival free of death or HF hospitalization was 43.2 % (95 % CI: 39.5 % to 46.9 %). Worse New York Heart Association (NYHA) functional class was associated with poor long-term survival, with mortality rates ranging from 7.9 % (95 % CI: 6.6-9.2 %) to 25.2 % (95 % CI: 20.2-30.3 %) per year. Among patients with minimal or no symptoms, no futility markers, and preserved left ventricular function, 5-year overall survival was 71.9 % (95 % CI: 66.4-77.4 %) and survival free of death or HF hospitalization was 61.4 % (95 % CI: 55.5-67.3 %). Risk factors associated with adverse events were age, NYHA class, low ejection fraction and high aortic valve velocity (all p < 0.05)., Conclusions: Patients with moderate AS are at significant risk of death. Our findings highlight the need for more study into appropriate therapeutic interventions to improve the prognosis of these patients.

Background: As a measure of the global left ventricular afterload, valvuloarterial impedance (ZVA) can be estimated using transthoracic echocardiography (TTE) and invasive measuring methods. The objective of this study was to compare the performance of TTE in measuring ZVA with invasive haemodynamics, direct Fick and thermodilution (TD), in patients with severe aortic stenosis (AS)., Methods: This is a retrospective cohort study of 66 patients with severe AS who underwent TTE and bilateral heart catheterisation preaortic valve replacement. ZVA was calculated non-invasively from TTE and invasively using TD and Fick. The differences in measurements were estimated using a generalised estimating equation approach. The exchangeability of the measurements from different methods was evaluated under binary risk stratification rules., Results: The mean±SD ZVA by TTE was 4.6±1.4 vs 4.9±1.6 by TD vs 4.3±1.2 mm Hg m 2 /mL by Fick. From multivariate analyses, ZVA by TTE was 5.9% (95% CI -15.0 to 2.5) lower than by TD and 5.9% (95% CI -1.5 to 12.8) higher than by Fick. At the same time, ZVA by TD was 12.5% (3.0 to 22.9) higher than with Fick. Risk classifications for ZVA-based binary decision rules showed poor agreement between TTE and invasive methods (kappa ≤0.3)., Conclusions: The differences in ZVA estimates between TTE and invasive standards do not appear to exceed those between the standards. As such TTE-based estimates may be deemed acceptable as a clinical measure of global haemodynamic load. However, TTE-based and invasive measurements may not be interchangeable to identify patients at risk using binary classification rules based on ZVA., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Limited data exist for rates and causes of readmission beyond short-term follow-up for patients undergoing surgical and transcatheter aortic valve replacement (SAVR and TAVR) METHODS: Patients undergoing isolated SAVR and TAVR between 2011 and 2017 at our institution were included in this study. The primary outcome was 5-year hospital readmission. The readmission cohort was identified from index readmission. Multivariable logistic regression analysis was used to evaluate the risk-adjusted impact of TAVR vs SAVR on outcomes., Results: A total of 2379 patients were included: 1034 TAVR (43.5%) and 1345 SAVR (56.5%). Patients undergoing TAVR were on average older (81.8 ± 7.8 years vs 69.1 ± 11.85 years, P < .0001) and had more comorbidities than SAVR patients as represented by a greater Society of Thoracic Surgeons Predicted Risk of Mortality (7.96% ± 4.71% vs 2.73% ± 2.93%, P < .0001). Operative mortality was higher in the TAVR cohort (3.19% vs 1.12%, P < .004) and remained high at 5 years despite risk adjustment. Significantly more cardiac readmissions were found at 5-year follow-up in the TAVR group (73.3% vs 60.0%, P < .0001). Heart failure was the most common cause of cardiac readmission in the TAVR cohort (58.7% vs 42.1%, P = .0001). No difference was found in overall readmission risk at 30 days (hazard ratio [HR] 1.23, 95% confidence interval [CI]: 0.94 to 1.61, P = .12), 1 year (HR 0.93, 95% CI: 0.77 to 1.16, P = .52), and 5 years (HR 0.99, 95% CI: 0.83 to 1.18, P = .89)., Conclusions: There is a disproportionately high rate of long-term hospital readmissions for cardiac causes, including heart failure, in patients who underwent TAVR. These data may support aggressive medical management of patients with careful follow-up in patients undergoing TAVR., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Recent data have suggested that women have a survival benefit at 1-year follow-up. However, long-term gender-based TAVR outcomes are lacking., Methods: All patients undergoing isolated TAVR from 2011 to 2017 were included. Patients were stratified by gender. The primary outcomes of the study were 3-year mortality and 3-year hospital readmissions. Multivariable logistic regression analysis was used to evaluate the risk-adjusted impact of gender on TAVR outcomes., Results: A total of 1,036 patients were divided into male ( n = 518) and female ( n = 518) cohorts. Women had a borderline significantly increased STS PROM (8.3% ± 5 vs. 7.7% ± 4.4; P = 0.05). The majority of procedures were performed under conscious sedation (male: 89% vs. female: 88%; P = 0.62) and via transfemoral access (male: 81.8% vs. female: 81.4%; P = 0.46). There was no difference in operative (30-day) mortality (male: 15 [3.3%] vs. female: 17 [3.7%]; P = 0.77) or 30-day readmissions (male: 40 [10.8%] vs. female: 44 [12.2%]; P = 0.56). Perioperative blood product usage was higher for women (male: 8.1% vs. female: 14.1%; P = 0.002). There was no significant difference in major vascular complications (male: 0.4% vs. female: 1.0%; P = 0.26) or major bleeding (male: 0.2% vs. female: 0.4%; P = 0.56). Permanent pacemaker placement was higher for males (11.6% vs. 7.0%; P = 0.01). On risk-adjusted multivariable analysis, gender was not a factor associated with mortality (HR 0.99 [0.76 to 1.30]; P = 0.99) or readmission (HR 0.90 [0.72 to 1.14]; P = 0.42) at 5 years., Conclusions: There was no difference in survival or readmissions on multivariable analysis for women undergoing TAVR at 3 years. Longitudinal multi-institutional data will be important to validate these findings.