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Objectives: Nutritional status, as one of the core characteristics of frailty, the impact of its changes on clinical outcomes in older patients following transcatheter aortic valve replacement (TAVR) remains unclear., Design: A retrospective cohort study., Setting: This study included a total of 781 patients who underwent TAVR at West China Hospital between 2012 and 2022., Method: The average age of the patients was 72.6 years, with a mean follow-up period of 2.2 years. All patients were followed for at least one year, and their nutritional status was assessed using the Controlling Nutritional Status (CONUT) score both before TAVR and six months post-TAVR. Based on post-TAVR changes in nutritional status, patients with normal nutritional status pre-TAVR were categorized into Non-malnutrition and New malnutrition groups, while patients with malnutrition pre-TAVR were categorized into Malnutrition regression and Malnutrition persistence groups., Result: The New malnutrition group experienced higher cumulative incidences of all-cause mortality (20.5% vs. 2.4%, P = 0.002), MACE (25.5% vs. 23.7%, P = 0.001), and readmissions for heart failure (13.1% vs. 7.3%, P = 0.027) compared to the Non-malnutrition group. Conversely, the Malnutrition regression group showed a lower cumulative incidence of all-cause mortality (3.1% vs. 18.0%, P = 0.016) compared to the Malnutrition persistence group, although no statistically significant differences were observed in MACE (14.7% vs. 28.5%, P = 0.087) and readmissions for heart failure (7.0% vs. 8.3%, P = 0.551)., Conclusion: Our study indicates that deterioration in nutritional status after TAVR is associated with poorer clinical outcomes, whereas improvement is associated with better outcomes., Competing Interests: Declaration of competing interest Mao Chen reports financial support was provided by National Natural Science Foundation of China. Mao Chen reports financial support was provided by Key Research and Development Project of Science & Technology Department of Sichuan Province. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Masson SAS.. All rights reserved.)

Background: Raphe-type bicuspid aortic valve (BAV) is a potential hostile scenario in trans-catheter aortic valve replacement (TAVR) due to pronounced calcium burden, possibly associated with tapered valve configuration. Trans-Catheter heart valve (THV) sizing strategy (annular vs. supra-annular) is controversial in this valve subtype., Objectives: To describe the phenotypical characteristics of severe, tapered, raphe-type, BAV stenosis undergoing TAVR and to explore safety and efficacy of modern-generation THVs, analysing the impact of annular and supra-annular sizing strategies on short- and mid-terms outcomes., Methods: This is a retrospective, multicenter registry enrolling consecutive stenotic Sievers type 1 BAV treated with TAVR. Study population was divided into tapered and non-tapered configuration according to MSCT analysis. Matched comparison between annular and supra-annular sizing groups was performed in tapered population., Results: From January 2016 to June 2023, 897 patients were enrolled. Of them, 696 patients displayed a tapered configuration. Of those, 510 received a THV according to annular sizing. After propensity score matching 186 matched pairs were selected. Technical success (96.2 % vs 94.1 %, OR 1.61 [0.61-4.24], p = 0.34), 30-day device success (83.6 % in both groups, OR 1.42 [0.78-2.57], p = 0.25) and 30-day early safety (71.8 % vs 70.5 %, OR 1.07 [0.68-1.68], p = 0.78) were similar between the annular and supra-annular sizing groups; a higher post-TAVR gradient was observed in supra-annular group, although it was only 2 mmHg mean. At mid-term follow-up, the rate of clinical efficacy was 84.7 %., Conclusions: TAVR with modern-generation devices is safe and effective for tapered raphe-type BAV, showing comparable results for annular and supra-annular sizing strategies., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Currently, there is a lack of evidence for the long-term bioprosthetic valve durability of patients with bicuspid aortic valve (BAV) following transcatheter aortic valve replacement (TAVR)., Methods and Results: This study aimed to evaluate hemodynamic outcome, structural valve deterioration, and bioprosthetic valve failure during long-term follow-up after TAVR in patients with BAV versus patients with tricuspid aortic valve (TAV). Patients with BAV and TAV who underwent TAVR between 2012 and 2020, with echocardiography followed for at least 3 years, were included. Baseline characteristics, long-term valve hemodynamic performance, structural valve deterioration, and bioprosthetic valve failure were compared between patients with BAV and TAV. A total of 170 patients with BAV and 145 patients with TAV were included. The mean duration of follow-up for patients with BAV and TAV was 5.2±1.8 and 5.0±1.7 years. No significant differences were observed in the rates of structural valve deterioration and bioprosthetic valve failure between patients with BAV and TAV: structural valve deterioration, BAV 20 (11.8%) versus TAV 16 (11.0%) at last follow-up ( P =0.861); bioprosthetic valve failure, BAV 3 (1.8%) versus TAV 7 (4.8%) at last follow-up ( P =0.196). More than moderate intravalvular aortic regurgitation (1.8% versus 4.8%, P =0.196) and paravalvular leak (6.5% versus 3.4%, P =0.305) were rare in both patients with BAV and patients with TAV., Conclusions: This study indicated satisfactory long-term valve durability of TAVR in patients with BAV. Comparable hemodynamic outcome, structural valve deterioration, and bioprosthetic valve failure could be achieved in patients with BAV and TAV during long-term follow-up after TAVR.

Background: The triglyceride glucose (TyG) index, as a reliable marker of insulin resistance, is associated with the incidence and poor prognosis of various cardiovascular diseases. However, the relationship between the TyG index and clinical outcomes in patients with severe aortic stenosis (AS) who underwent transcatheter aortic valve replacement (TAVR) remains unclear., Methods: This study consecutively enrolled 1569 patients with AS underwent TAVR at West China Hospital of Sichuan University between April 2014 and August 2023. The outcomes of interest included all-cause mortality, cardiovascular mortality, and major adverse cardiovascular events (MACE). Multivariate adjusted Cox regression and restricted cubic splines (RCS) regression analyses were used to assess the associations between the TyG index and the clinical outcomes. The incremental prognostic value of the TyG index was further assessed by the time-dependent Harrell's C-index, integrated discrimination improvement (IDI) and the net reclassification improvement (NRI)., Results: During a median follow-up of 1.09 years, there were 146, 70, and 196 patients experienced all-cause death, cardiovascular death, and MACE, respectively. After fully adjusting for confounders, a per-unit increase of TyG index was associated with a 441% (adjusted HR: 5.41, 95% CI: 4.01-7.32), 385% (adjusted HR: 4.85, 95% CI: 3.16-7.43), and 347% (adjusted HR: 4.47, 95% CI: 3.42-5.85) higher risk of all-cause mortality, cardiovascular mortality and MACE, respectively. The RCS regression analyses revealed a linear association between TyG index and endpoints (all P for non-linearity > 0.05) with 8.40 as the optimal binary cutoff point. Furthermore, adding TyG index to the basic risk model provided a significant incremental value in predicting poor prognosis (Time-dependent Harrell's C-index increased for all the endpoints; All-cause mortality, IDI: 0.11, P < 0.001; NRI: 0.32, P < 0.001; Cardiovascular mortality, IDI: 0.043, P < 0.001; NRI: 0.37, P < 0.001; MACE, IDI: 0.092, P < 0.001; NRI: 0.32, P < 0.001)., Conclusions: In patients with severe AS receiving TAVR, there was a positive linear relationship between TyG index and poor prognosis, with 8.4 as the optimal bivariate cutoff value. Our findings suggest TyG index holds potential value for risk stratification and guiding therapeutic decisions in patients after TAVR., (© 2024. The Author(s).)

Background: Transcatheter aortic valve replacement (TAVR) in patients with bicuspid aortic valve (BAV) stenosis is technically challenging and is burdened by an increased risk of paravalvular regurgitation (PVR)., Objectives: The aim of this study was to identify the incidence, predictors, and clinical outcomes of PVR after TAVR in Sievers type 1 BAV stenosis., Methods: Consecutive patients with Sievers type 1 BAV stenosis undergoing TAVR with current-generation transcatheter heart valves (THVs) in 24 international centers were enrolled. PVR was graded as none/trace, mild, moderate, and severe according to echocardiographic criteria. The endpoint of major adverse events (MAEs), defined as a composite of all-cause death, stroke, or hospitalization for heart failure, was assessed at the last available follow-up., Results: A total of 946 patients were enrolled. PVR occurred in 423 patients (44.7%)-mild, moderate, and severe in 387 (40.9%), 32 (3.4%), and 4 (0.4%) patients, respectively. Independent predictors of moderate or severe PVR were a larger virtual raphe ring perimeter (adjusted OR: 1.07; 95% CI: 1.02-1.13), severe annular or left ventricular outflow tract calcification (adjusted OR: 5.21; 95% CI: 1.45-18.77), a self-expanding valve (adjusted OR: 9.01; 95% CI: 2.09-38.86), and intentional supra-annular THV positioning (adjusted OR: 3.31; 95% CI: 1.04-10.54). At a median follow-up of 1.3 years (Q1-Q3: 0.5-2.4 years), moderate or severe PVR was associated with an increased risk of MAEs (adjusted HR: 2.52; 95% CI: 1.24-5.09)., Conclusions: After TAVR with current-generation THVs in Sievers type 1 BAV stenosis, moderate or severe PVR occurred in about 4% of cases and was associated with an increased risk of MAEs during follow-up., Competing Interests: Funding Support and Author Disclosures Dr Aurigemma has reported speaker fees from Abbott, Medtronic, Abiomed, and Terumo. Dr Trani has been involved in advisory board meetings or received speaker fees from Medtronic, Abbott, Terumo, Daiichi-Sankyo, and Abiomed. Dr Adamo has reported speaker honoraria from Abbott Vascular and Edwards Lifesciences. Dr Burzotta has been involved in advisory board meetings or has received speaker fees from Medtronic, Abbott, Terumo, Daiichi-Sankyo, and Abiomed. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

The identification and management of patients at high bleeding risk (HBR) undergoing transcatheter aortic valve implantation (TAVI) are of major importance, but the lack of standardised definitions is challenging for trial design, data interpretation, and clinical decision-making. The Valve Academic Research Consortium for High Bleeding Risk (VARC-HBR) is a collaboration among leading research organisations, regulatory authorities, and physician-scientists from Europe, the USA, and Asia, with a major focus on TAVI-related bleeding. VARC-HBR is an initiative of the CERC (Cardiovascular European Research Center), aiming to develop a consensus definition of TAVI patients at HBR, based on a systematic review of the available evidence, to provide consistency for future clinical trials, clinical decision-making, and regulatory review. This document represents the first pragmatic approach to a consistent definition of HBR evaluating the safety and effectiveness of procedures, devices and drug regimens for patients undergoing TAVI..

Background: The COVID-19 pandemic adversely affected health care systems. Patients in need of transcatheter aortic valve replacement (TAVR) are especially susceptible to treatment delays., Objectives: This study sought to evaluate the impact of the COVID-19 pandemic on global TAVR activity., Methods: This international registry reported monthly TAVR case volume in participating institutions prior to and during the COVID-19 pandemic (January 2018 to December 2021). Hospital-level information on public vs private, urban vs rural, and TAVR volume was collected, as was country-level information on socioeconomic status, COVID-19 incidence, and governmental public health responses., Results: We included 130 centers from 61 countries, including 65,980 TAVR procedures. The first and second pandemic waves were associated with a significant reduction of 15% (P < 0.001) and 7% (P < 0.001) in monthly TAVR case volume, respectively, compared with the prepandemic period. The third pandemic wave was not associated with reduced TAVR activity. A greater reduction in TAVR activity was observed in Africa (-52%; P = 0.001), Central-South America (-33%; P < 0.001), and Asia (-29%; P < 0.001). Private hospitals (P = 0.005), urban areas (P = 0.011), low-volume centers (P = 0.002), countries with lower development (P < 0.001) and economic status (P < 0.001), higher COVID-19 incidence (P < 0.001), and more stringent public health restrictions (P < 0.001) experienced a greater reduction in TAVR activity., Conclusions: TAVR procedural volume declined substantially during the first and second waves of the COVID-19 pandemic, especially in Africa, Central-South America, and Asia. National socioeconomic status, COVID-19 incidence, and public health responses were associated with treatment delays. This information should inform public health policy in case of future global health crises., Competing Interests: Funding Support and Author Disclosures Dr Lefèvre has served as a proctor for Edwards Lifesciences; and received minor fees from Boston Scientific, Terumo, and Abbott. Dr Pilgrim has received research, travel, or educational grants to the institution without personal remuneration from Biotronik, Boston Scientific, Edwards Lifesciences, and ATSens; and speaker fees and consultancy fees to the institution from Biotronik, Boston Scientific, Edwards Lifesciences, Abbott, Medtronic, Biosensors, and Highlife. Dr Van Mieghem has received research grant support from Abbott Vascular, Boston Scientific, Edwards Lifesciences, Medtronic, Daiichi Sankyo, AstraZeneca, Teleflex; and advisory board fees from Abbott Vascular, Boston Scientific, Inari, JenaValve, Medtronic, Daiichi Sankyo, AstraZeneca, Siemens, Pie Medical, and Teleflex. Dr Swaans has served as a proctor/lecturer for Abbott Vascular, Boston Scientific, Bioventrix Inc, Cardiac Dimensions, Edwards Lifesciences, GE Healthcare, Medtronic, and Philips Healthcare. Dr Prendergast has received speaker/consultancy fees from Medtronic, MicroPort, Anteris, and Edwards Lifesciences. Dr Resar has received institutional research funding from Medtronic, Edwards Lifesciences, and Abbott; and served as a TAVR proctor for Medtronic. Dr Chen has served as a consultant for Venus MedTech. Dr Hildick-Smith has received research funds and speaker fees from Medtronic. Dr Spence has received TAVR proctoring and consultancy fees from Medtronic, Boston Scientific, and Edwards Lifesciences. Dr Bunc has served as a proctor for Abbott, Meril, Edwards Lifesciences, and Medtronic. Dr Molnár has served as a consultant for Medtronic and Abbott. Dr Toggweiler has served as a consultant and proctor for Medtronic, Boston Scientific, and Biosensors; has served as a proctor for Edwards Lifesciences and Abbott Vascular; has served as a consultant for Medira, Shockwave, Teleflex, atHeart Medical, Cardiac Dimensions, and Polares Medical; has received institutional research grants from Boston Scientific, Fumedica, and Novartis; has received speaker honoraria from Sanofi, AstraZeneca, ReCor Medical, and Daiichi Sankyo; and holds equity in Hi-D Imaging. Dr Ojeda has received consulting fees from Medtronic and Edwards Lifesciences; and speaker fees from Philips and Word Medica. Dr Toutouzas has served as a proctor for Medtronic, Abbott, Myval, and Boston Scientific. Dr AlMerri has served as a TAVR proctor for Medtronic. Dr Noble has served as a proctor for Medtronic; and received institutional grant support from Edwards Lifesciences, Boston Scientific, Abbott Vascular, and Medtronic. Dr Kala has served as a consultant for Boston Scientific; served on the Speakers Bureau for Edwards Lifesciences, Servier, and AstraZeneca; and received research support from Novartis. Dr Kurt has served as a TAVR proctor for Abbott. Dr Yin has served as a TAVR proctor for Medtronic, Edwards Lifesciences, and Abbott. Dr Sztejfman has served as a proctor for Boston Scientific, Edwards Lifesciences, Medtronic, Meril Life Sciences, and MicroPort. Dr Mendiz has served as a proctor for Medtronic, Boston Scientific, and Edwards Lifesciences. Dr Gunasekaran has received fees from Medtronic, Meril Life Sciences, Abbott, and Boston Scientific. Dr Kao has served as a proctor for Medtronic and Edwards Lifesciences. Dr Dager has served as a consultant for Medtronic. Dr Ferrero-Guadagnoli has served as a proctor for Boston Scientific, Edwards Lifesciences, and Medtronic. Dr Modine has served as a consultant for and received honorarium from Abbott, Medtronic, and Edwards Lifesciences. Dr Hayashida has served as a proctor for Edwards Lifesciences, Medtronic, and Abbott. Dr Makkar has received research grants from Abbott, Edwards Lifesciences, and Boston Scientific, and served as a consultant for Cordis and Medtronic. Dr Mylotte has received institutional grant funding from Boston Scientific and Medtronic; and personal fees from Boston Scientific, Medtronic, and MicroPort. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Introduction: Decisions regarding the optimal timing of intervention for asymptomatic aortic stenosis (AS) are controversial. The study aims to identify potential risk factors for asymptomatic patients with severe AS that are associated with worse prognosis and to evaluate the benefits of early interventions for asymptomatic patients presenting with one or more additional risk factors., Methods and Analysis: This is a non-interventional, prospective, open-label, multicentre registry study across China. A total of 1000 patients will be enrolled and categorised as symptomatic or asymptomatic. The primary endpoint is the occurrence of all-cause mortality, stroke, acute myocardial infarction and heart failure-related hospitalisation at 1-year follow-up. In asymptomatic severe AS patients presenting with one or more risk factors, the occurrence rate of the primary endpoint between those who undergo transcatheter aortic valve replacement (TAVR) and those who do not will be compared. We will also compare the occurrence rate of the primary endpoint for asymptomatic severe AS patients with additional risk factors who undergo TAVR with those presenting with symptoms. This study is believed to provide additional evidence to help clinicians identify and refer severe AS patients who are asymptomatic but present with additional risk factors for early intervention of TAVR., Ethics and Dissemination: The study protocol has been approved by the local ethics committee of each participating site: West China Hospital, Sichuan University; Sir Run Run Shaw Hospital, Zhejiang University School of Medicine; Second Hospital of Hebei Medical University; Tianjin Chest Hospital; and First Affiliated Hospital of Nanchang University. All participants will provide written informed consent. Study results will be published through academic conferences and peer-reviewed journals., Trial Registration: This study was registered at the Chinese Clinical Trial Registry (https:// www.chictr.org.cn), with the registration number ChiCTR2200064853., Competing Interests: Competing interests: Dr Chen and Feng are consultants and proctors for Venus MedTech, MicroPort and TaurusOne. All other authors have nothing relevant to disclosure., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Data concerning the outcomes of transcatheter aortic valve replacement in type 0 bicuspid aortic stenosis (AS) are scarce. The study aims to compare the outcomes of transcatheter aortic valve replacement for AS in patients with type 0 bicuspid, type 1 bicuspid, and tricuspid aortic valve anatomy., Methods: We enrolled consecutive patients undergoing transcatheter aortic valve replacement for severe AS between 2012 and 2022 in this single-center retrospective cohort study. The primary outcome was mortality, while secondary outcomes included in-hospital complications such as stroke and pacemaker implantation and transcatheter heart valve hemodynamic performance., Results: The number of patients with AS with type 0 bicuspid, type 1 bicuspid, and tricuspid aortic valve anatomy was 328, 302, and 642, respectively. Self-expanding transcatheter heart valves were used in the majority of patients (n=1160; 91.4%). In the matched population, differences in mortality (30 days: 4.2% versus 1.7% versus 1.7%, P overall =0.522; 1 year: 10% versus 2.3% versus 6.2%, P overall =0.099) and all stroke (30 days: 1.0% versus 0.9% versus 0.0%, P overall =0.765; 1 year: 1.4% versus 1.6% versus 1.3%, P overall =NS) were nonsignificant, and the incidence of overall in-hospital complications was comparable among groups. Ascending aortic diameter was the single predictor of 1-year mortality in type 0 bicuspid patients (hazard ratio, 1.59 [95% CI, 1.03-2.44]; P =0.035). The proportion of patients with a mean residual gradient ≥20 mm Hg was the highest in those with type 0 bicuspid anatomy, although the need for permanent pacemaker implantation was the lowest in this group., Conclusions: Major clinical outcomes of transcatheter aortic valve replacement for AS in patients with type 0 bicuspid, type 1 bicuspid, and tricuspid aortic valve anatomy are equivalent at short- and mid-term follow-up. These observations merit further exploration in prospective international registries and randomized controlled trials., Competing Interests: Disclosures M. Chen and Dr Feng are proctors/consultants of Venus MedTech, MicroPort, and Peijia Medical. Dr Mylotte is a proctor and consultant for Medtronic and Microport and a consultant for Boston Scientific. Dr Piazza is a consultant and proctor for Medtronic and Peijia Medical. Dr Prendergast has received institutional educational and research grants from Edwards Lifesciences and speaker/consultancy fees from Abbott, Anteris, Edwards Lifesciences, Medtronic, and Microport. The other authors report no conflicts.

A higher incidence of conduction disturbances and permanent pacemaker implantation (PPI) has been observed after transcatheter aortic valve implantation (TAVI) in patients with bicuspid aortic valves (BAVs) as compared to those with tricuspid aortic valves (TAVs). This study aimed to provide an anatomical explanation for this observation, supported by an in-depth anatomical mapping of the membranous septum (MS) in a large cohort of BAVs and TAVs using cardiac computed tomography (CT). A total of 300 cardiac CT scans were analysed, revealing a significantly shorter sub-annular length of the MS in BAVs at all measuring points compared to TAVs (p < 0.001). In the current BAV cohort, the MS was found to be at its shortest at the RCC site, measuring less than 1 mm in depth. In addition, the MS was located more anteriorly towards the RCC in BAVs, where the transcatheter aortic valve tends to be implanted deeper, and we observed a trend towards a higher PPI rate in BAVs. Future studies should investigate whether anatomical mapping of the MS in patients undergoing TAVI could be a useful tool for decision-making and potentially mitigate the risk of conduction disturbances., (© 2023. The Author(s), under exclusive licence to Springer Nature B.V.)

Background: We aim to determine predictors of inadequate left ventricular mass index (LVMi) regression at mid-term after transcatheter aortic valve replacement (TAVR), including the potential role of epicardial adipose tissue (EAT)., Methods: We retrospectively reviewed patients with both echocardiographic assessments and multi-slice computed tomography (MSCT) obtained one year after TAVR. The change of LVMi, the volume and the average CT attenuation of EAT from baseline to one-year follow-up was calculated. Patients were divided into two groups by the percentage change of LVMi at a cut-off of 15%., Results: A total of 152 patients were included with a median age of 74 years (interquartile range [IQR] 69-78 years) and 56.6% being male. LVMi decreased (P < 0.0001) while EAT volume increased and the average CT attenuation decreased (both P < 0.0001) at one year. Baseline atrial fibrillation (P = 0.042), mitral regurgitation ≥ mild (P = 0.006), aortic regurgitation (AR) > mild (P = 0.001) and the change in the average CT attenuation of EAT (P = 0.026) were different between the decrease of LVMi ≥ 15% and < 15%. AR > mild at baseline was the only statistically significant predictor of a decrease of LVMi < 15% at one year (OR 0.33, 95% CI: 0.13 to 0.84, P = 0.021) in multivariate regression., Conclusions: Concomitant more-than-mild AR might predict better left ventricular reverse remodeling regression after TAVR., (© 2023. The Author(s).)

Competing Interests: Funding Support and Author Disclosures Dr De Backer has received institutional research grants from and has been an adviser for Abbott, Boston Scientific, and Medtronic. Dr Sathananthan has received research grants from and is a consultant for Edwards Lifesciences, Medtronic, Boston Scientific, Anteris Technologies, and Hi-D Imaging. Dr Treede is an adviser for Medtronic, Edwards Lifesciences, Boston Scientific, JenaValve, and TriCares. Dr Leipsic has conducted institutional computed tomography core laboratory activities for Edwards Lifesciences, Medtronic, Abbott, Boston Scientific, and Pi-Cardia. Dr Bax is a member of the Speakers Bureau for and has received unrestricted research grants from Abbott and Edwards Lifesciences. Dr Webb is a consultant for Edwards Lifesciences. Dr Chen is a consultant for CardioFlow, Venus MedTech, and Peijia Medical. Dr Reardon is a consultant for Medtronic, Boston Scientific, Abbott Medical, and Gore Medical. Dr Leon has received institutional clinical research grants from Abbott, Boston Scientific, Edwards Lifesciences, and Medtronic. Dr Søndergaard has received institutional research grants from and has been an adviser for Abbott, Boston Scientific, and Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Background: Transcatheter aortic valve implantation (TAVI) has emerged as a safe and effective alternative to surgery for aortic stenosis (AS). However, there are still differences in the procedural process and outcome of bicuspid aortic valve (BAV) treated with TAVI compared with tricuspid aortic valve., Areas Covered: This review paper aims to summarize the main characteristics and clinical evidence of TAVI in patients with bicuspid and tricuspid aortic valves and compare the outcomes of TAVI procedure., Expert Opinion: The use of TAVI in patients with BAV has shown similar clinical outcomes compared with tricuspid aortic valve. The efficacy of TAVI for challenging BAV anatomies remains a concern due to the lack of randomized trials. Detailed preprocedural planning is of great importance in low-surgical-risk BAV patients. A better understanding of which subtypes of BAV anatomy are at greater risk for adverse outcomes can potentially benefit the selection of TAVI or open-heart surgery in low surgical risk AS patients.

Background: Transcatheter aortic valve replacement (TAVR)-related coronary artery obstruction prediction remains unsatisfactory despite high mortality and novel preventive therapies., Objectives: This study sought to develop a predictive model for TAVR-related coronary obstruction in native aortic stenosis., Methods: Preprocedure computed tomography and fluoroscopy images of patients in whom TAVR caused coronary artery obstruction were collected. Central laboratories made measurements, which were compared with unobstructed patients from a single-center database. A multivariate model was developed and validated against a 1:1 propensity-matched subselection of the unobstructed cohort., Results: Sixty patients with angiographically confirmed coronary obstruction and 1,381 without obstruction were included. In-hospital death was higher in the obstruction cohort (26.7% vs 0.7%; P < 0.001). Annular area and perimeter, coronary height, sinus width, and sinotubular junction height and width were all significantly smaller in the obstructed cohort. Obstruction was most common on the left side (78.3%) and at the level of the coronary artery ostium (92.1%). Coronary artery height and sinus width, but not annulus area, were significant risk factors for obstruction by logistic regression but performed poorly in predicting obstruction. The new multivariate model (coronary obstruction IF cusp height > coronary height, AND virtual valve-to-coronary distance ≤4 mm OR culprit leaflet calcium volume >600 mm 3 ) performed well, with an area under the curve of 0.93 (sensitivity = 0.93, specificity = 0.84) for the left coronary artery and 0.94 (sensitivity = 0.92, specificity = 0.96) for the right., Conclusions: A novel computed tomography-based multivariate prediction model that can be implemented routinely in real-world practice predicted coronary artery obstruction from TAVR in native aortic stenosis., Competing Interests: Funding Support and Author Disclosures This work was supported by a research grant from Medtronic to MedStar Cardiovascular Research Network and MedStar Health. Dr Kamioka has served as a proctor for Edwards Lifesciences. Dr Ludwig has received grant support from the German Heart Foundation; and received travel compensation from Edwards Lifesciences. Dr. Sinning has received speaker honoraria and research grants from Abbott, Abiomed, Medtronic, Boston Scientific, and Edwards Lifesciences; and served as a proctor for Medtronic and Boston Scientific. Dr Fuku has served as a proctor for Edwards Lifesciences and Medtronic. Dr Iyer has served as a proctor for Edwards Lifesciences, Medtronic, and Boston Scientific. Dr Rodriguez has served as a speaker for Medtronic, Abbott, and Edwards Lifesciences. Dr Montorfano has served as a proctor for Edwards Lifesciences, Boston Scientific, and Abbott. Dr Ancona has received consulting fees from Abbott and Abiomed. Dr Ahmad has served as a proctor for Edwards Lifesciences. Dr Ruggiero has served as a proctor for Abbott and Edwards Lifesciences; served as a consultant for Abbott, Edwards Lifesciences, and RegenX-Bio; and received research support from Ancora Heart and Bard. Dr Weissman has served as the director of an academic cardiac computed tomography core lab with institutional contracts with Ancora Heart and LivaNova. Dr Waksman has served on the advisory board for Abbott Vascular, Boston Scientific, Medtronic, Philips IGT, and Pi-Cardia Ltd; has served as a consultant for Abbott Vascular, Biotronik, Boston Scientific, Cordis, Medtronic, Philips IGT, Pi-Cardia Ltd, Swiss Interventional Systems/SIS Medical AG, Transmural Systems Inc, and Venous MedTech; has received institutional grant support from Amgen, Biotronik, Boston Scientific, Chiesi, Medtronic, and Philips IGT; and is an investor in MedAlliance and Transmural Systems Inc. Dr Rogers has served as a proctor and consultant for Boston Scientific, Edwards Lifesciences, and Medtronic; has served on the advisory board for Medtronic; and holds equity interest in Transmural Systems Inc. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. All rights reserved.)

Aims: Inspiratory muscle training (IMT) can increase the strength or endurance of the diaphragm and accessory muscles of inspiration, yet there is no evidence that endorses the role of IMT in patients of transcatheter aortic valve replacement (TAVR). This study for the first time tested the effects of IMT plus usual cardiac rehabilitation (CR) function in patients after TAVR., Methods and Results: A double-blinded, randomized controlled, single-centre clinical trial was undertaken. Participants who had a confirmed diagnosis of valve heart disease and were clinically stable after TAVR were recruited and received a CR programme during the hospital stay. A total of 96 patients were recruited and randomly assigned to the IMT + CR group (n = 48) or the CR group (n = 48) in a 1:1 ratio. The group difference in the primary outcome, the 6-min walk distance at the discharge of the hospital, significantly favoured the IMT + CR group (mean difference -33.52, 95% CI: -64.42 to -2.62, P = 0.034). The significant difference was maintained at the 1-month and 3-month follow-ups (mean difference: 41.51, 95% CI: 1.82-81.21, P = 0.041). In addition, the mean hospital stays of subjects in the IMT + CR group was 11 days, which was significantly shorter than the 12.5 days in the CR group (P = 0.016). Sensitivity analysis using per-protocol analysis supported these findings. No adverse treatment-related events were reported., Conclusion: Compared with usual CR, IMT plus CR can effectively improve exercise endurance, pulmonary ventilation function, and inspiratory muscle strength in patients after TAVR and shorten the length of hospital stay., Competing Interests: Conflict of interest: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Renal and liver dysfunctions are risk factors for mortality in patients with severe aortic stenosis (AS). Transcatheter aortic valve implantation (TAVI) has the potential to break the vicious cycle between AS and hepatorenal dysfunction by relieving aortic valve obstruction., Hypothesis: A part of patients can derive hepatorenal function improvement from TAVI, and this noncardiac benefit improves the intermediate-term outcomes., Methods: We developed this retrospective cohort study in 439 consecutive patients undergoing TAVI and described the dynamic hepatorenal function assessed by model for end-stage liver disease model for end-stage liver disease (MELD)-XI score in subgroups. The endpoint was 2-year all-cause mortality., Results: Receiver-operating characteristic analysis showed that the baseline MELD-XI score of 10.71 was the cutoff point. A high MELD-XI score (>10.71) at baseline was an independent predictor of the 2-year mortality hazard ratio (HR: 2.65 [1.29-5.47], p = .008). After TAVI, patients with irreversible high MELD-XI scores had a higher risk of 2-year mortality than patients who improved from high to low MELD-XI scores (HR: 2.50 [1.06-5.91], p = .03). Factors associated with reversible MELD-XI scores improvement were low baseline MELD-XI scores (≤12.00, odds ratio [OR]: 2.02 [1.04-3.94], p = .04), high aortic valve peak velocity (≥5 m/s, OR: 2.17 [1.11-4.24], p = .02), and low body mass index (≤25 kg/m 2 , OR: 2.73 [1.25-5.98], p = .01)., Conclusion: High MELD-XI score at baseline is an independent predictor for 2-year mortality. Patients with hepatorenal function improvement after TAVI have better outcomes. For patients with irreversible hepatorenal dysfunction after TAVI, further optimization of the subsequent treatment after TAVI is needed to improve the outcomes., (© 2022 The Authors. Clinical Cardiology published by Wiley Periodicals, LLC.)

Indications for transcatheter aortic valve implantation (TAVI) have expanded in many countries to include patients with aortic stenosis who are at low surgical risk, and a similar expansion to this cohort is anticipated elsewhere in the world, together with an increase in the proportion of patients with bicuspid aortic valve (BAV) morphology as the age of the patients being treated decreases. To date, patients with BAV have been excluded from major randomized trials of TAVI owing to anatomical considerations. As a consequence, BAV has been a relative contraindication to the use of TAVI in international guidelines. Although clinical experience and observational data are accumulating, BAV presents numerous anatomical challenges for successful TAVI, despite advances in device design. Furthermore, in those with BAV, substantial geographical variation exists in patient characteristics, clinical approach and procedural strategy. Therefore, in this Roadmap article, we summarize the existing evidence and provide consensus recommendations from an international group of experts on the application of TAVI in patients with BAV in advance of the anticipated growth in the use of this procedure in this challenging cohort of patients., (© 2022. Springer Nature Limited.)

Objective: To investigate the characteristics of delayed high-degree atrioventricular block (DHAVB) after transcatheter aortic valve replacement (TAVR). Methods: One hundred and seventy-six patients who underwent TAVR with a self-extending valve between May 2014 and November 2018 in the Department of Cardiology, West China Hospital of Sichuan University, were retrospectively enrolled, including 101 males and 75 females, aged 54-92 (73±7) years, and the data were collected during the perioperative and 30 d follow-up periods. According to the occurrence of HAVB after TAVR, 160 patients were divided into no-HAVB group (145 cases) and DHAVB group (15 cases), except 16 patients who developed HAVB within 2 days after TAVR. Baseline data, intraoperative data, and immediate postoperative ECG characteristics were compared between the two groups, and logistic regression models were used to analyze the factors associated with the occurrence of DHAVB after TAVR. Meanwhile, the diagnostic ability of the postoperative routine 12-lead ECG for DHAVB was evaluated using the ambulatory ECG findings as the standard diagnosis. Results: The incidence of DHAVB was 8.5% (15/176) and occurred at 5 (4, 6) d. Compared with the no-HAVB group. The percentage of no new conduction block on the immediate postoperative ECG was lower in the DHAVB group [6/15 vs 66.2%(96/145), P =0.044], and the percentage of new right bundle branch block on the immediate postoperative ECG was higher [4/15 vs 3.4%(5/145), P =0.002]. Multifactorial logistic regression analysis showed that right bundle branch block on the immediate postoperative ECG [ OR (95% CI ):6.60 (1.26-34.47), P =0.025] was an associated factor for the development of DHAVB after TAVR. The specificity of postoperative routine 12-lead ECG for the diagnosis of DHAVB was 100% (145/145), but the sensitivity was only 73.3% (11/15). Conclusions: The incidence of DHAVB after TAVR is also high in Chinese. The immediate postoperative ECG characteristics of patients who underwent TAVR are associated with DHAVB events, and applying these characteristics to risk stratify patients may optimize the management of DHAVB after TAVR.

Competing Interests: Funding Support and Author Disclosures This work was supported by the West China Hospital “1·3·5” Discipline of Excellence Project-“Mechanisms of aortic stenosis and the clinical applications.” Dr Niu is an employee of Venus Medtech. Drs Feng and M. Chen are proctors/consultants for Venus Medtech. Dr F. Chen has no relationships relevant to the contents of this paper to disclose.

Background: It is unknown whether the sex difference whereby female transcatheter aortic valve replacement (TAVR) candidates had a lower risk profile, a higher incidence of in-hospital complications, but more favorable short- and long-term survival observed in tricuspid cohorts undergoing TAVR would persist in patients with bicuspid aortic valves (BAVs)., Objectives: The aim of this study was to reexamine the impact of sex on outcomes following TAVR in patients with BAVs., Methods: In this single-center study, patients with BAVs undergoing TAVR for severe aortic stenosis from 2012 to 2021 were retrospectively included. Baseline characteristics, aortic root anatomy, and in-hospital and 1-year valve hemodynamic status and survival were compared between sexes., Results: A total of 510 patients with BAVs were included. At baseline, women presented with fewer comorbidities. Men had a greater proportion of Sievers type 1 BAV, higher calcium volumes (549.2 ± 408.4 mm 3 vs 920.8 ± 654.3 mm 3 ; P < 0.001), and larger aortic root structures. Women experienced more vascular complications (12.9% vs 4.9%; P = 0.002) and bleeding (11.1% vs 5.3%; P = 0.019) and higher residual gradients (16.9 ± 7.7 mm Hg vs 13.2 ± 6.4 mm Hg; P < 0.001), while men were more likely to undergo second valve implantations during index TAVR (6.3% vs 15.9%; P = 0.001). Death at 1 year was not significantly different between sexes (HR: 1.15; 95% CI: 0.56-2.35; P = 0.70). Bleeding (adjusted HR: 4.62; 95% CI: 1.51-14.12; P = 0.007) was the single independent predictor of 1-year death for women., Conclusions: In patients with BAVs undergoing TAVR, women presented with fewer comorbidities, while men had a greater proportion of type 1 BAV, more calcification, and larger aortic roots. In-hospital outcomes favored men, with fewer complications except for the need for second valve implantation, but 1-year survival was comparable between sexes., Competing Interests: Funding Support and Author Disclosures This work was supported by the National Natural Science Foundation of China (grants 81970325, 82170375, and 82102129); Sichuan Province Department of Science and Technology (grant number 2022YFS0364); West China Hospital “1·3·5” Discipline of Excellence Project “Percutaneous Transcatheter Aortic Valve Implantation” and “Mechanisms of Aortic Stenosis and the Clinical Applications”; and a fellowship of the China Postdoctoral Science Foundation (2020M683327). Drs Mao Chen and Feng are proctors and consultants for Venus MedTech, MicroPort, and Peijia Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: It is unknown whether there are differences in coronary access after transcatheter aortic valve replacement (TAVR) between bicuspid and tricuspid anatomy., Aims: Our aim was to investigate coronary access after TAVR using a self-expanding transcatheter heart valve (THV) in bicuspid versus tricuspid aortic valves (BAV vs TAV), based on CT simulation., Methods: A total of 86 type 0 BAV, 70 type 1 BAV, and 132 TAV patients were included. If the coronary ostium faced the sealed parts of the THV or the tilted-up native leaflet (NL), this was defined as THV- or NL-related challenging coronary access, respectively. If coaxial engagement was not allowed due to interference from the unwrapped frame, THV-related complex coronary access was defined., Results: The incidence of THV-related challenging coronary access was 21.2% for the left coronary artery (LCA) and 17.7% for the right coronary artery (RCA), and type 0 BAV patients encountered fewer THV-related challenging LCA access than their TAV counterparts (OR 0.42, 95% CI: 0.20-0.89). NL-related challenging coronary access was observed in 3.1% for LCA and 1.4% for RCA, and THV-related complex coronary access was identified in 5.9% for LCA and 17.0% for RCA; however, no significant differences were found among groups. The proportion of optimal fluoroscopic viewing angles suitable for guiding LCA engagement was similar among groups (64.0% vs 70.0% vs 62.1%), but those suitable for guiding RCA engagement were significantly higher in the type 0 BAV group (31.4% vs 4.3% vs 9.1%)., Conclusions: Coronary access may be challenging or complex in a significant proportion of both BAV and TAV patients after TAVR. Type 0 BAV anatomy may be more favourable for post-TAVR coronary access.

Background: The present study aims to evaluate how nutritional status may affect transcatheter aortic valve implantation (TAVI) outcomes., Materials and Methods: This is a retrospective study of 383 TAVI patients. In-hospital, 1-month, and 12-month survival was evaluated. Since most patients undergoing TAVI are over 75 years old, the NRI definition for a geriatric population (GNRI) was used. Preoperative baseline clinical and laboratory data were collected and then the corresponding nutritional status was calculated, including Geriatric Nutritional Risk Index (GNRI), Prognostic Nutritional Index (PNRI), and Controlling Nutritional Status Score (CONUT). Survival analysis and receiver operating characteristic curve (ROC) analysis were used to evaluate the correlation between these parameters and TAVI outcome., Results: By CONUT and GNRI scores, 168 (58.9%) and 40 (14.0%) patients were considered to have mild malnutrition, respectively. By using PNI, CONUT, and GNRI scores, 16 (5.7%), 29 (10.3%), and 39 (13.7%) patients were moderately or severely malnourished. Survival analysis showed that patients with worse nutritional status had a worse prognosis regardless of the nutritional score used. Subgroup analysis showed that these differences remained significant in subgroups of patients over age 75. COX multivariate analysis showed that GNRI, PNI, and CONUT were independently associated with all-cause mortality during the follow-up., Conclusion: Patients with worse nutritional status had a worse prognosis regardless of the nutritional score used. Subgroup analysis showed that these differences remained significant in subgroups of patients over age 75. GNRI, PNI, and CONUT were independent predictors of all-cause mortality after TAVI.

Objectives: The aim of this study was to investigate the risk of coronary obstruction during redo-transcatheter aortic valve replacement (TAVR) within a previously implanted self-expanding valve in bicuspid aortic valve (BAV) versus tricuspid aortic valve (TAV) stenosis., Background: The prevalence of BAV in TAVR patients is expected to increase as the indication expands; however, no study has investigated the risk of coronary obstruction for future redo-TAVR in these patients., Methods: Computed tomography (CT) simulation analysis was performed in 86 type 0 BAV, 70 type 1 BAV, and 132 TAV patients who underwent TAVR with 1 VenusA-Valve (Venus Medtech) between January 2014 and December 2019., Results: CT-identified risk of coronary obstruction during redo-TAVR was observed in 36.1% of patients for the left coronary ostium (LCO) and 27.8% of patients for the right coronary ostium (RCO); however, the incidences were significantly lower in the type 0 BAV group than in the type 1 BAV or TAV group (for LCO: OR: 1.00 [reference] vs OR: 2.49; 95% CI: 1.24-5.01 vs OR: 2.60; 95% CI: 1.40-4.81; for RCO: OR: 1.00 [reference] vs OR: 2.14; 95% CI: 1.02-4.48 vs OR: 1.97; 95% CI: 1.02-3.80). The leaflet laceration technique may be unfeasible to improve coronary flow in 61.5% of the threatened LCOs and 58.8% of the threatened RCOs during redo-TAVR. The percentages were significantly or numerically lower in the type 0 BAV group than other groups (for LCO: 26.3% vs 62.1% vs 73.2%; P overall = 0.001; for RCO: 43.8% vs 65.2% vs 61.0%; P overall = 0.374)., Conclusions: Differences in anatomical features may impact the feasibility of future redo-TAVR. Type 0 BAV anatomy was associated with the lower incidence of CT-identified risk of coronary obstruction during redo-TAVR, and the leaflet laceration technique may be more feasible to ensure coronary flow in this population., Competing Interests: Funding Support and Author Disclosures This work was supported by the National Natural Science Foundation of China (81970325, 82102129 and 82170375); West China Hospital “1·3·5” Discipline of Excellence Project-“Percutaneous transcatheter aortic valve implantation” and “Mechanisms of aortic stenosis and the clinical applications. Drs Mao Chen and Yuan Feng are consultants of Venus MedTech. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: In the last decade, transcatheter aortic valve implantation (TAVI) has developed rapidly in China. As TAVI progresses towards low surgical risk patients, the total number of TAVI procedures will grow exponentially. There is a need to develop a domestic TAVI device designed for Chinese patients., Aims: The aim of this study was to evaluate the safety and efficacy of a self-expanding valve (TaurusOne transcatheter aortic valve system) in the treatment of patients with symptomatic severe aortic stenosis in China., Methods: A prospective, multicentre, single-arm study was designed to enrol 120 patients with symptomatic severe aortic stenosis undergoing TAVI using the TaurusOne valve. The primary endpoint was all-cause mortality at one year., Results: From September 2017 to April 2019, 120 patients were enrolled (35% bicuspid aortic valve, mean Society of Thoracic Surgeons [STS] score 9.95%). One-year mortality in 120 patients (follow-up rate, 100%), was 6.7% (upper 95% confidence interval: 12.9%), which was significantly lower than the performance goal of 30% (p<0.0001). All stroke, myocardial infarction, paravalvular leak ≥moderate, and new pacemaker implantation occurred in 4.4%, 1.8%, 0.8%, and 22.1% of patients, respectively, at one year. The haemodynamic results and quality of life scores also improved significantly. Patients with a bicuspid valve had similar outcomes to those with a tricuspid aortic valve., Conclusions: The one-year clinical results confirm the safety and efficacy of the TaurusOne transcatheter aortic valve system in the treatment of patients with symptomatic severe tricuspid and bicuspid aortic stenosis.

Objectives: The aim of this study was to assess cusp symmetry and coronary ostial eccentricity and its impact on coronary access following transcatheter aortic valve replacement (TAVR) using a patient-specific commissural alignment implantation technique., Background: TAVR implantation techniques to obtain neocommissural alignment have been introduced. The impact of cusp symmetry and coronary ostial eccentricity on coronary access after TAVR remains unknown., Methods: Cardiac computed tomographic scans from 200 tricuspid aortic valves (TAVs) and 200 type 1 bicuspid aortic valves (BAVs) were studied. Cusp symmetry and coronary ostial eccentricity were assessed. In addition, the right coronary cusp/left coronary cusp and right coronary artery (RCA)/left coronary artery (LCA) ostia overlap views were calculated and compared., Results: Severe cusp asymmetry (>135°) was more frequent in BAVs (52.5%) than in TAVs (2.5%) (P < 0.001), with the noncoronary cusp being the most common dominant cusp. The RCA ostium was found to be more often eccentric (>20°) than the LCA ostium (28% vs 6%, respectively; P < 0.001). Considering the right/left cusp overlap view, there was <20° deviation between the right coronary cusp-left coronary cusp centered line and the RCA-LCA centered line in 95% of all patients (TAV, 97%; BAV, 93%). The right/left cusp and coronary ostia overlap view differed by <10° and <20° fluoroscopic angulation in 75% and 98% of all cases, respectively., Conclusions: Using the right/left cusp overlap view to obtain commissural alignment in TAVR is also an effective approach to implant one of the transcatheter heart valve commissures in the near center between both coronary ostia in most TAVs and type 1 BAVs. Preprocedural CT assessment remains crucial to assess cusp symmetry and coronary ostial eccentricity., Competing Interests: Funding Support and Author Disclosures Dr De Backer has received institutional research grants and consulting fees from Abbott and Boston Scientific. Dr Bieliauskas has received consulting fees from Abbott, Boston Scientific, and Medtronic. Dr Kofoed has received institutional grants from AP Møller og hustru Chastine McKinney Møllers Fond, the Meyer Foundation, the Danish Heart Foundation, the Danish Agency for Science, Technology, and Innovation by the Danish Council for Strategic Research, and Canon Medical. Dr Chen is the consultant for CardioFlow, Venus MedTech, and Peijia Medical. Dr Sondergaard has received institutional research grants and consulting fees from Abbott, Medtronic, Boston Scientific, and Edwards Lifesciences. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Introduction: The aim of this systematic review and meta-analysis was to investigate the efficacy and safety of emergent transcatheter aortic valve implantation (TAVI) in patients with decompensated aortic stenosis (AS) by comparing the clinical outcomes with the patients who had received the elective TAVI., Methods: By searching PubMed, EMBASE, and Cochrane databases, we obtained the studies comparing the clinical outcomes of emergent TAVI and elective TAVI. Finally, 14 studies were included., Results: A total of 14 eligible articles with 73,484 patients were included in this meta-analysis. Emergent TAVI was associated with a higher mortality during hospitalization (HR 2.09, 95% CI [1.39 to 3.14]), 30 days (HR 2.29, 95% CI [1.69 to 3.10]), and 1 year (HR 1.96, 95% CI [1.55 to 2.49]). Consistently, the incidence of acute kidney injury (AKI) (RR 2.48, 95% CI [1.85 to 3.32]), dialysis (RR 2.37, 95% CI [1.95 to 2.88]), bleeding (RR 1.62, 95% CI [1.27 to 2.08]), major bleeding (RR 1.05, 95% CI [1.00 to 1.10]), and 30-day rehospitalization (RR 1.30, 95% CI [1.07, 1.58]) were more common in patients receiving emergent TAVI. No statistical differences were found in the occurrence rate of vascular complications (RR 1.11, 95% CI [0.90, 1.36]), major vascular complications (RR 1.14, 95% CI [0.52, 2.52]), permanent pacemaker (PPM) placement (RR 1.05, 95% CI [0.99, 1.11]), cerebrovascular events (RR 1.11, 95% CI [0.98, 1.25]), moderate to severe paravalvular leakage (PVL) (RR 1.23, 95% [CI 0.94 to 1.61]), and device success (RR 0.99, 95% CI [0.97, 1.01])., Conclusion: Emergent TAVI is associated with some postoperative complications and increased mortality compared with elective TAVI. Emergent TAVI should be implemented cautiously and individually., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2021 Ruochen Shao et al.)

Background: Optimal projection is essential for valve deployment during transcatheter aortic valve implantation (TAVI). The purpose of this study was to propose an approach to predict optimal projection in TAVI candidates with different aortic valve anatomies., Methods: 331 patients undergoing self-expanding TAVI were included and the so-called non-coronary cusp (NCC)-parallel technique was utilized, which generated the predicted projection by connecting NCC commissures on the transverse plane on the pre-procedural computed tomography images., Results: 37.8% of the study cohort were bicuspid aortic valve (BAV) patients. Around 80% of both NCC-parallel views and final views were in the right anterior oblique (RAO) and caudal (CAU) quadrant. There was less than 5° change required from the NCC-parallel view to the final implanted view in 79% of tricuspid aortic valve (TAV) patients but only in 27% (13/48) of type 0 BAV patients with coronary arteries originated from the different cusps. After excluding the above mentioned BAV patients, 62.3% (48/77) of BAV patients needed less than 5° change to achieve optimal projection and only in 8 patients, the angular change was larger than 10° in either left/right anterior oblique or cranial/caudal direction., Conclusions: The NCC-parallel technique provides reliable prediction for optimal projection in self-expanding TAVI in all TAV and most BAV patients, with a vast majority of views in the RAO and CAU quadrant., (© 2021. The Author(s).)

Background: The past decade has witnessed an ever-increasing momentum of transcatheter aortic valve replacement (TAVR) and a subsequent paradigm shift in the contemporary management of severe aortic stenosis (AS). We conducted a multi-centric TAVR registry based on Chinese patients (the China Aortic valve tRanscatheter Replacement registrY [CARRY]) to delineate the clinical characteristics and outcomes of Chinese patients who underwent TAVR and compare the results between different valve types in different Chinese regions., Methods: CARRY is an all-comer registry of aortic valve disease patients undergoing TAVR across China and was designed as an observational study that retrospectively included all TAVR patients at each participating site. Seven hospitals in China participated in the CARRY, and 1204 patients from April 2012 to November 2020 were included. Categorical variables were compared using the chi-squared test, and continuous variables were analyzed using a t test or analysis of variance (ANOVA) test. The Kaplan-Meier curve was used to estimate the risk of adverse events during follow-up., Results: The mean age of the patients was 73.8 ± 6.5 years and 57.2% were male. The median Society of Thoracic Surgeon-Predicted Risk of Mortality score was 6.0 (3.7-8.9). Regarding the aortic valve, the proportion of bicuspid aortic valve (BAV) was 48.5%. During the hospital stay, the stroke rate was 0.7%, and the incidence of high-degree atrioventricular block indicating permanent pacemaker implantation was 11.0%. The in-hospital all-cause mortality rate was 2.2%. After 1 year, the overall mortality rate was 4.5%. Compared to patients with tricuspid aortic valve (TAV), those with BAV had similar in-hospital complication rates, but a lower incidence of in-hospital mortality (1.4% vs. 3.3%) and 1 year mortality (2.3% vs. 5.8%)., Conclusions: TAVR candidates in China were younger, higher proportion of BAV, and had lower rates of post-procedural complications and mortality than other international all-comer registries. Given the use of early generation valves in the majority of the population, patients with BAV had similar rates of complications, but lower mortality than those with TAV. These findings further propel the extension of TAVR in low-risk patients., Trial Registration: https://www.chictr.org.cn/ (No. ChiCTR2000038526)., (Copyright © 2021 The Chinese Medical Association, produced by Wolters Kluwer, Inc. under the CC-BY-NC-ND license.)

We sought to assess the amount and distribution of force on the valve frame after transcatheter aortic valve replacement (TAVR) via patient-specific computer simulation. Patients successfully treated with the self-expanding Venus A-Valve and multislice computed tomography (MSCT) pre- and post-TAVR were retrospectively included. Patient-specific finite element models of the aortic root and prosthesis were constructed. The force (in Newton) on the valve frame was derived at every 3 mm from the inflow and at every 22.5° on each level. Twenty patients of whom 10 had bicuspid aortic valve (BAV) were analyzed. The total force on the frame was 74.9 N in median (interquartile range 24.0). The maximal force was observed at level 5 that corresponds with the nadir of the bioprosthetic leaflets and was 9.9 (7.1) N in all patients, 10.3 (6.6) N in BAV and 9.7 (9.2) N for patients with tricuspid aortic valve (TAV). The level of maximal force located higher from the native annulus in BAV and TAV patients (8.8 [4.8] vs. 1.8 [7.4] mm). The area of the valve frame at the level of maximal force decreased from 437.4 (239.7) mm 2 at the annulus to 377.6 (114.3) mm 2 in BAV, but increased from 397.5 (114.3) mm 2 at the annulus to 406.7 (108.9) mm 2 in TAV. The maximum force on the bioprosthetic valve frame is located at the plane of the nadir of the bioprosthetic leaflets. It remains to be elucidated whether this may be associated with bioprosthetic frame and leaflet integrity and/or function., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Competing Interests: Funding Support and Author Disclosures The work was supported by National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University (Z20192010). The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Background There are conflicting results over the improvement rate and predictors of mitral regurgitation in patients undergoing transcatheter aortic valve replacement (TAVR). Purpose To define the cause, degree of improvement, and improvement predictors of moderate to severe mitral regurgitation in patients undergoing TAVR by using a simplified D-shaped mitral annulus model derived from multisection CT (MSCT). Materials and Methods This retrospective cohort study included 528 consecutive patients who underwent TAVR between April 2012 and October 2019. Patients with previous surgical aortic valve replacement and those with moderate or severe mitral stenosis were excluded. A total of 104 patients with moderate to severe mitral regurgitation met the inclusion criteria and were included in the final analysis. At least one grade reduction in the severity of mitral regurgitation was considered indicative of mitral regurgitation improvement after TAVR. Up to 5-year post-TAVR follow-up of mitral regurgitation improvement was evaluated. Mitral annular dimensions (annular area, circumference, and trigone-to-trigone, intercommissural, and anteroposterior distances) and annular calcification were assessed at MSCT with use of dedicated postprocessing software. Associations with mitral regurgitation improvement after TAVR were explored. Results A total of 104 patients with concomitant mitral regurgitation who underwent TAVR (mean age, 74 years ± 7; 61 men) were included in the study. Mitral regurgitation improved in 79 patients after TAVR and remained unchanged in the remaining 25 patients. Maximum improvement was observed in the 1st year after TAVR. D-shaped mitral annular parameters, including annular circumference (odds ratio [OR], 1.05; 95% CI: 1.01, 1.1; P = .02) and trigone-to-trigone (OR, 1.2; 95% CI: 1.03, 1.39; P = .02) and intercommissural (OR, 1.15; 95% CI: 1.02, 1.31; P = .02) distances, were related to mitral regurgitation improvement. In addition, patients with coronary artery disease had greater improvement in mitral regurgitation after TAVR (OR, 0.17; 95% CI: 0.04, 0.76; P = .02). Primary mitral regurgitation (OR, 5.1; 95% CI: 1.1, 24; P = .04) and D-shaped annular circumference (OR, 1.06; 95% CI: 1, 1.11; P = .04) were independent predictors of less mitral regurgitation improvement after TAVR. Conclusion Concomitant mitral regurgitation in patients undergoing transcatheter aortic valve replacement (TAVR) tends to improve after the procedure, with maximum improvement in the 1st year after TAVR. D-shaped annular circumference and primary mitral regurgitation were independent predictors of less mitral regurgitation improvement after TAVR. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Collins in this issue.

Background: Some patients referred for transcatheter aortic valve replacement (TAVR) have excessively large annuli (ELA) without device options according to current sizing charts. This retrospective study aims to summarize the presentation and outcomes of ELA patients receiving first-generation self-expanding valves., Methods: The TAVR database was reviewed in search for cases of self-expanding valves. Patients who had annuli exceeding the perimeter limit on the device sizing chart were referred to as the ELA group. Patients who had annuli within the range covered by the two largest sizes and received the corresponding valve size served as the control group (CG). Baseline, procedures, outcomes, and imaging characteristics on multislice computed tomography (MSCT), such as native anatomy and postimplant stent geometry, were compared., Results: A total of 28 patients were included in the ELA group and 82 in the CG. The patients in the ELA group were younger than those in the CG (72.5 ± 6.2 vs. 75.4 ± 5.8 years, P = 0.03). The median intended perimeter oversizing in relation to the annulus in the ELA group was much smaller than in the CG (-0.4 [-4.6, 4.1] % vs. 16.1 [11.7, 20.8] %, P < 0.01). The calcium burden in the aortic root was around 1.3-fold greater in the ELA group than the CG (756.0 [534.5, 1670.9] vs. 582.1 [310.3, 870.9] mm 3 , P = 0.01). The need for second valve implantation was higher in ELA (21.4% vs. 12.2%, P = 0.23) but no valve embolization was encountered. The 1‑year follow-up was comparable, including >mild paravalvular leak., Conclusion: Under cautious patient selection using MSCT, TAVR with self-expanding valves in patients with ELA appears feasible. Supra-annular structures likely provide the extra anchoring., (© 2020. Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Objectives: We sought to identify the impact of transcatheter aortic valve implantation (TAVI) on changes of fractional flow reserve computed tomography (FFR CT ) values and the associated clinical impact., Methods: A retrospective analysis was done with CT obtained pre-TAVI, prior to hospital discharge and at 1-year follow-up, which provided imaging sources for the calculation of FFR CT values based on an online platform., Results: A total of 190 patients were enrolled. Patients with pre-procedural FFR CT value > 0.80 (i.e., negative) and ≤ 0.80 (i.e., positive) demonstrated a significantly opposite change in the value after TAVI (0.8798 vs. 0.8718, p < 0.001 and 0.7634 vs. 0.8222, p < 0.001, respectively). The history of coronary artery disease (CAD) was identified as an independent predictor for FFR CT changing from negative to positive after TAVI (odds ratio [OR] 2.927, 95% confidence interval [CI] 1.130-7.587, p = 0.027), with lesions more severely stenosed (OR 1.039, 95% CI 1.003-1.076, p = 0.034) and in left anterior descending coronary artery (LAD) (OR 3.939, 95% CI 1.060-14.637, p = 0.041) being prone to change., Conclusions: TAVI directly brings improvement in FFR CT values in patients with compromised coronary flow. Patients with a history of CAD, especially with lesions more severely stenosed and in LAD, were under risk of FFR CT changing from negative to positive after TAVI., Key Points: •The effect of TAVI on coronary hemodynamics might be influenced by different ischemic severity and coronary territories reflected by FFR CT values. •As different FFR CT variations did not impact outcomes of TAVI patients, AS, but not coronary issues, may be the primary problem to affect, which needs further validation., (© 2021. European Society of Radiology.)

Background: With the expanded utilization of transcatheter aortic valve implantation (TAVI) to younger and lower surgical risk patients with severe aortic stenosis (AS), optimal medical therapy after TAVI procedure has become the main concern. Renin-angiotensin system inhibitors (RASi) are widely utilized in the area of cardiovascular disease including heart failure and myocardial infarction and revealed the ability to reverse left ventricular (LV) remodeling. Interests have, thus, been drawn in investigating whether the prescription of RASi after the TAVI procedure can prevent or reverse cardiac remodeling and improve long-term clinical outcomes. No recommendation regarding the prescription of RASi after TAVI is proposed yet due to the lack of evidence from randomized controlled trials, especially in the Chinese population. We, therefore, designed this randomized controlled trial to explore the effect of adding fosinopril to standard care in patients who underwent a successful TAVI procedure on the LV remodeling., Methods: A total of 200 post-TAVI patients from seven academic hospitals across China will be recruited and randomized with a ratio of 1:1 to receive standard care or standard care plus fosinopril. Follow-up visits will take place at 30 days, 3 months, 6 months, 12 months, and 24 months from randomization to assess the clinical symptoms, any adverse events, cardiac function, and quality of life. Cardiac magnetic resonance will be performed at baseline and repeated at the 24-month follow-up visit to assess LV remodeling., Discussion: This study will provide evidence regarding medical therapy for AS patients who underwent TAVI and filling the gap in the Chinese population., Trial Registration: Chinese Clinical Trial Registry ChiCTR2100042266 . Registered on 17 January 2021., (© 2021. The Author(s).)

Background: Since readmission rate is an important clinical index to determine the quality of inpatient care and hospital performance, the aim of this study was to explain the causes and predictors of readmission following transcatheter aortic valve implantation (TAVI) at short-term and mid-term follow-up., Methods and Results: A systematic review and meta-analysis of all published articles from Embase, Pubmed/MEDLINE, and Ovid was carried out. In all, 10 studies including 52,702 patients were identified. The pooled estimate for the overall event rate was 0.15, and cardiovascular causes were the main reason for 30-day readmission (0.42, 95% confidence interval [CI]: 0.39-0.45). In addition, the pooled incidence of 1‑year readmission was 0.31, and cardiovascular events were still the main cause (0.41, 95% CI: 0.33-0.48). Patients with major and life-threatening bleeding, new permanent pacemaker implantation, and clinical heart failure were associated with a high risk for early readmission after TAVI. Moreover, an advanced (≥3) New York Heart Association classification, acute kidney injury, paravalvular leak, mitral regurgitation (≥ moderate), and major bleeding predicted unfavorable outcome to 1‑year readmission. Female gender and transfemoral TAVI was associated with a lower risk for unplanned rehospitalization., Conclusions: This meta-analysis found cardiovascular factors to be the main causes for both 30-day and 1‑year rehospitalization. Heart failure represented the most common cardiovascular event at both short-term and mid-term follow-up. Several baseline characteristics and procedure-related factors were deemed unfavorable predictors of readmission. Importantly, transfemoral access and female gender were associated with a lower risk of readmission.

Background: Data reporting the impact of renin-angiotensin system inhibitor (RASi) after aortic valve replacement (AVR) is controversy., Methods: The PubMed database was systematically searched for studies reporting the mortality and hazard ratios (HRs) of RASi following surgical and transcatheter AVR (SAVR, TAVR). Random-effects model was used when the I2 statistic was more than 50% and its P value was less than 0.05, otherwise, the fixed-effects model was conducted., Results: Nine articles incorporating 33,063 patients were eligible. Patients having the description of RASi were associated with lower all-cause mortality at 30 days (OR, 0.80, 95% CI, 0.69 to 0.94), 1 year (OR, 0.75, 95% CI, 0.69 to 0.81) and beyond 1 year (OR, 0.52, 95% CI, 0.38 to 0.73) after AVR. Consistently, patients with RASi had lower risk for all-cause mortality (HR, 0.87, 95% CI, 0.84 to 0.91) beyond 1 year following AVR albeit adjusting confounders. Interestingly, beneficial effect of RASi was still observed in patients with preserved ejection fraction following TAVR (HR, 0.90, 95% CI, 0.87 to 0.94). In addition, patients taking RASi had lower cardiovascular mortality than those patients without RASi after TAVR (30 days, OR, 0.63, 95% CI, 0.44 to 0.90; 1 year, OR, 0.60, 95% CI, 0.50 to 0.73; beyond 1 year, OR, 0.63, 95% CI, 0.54 to 0.74)., Conclusions: Patients with RASi exhibited better short- and long-term survival following AVR compared to those patients without RASi, which warranted further studies to support such findings.

Objectives: Transcatheter aortic valve replacement (TAVR) is increasingly performed. Physically small Asians have smaller aortic root and peripheral vessel anatomy. The influence of gender of Asian patients undergoing TAVR is unknown and may affect outcomes. The aim of this study was to assess sex differences in Asian patients undergoing TAVR., Methods: Patients undergoing TAVR from eight countries were enrolled. In this retrospective analysis, we examined differences in characteristics, 30-day clinical outcomes and 1-year survival between female and male Asian patients., Results: Eight hundred and seventy-three patients (54.4% women) were included. Women were older, smaller and had less coronary artery and lung disease but tended to have higher logistic EuroSCOREs. Smaller prostheses were used more often in women. Major vascular complications occurred more frequently in women (5.5% vs 1.8%, p<0.01); however, 30-day stroke and mortality (women vs men: 1.5% vs 1.6%, p=0.95% and 4.3% vs 3.4%, p=0.48) were similar. Functional status improvement was significant and comparable between the sexes. Conduction disturbance and permanent pacemaker requirements (11.2% vs 9.0%, p=0.52) were also similar as was 1-year survival (women vs men: 85.6% vs 88.2%, p=0.25). The only predictors of 30-day mortality were major vascular injury in women and age in men., Conclusions: Asian women had significantly smaller stature and anatomy with some differences in clinical profiles. Despite more frequent major vascular complications, women had similar 30-day stroke or mortality rates. Functional status improvement was significant and comparable between the sexes. Conduction disturbance and permanent pacemaker requirements were similar as was 1-year survival., Competing Interests: Competing interests: PTLC, KH, YW, W-HY, MKYL, MC, WJK, KC, M-SL and HSK have served as proctors for Edwards Lifesciences. PTLC, YW, W-HY, H-LK, MKYL, WB, Dy, KC, M-SL, KWH and HSK have served as proctors for Medtronic. WJK has served as a consultant for Medtronic., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: We hypothesize that different degree of pre-existing aortic regurgitation (AR) may affect the presence of hypo-attenuated leaflet thickening (HALT) after transcatheter aortic valve replacement (TAVR)., Background: The mechanism of the presence of HALT post-TAVR is not fully understood., Methods: We retrospectively evaluated the post-procedural multi-slice computed tomography (MSCT) before discharge for evidence of HALT. Patients were grouped according to the degree of pre-existing AR. Baseline, native anatomy and procedure details were compared, then multivariate regression was performed., Results: MSCT analyzed was performed at a median of 6 days post-TAVR in 179 patients. HALT was detected in 10.6% of patients. After adjusting for variables that were significantly different between groups, pre-existing ≥ moderate AR was protective to the risk of HALT (OR 0.15, 95% CI 0.03-0.84, p = .03). Stratifying for factors that might explain the impact of pre-existing AR on HALT, patients with a small Sinus of Valsalva, non-eccentric remodeling and receiving a large bioprosthesis experienced a sevenfold higher risk for HALT (OR 7.16, 95% CI 2.05-25.08, p = .002)., Conclusions: Patients underwent TAVR with pre-existing ≥ moderate AR appeared to experience a lower incidence of early HALT compared to those patients with less than moderate AR, which may be explained by a larger Sinus of Valsalva and a higher proportion of LV eccentric remodeling., (© 2020 Wiley Periodicals, Inc.)

Objectives: The impact of the COVID-19 pandemic on the treatment of patient with aortic valve stenosis is unknown and there is uncertainty on the optimal strategies in managing these patients., Methods: This study is supported and endorsed by the Asia Pacific Society of Interventional Cardiology. Due to the inability to have face to face discussions during the pandemic, an online survey was performed by inviting key opinion leaders (cardiac surgeon/interventional cardiologist/echocardiologist) in the field of transcatheter aortic valve implantation (TAVI) in Asia to participate. The answers to a series of questions pertaining to the impact of COVID-19 on TAVI were collected and analyzed. These led subsequently to an expert consensus recommendation on the conduct of TAVI during the pandemic., Results: The COVID-19 pandemic had resulted in a 25% (10-80) reduction of case volume and 53% of operators required triaging to manage their patients with severe aortic stenosis. The two most important parameters used to triage were symptoms and valve area. Periprocedural changes included the introduction of teleconsultation, preprocedure COVID-19 testing, optimization of protests, and catheterization laboratory set up. In addition, length of stay was reduced from a mean of 4.4 to 4 days., Conclusion: The COVID-19 pandemic has impacted on the delivery of TAVI services to patients in Asia. This expert recommendation on best practices may be a useful guide to help TAVI teams during this period until a COVID-19 vaccine becomes widely available., (© 2020 Wiley Periodicals LLC.)