Akihisa Kataoka

Pre-procedural dual antiplatelet therapy in patients undergoing transcatheter aortic valve implantation increases risk of bleeding.

Objective To evaluate the clinical benefit of pre-procedural antiplatelet therapy in patients undergoing transfemoral (TF) transcatheter aortic valve implantation (TAVI). Methods OCEAN (Optimized transCathEter vAlvular interveNtion)-TAVI is a prospective, multicentre, observational cohort registry, enrolling 749 patients who underwent TAVI from October 2013 to August 2015 in Japan. We identified 540 patients (median age 85 years, 68.1% female) undergoing TF-TAVI; of these, 80 had no pre-procedural antiplatelet therapy and 460 had antiplatelet therapy. The endpoints were any bleeding (life-threatening, major, and minor bleeding) and thrombotic events (stroke, myocardial infarction, and valve thrombosis) during hospitalisation. Results Patients with dual antiplatelet therapy (DAPT) had a significantly higher incidence of any bleeding than those with single antiplatelet therapy (SAPT) (36.5% vs 27.5%, p=0.049) and no antiplatelet therapy (36.5% vs 21.3%, p=0.010). Patients without pre-procedural antiplatelet therapy did not experience an increased risk of thrombotic events. In multivariable logistic regression analysis, DAPT before TF-TAVI significantly increased any bleeding compared with SAPT (OR 2.05, 95% CI 1.16 to 3.65) and no antiplatelet therapy (OR 2.30, 95% CI 1.08 to 4.90). Conclusions The current study demonstrated that DAPT before TF-TAVI increased the risk of bleeding compared with single or no antiplatelet therapy. Lower intensity antiplatelet therapy was not associated with thrombotic events. In modern practice, it might be reasonable to perform TAVI using single or no pre-procedural antiplatelet therapy with an expectation of no increase of adverse events. Trial registration number UMIN-ID; 000020423; Results.

Propensity-matched comparison of percutaneous and surgical cut-down approaches in transfemoral transcatheter aortic valve implantation using a balloon-expandable valve

AIMS This study aimed to compare the clinical outcomes of patients undergoing transfemoral transcatheter aortic valve implantation (TAVI) via a percutaneous or surgical cut-down approach. METHODS AND RESULTS Between October 2013 and July 2015, 586 patients underwent transfemoral TAVI according to the Optimized CathEter vAlvular iNtervention (OCEAN)-TAVI registry (percutaneous approach, n=305; surgical cut-down approach, n=281). After propensity matching, 166 patients underwent transfemoral TAVI via each approach. Major vascular complications, as defined per the Valve Academic Research Consortium-2 criteria, were found less frequently in patients who underwent a percutaneous approach (15.1% vs. 27.1%, p<0.01), and femoral artery injuries requiring surgical repair were mostly the result of a closure device failure (seven cases, 4.2%). In these patients, major bleeding was less (7.2% vs. 16.9%, p=0.01) and blood transfusion less frequent (21.1% vs. 38.0%, p<0.01); therefore, cases of acute kidney injury (AKI) were rare (6.0% vs. 15.1%, p<0.01). CONCLUSIONS Transfemoral TAVI using the percutaneous approach proved safe and feasible and resulted in fewer major vascular complications, bleeding and AKI events compared to the surgical cut-down approach.

Timing of Susceptibility to Mortality and Heart Failure in Patients With Preexisting Atrial Fibrillation After Transcatheter Aortic Valve Implantation

The relationship between cardiac rhythm and adverse events after transcatheter aortic valve implantation (TAVI) remains unclear. To compare the prognostic impact of preexisting atrial fibrillation (AF) and new-onset AF (NOAF) after TAVI, we assessed 1,124 patients (846 with sinus rhythm [SR], 49 with NOAF, and 229 with preexisting AF) who underwent TAVI with a balloon-expandable valve from October 2013 to April 2016. The incidences of all-cause death and rehospitalization for heart failure (HF) were retrospectively evaluated. The median follow-up period was 370 days (range 188 to 613). In the Kaplan-Meier analysis, the incidences of all-cause death and rehospitalization for HF were significantly higher in patients with preexisting AF than those in patients with NOAF and SR. The multivariable analysis showed that preexisting AF was significantly associated with increased all-cause death (hazard ratio [HR] 1.54; 95% confidence interval [CI] 1.02 to 2.34) and rehospitalization for HF (HR 2.94; 95% CI 1.75 to 4.93). The landmark analysis demonstrated that patients with preexisting AF had a significantly higher incidence of rehospitalization for HF within the first 6 months after TAVI (HR 4.04; 95% CI 2.23 to 7.32), and a higher incidence of all-cause death from 6 months to 2 years after TAVI (HR 2.12; 95% CI 1.15 to 3.90). Our study demonstrated that preexisting AF increased the risk of all-cause death and rehospitalization for HF after TAVI in comparison with NOAF or SR. Moreover, there was a specific timing of susceptibility to all-cause death and rehospitalization for HF after TAVI.

Balloon Valvuloplasty for Evolut R Infolding: Useful Transesophageal Echocardiographic Monitoring for Diagnosis and Efficacy

An 89-year-old man with symptomatic severe aortic stenosis underwent 29-mm Evolut R (Medtronic, Minneapolis, Minnesota) implantation under general anesthesia. During the procedure, the Evolut R was deployed using the left subclavian artery approach. However, systemic hypotension persisted.

Incidence, Predictors, and Midterm Clinical Outcomes of Myocardial Injury After Transcatheter Aortic-Valve Implantation

Our aim was to assess the clinical effects of myocardial injury after transcatheter aortic-valve implantation (TAVI). Between October 2013 and July 2016, 157 patients underwent TAVI with Sapien XT, Sapien 3, or CoreValve prostheses at our institute. Of these, 130 patients for whom the transapical approach was not used were included in this study. Myocardial injury was defined as a peak troponin I level of ≥1.5 ng/mL within 48 hours after TAVI. We evaluated the predictors of myocardial injury and compared the clinical outcomes of 82 patients classified as the myocardial injury group and 44 patients classified as the non-myocardial injury group. The patients were aged 85 ± 6 years. Myocardial injury occurred in 82 patients (65.1%). Age (per 1 increase) (odds ratio [OR]: 1.11, 95% confidence interval [CI]: 1.01-1.22, P = 0.041), female sex (OR: 3.88, 95% CI: 1.23-12.22, P = 0.021), valve type (Sapien XT; OR: 4.22, 95% CI: 1.15-15.47, P = 0.03, Core valve; OR: 18.12, 95% CI: 2.86-114.59, P = 0.002), balloon aortic valvuloplasty as a bridge therapy (OR: 0.10, 95% CI: 0.02-0.42, P = 0.002), and left ventricular end-diastolic volume (LVEDV) (per 1 increase) (OR: 0.97, 95% CI: 0.95-0.99, P = 0.003) were associated with myocardial injury in a multivariate model. The myocardial injury group did not have a higher rate of midterm (365-day) mortality (log-rank test P = 0.57) than the non-myocardial injury group on Kaplan-Meier analysis. Myocardial injury after TAVI was not associated with midterm mortality.

A case of prosthetic aortic valve endocarditis with massive vegetation underestimated by conventional two-dimensional transesophageal echocardiography: efficacy of three-dimensional transesophageal echocardiography.

A 71-year-old man who had undergone aortic valve replacement (AVR) twice due to infective endocarditis (IE) and a subsequent failed bioprosthetic valve (CarpentierEdwards PERIMOUNT Magna Ease 23-mm) was admitted to our hospital because of high fever for 2 weeks. Blood tests showed an elevated white blood cell (WBC) count (11.1 9 10/l) and C-reactive protein (CRP) level (20.8 mg/dl), without any remarkable findings upon physical examination. Aggregatibacter aphrophilus, one of the HACEK organisms, was identified in blood culture tests. Conventional two-dimensional (2D) transesophageal echocardiography (TEE) and transthoracic echocardiography (TTE) demonstrated no findings of prosthetic valve endocarditis (PVE) and malfunctions (Fig. 1a, b). High doses of multiple antibiotics were started intravenously due to suspected PVE. Even after 4 weeks, the high fever persisted, and the WBC count and CRP level remained elevated. There were no remarkable findings on repeat blood culture tests and the bedside 2D-TTE. A second 2D-TEE showed an unusual structural object attached to the tip of the valve leaflet, which was suspected as being vegetation (Fig. 1c). Thus, 3D-TEE images were acquired and analyzed, which revealed a vegetation mass attached to the valve leaflet. This resulted in the final diagnosis of PVE (Fig. 1d). Two weeks later, the patient’s third AVR was performed. In contrast to the intraoperative 2D-TEE findings, which were not substantially different from those of the second 2DTEE (Fig. 1e), the 3D-TTE images and operative findings showed massive vegetation (u15 mm) attached to the valve leaflet and covered by the stent, which is a blind spot in 2D-TEE (Fig. 1f, g, i). With antibiotic administration for another 2 weeks, the patient’s fever subsided and blood test results normalized. Thereafter, he was discharged without any other complaints. Compared to native valve IE, PVE is difficult to diagnose [1]. Although performing repeated TTE and TEE is useful in cases of suspected PVE, echocardiogram quality of the prosthetic valve leaflet, especially in an aortic position, still remains poor [1, 2]. Alternatively, the latest ESC guideline recommend the use of 18F-fluorodeoxyglucose positron emission tomography/computed tomography for diagnosing PVE [1, 3]; however, these procedures are not covered by the standard health care in Japan. Therefore, 3D-TEE may be useful in detecting vegetation, especially in Japan, since it allows 3D volume analysis of cardiac structures in any possible plane. This circumvents the vegetation blind spot that exists in 2D echocardiography, as shown in this case [4]. Electronic supplementary material The online version of this article (doi:10.1007/s12574-016-0311-7) contains supplementary material, which is available to authorized users.

TCT-685 Pre-existing Right Bundle-Branch Block Increases Risk of Death after Transcatheter Aortic Valve Implantation with a Balloon-Expandable Valve.

TCT-684 Frailty Profile is Independently Associated with Higher Cost for Patients undergoing Transcatheter Aortic Valve Replacement for Symptomatic Severe Aortic Stenosis: a Single Center Experience Jay Patel, Sandeep Banga, Min-Chul Kim, Keattiyoat Wattanakit, Marco A. Barzallo, Sudhir Mungee OSF Saint Francis Medical Center/UICOMP; OSF Saint Francis Medical Center, UICOMP, Peoria, Illinois, United States; University of Illinois College of Medicine at Peoria; OSF St. Francis Medical Center; OSF Saint Francis Medical Center/UICOMP; Heartcare Midwest, Peoria, Illinois, United States