Audrey Agullo

Management of advanced heart failure: a review

ABSTRACT Introduction: Heart failure (HF) has become a global pandemic. Despite recent developments in both medical and device treatments, HF incidences continues to increase. The current definition of HF restricts itself to stages at which clinical symptoms are apparent. In advanced heart failure (AdHF), it is universally accepted that all patients are refractory to traditional therapies. As the number of HF patients increase, so does the need for additional treatments, with an increased proportion of patients requiring advanced therapies. Areas covered: This review discusses extensive evidence for the effect of medical treatment on HF, although the data on the effect on AdHF is scare. Authors review the relevant literature for treating AdHF patients. Furthermore, mechanical circulatory devices (MCD) have emerged as an alternative to heart transplantation and have been shown to enhance quality of life and reduce mortality therefore authors also review the current literature on the different MCD and technologies. Expert commentary: More patients will need advanced therapies, as the access to heart transplantation is limited by the number of available donors. AdHF patients should be identified timely since the window of opportunities for advanced therapy is narrow as their morbidity is progressive and survival is often short.

Potential Uses of Sacubitril/Valsartan: Need for Data on Efficacy and Safety

Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers have been the cornerstone for the treatment of heart failure (HF) with reduced ejection fraction for decades. According to recent and promising studies, sacubitril/valsartan (SV) might be efficient in alternative indications in the area of HF with preserved left ventricular ejection fraction, chronic kidney disease, and so on. This review briefly summarizes these promising therapeutic options regarding SV and the potential limits and pitfalls for its use in routine practice (due to cognitive uncertainties).

Prognostic Impact of Calcium Score after Transcatheter Aortic Valve Implantation Performed With New Generation Prosthesis

Calcium score (CS) is a well-known prognostic factor after transcatheter aortic valve implantation (TAVI) performed with first generation prosthesis but few data are available concerning new generation valves. The aim of this study was to evaluate if CS remains a prognostic factor after Sapien 3 and Evolut R valves implantation. Agatston CS was evaluated on multislice computed tomography before TAVI in 346 patients implanted with Sapien XT (n = 61), CoreValve (n = 57) devices, (group 1, n = 118), and with new generation Sapien 3 (n = 147), Evolut R (n = 81) prosthesis, (group 2, n = 228). Major adverse cardiovascular events and aortic regurgitation (AR) were evaluated at 1 month. The 2 groups were similar at baseline except for logistic Euroscore (20.1% in group 1 vs 15.0 % in group 2; p = 0.001), chronic renal failure (44.1% vs 37.2% respectively, p = 0.007) and preprocedural CS (4,092 ± 2,176 vs 3,682 ± 2,109 respectively, p = 0.022). In group 1, 28 patients (23.7%) had adverse clinical events vs 21 (9.2%) in group 2 (p <0.01). In multivariate analysis, a higher CS was predictive of adverse events in group 1 (5,785 ± 3,285 vs 3,565 ± 1,331 p <0.0001) but not in group 2 (p = 0.28). A higher CS was associated with AR in group 1 (6,234 ± 2711 vs 3,429 ± 1,505; p <0.001) and in patients implanted with an Evolut R device from group 2 (4,085 ± 3,645 vs 2,551 ± 1,356; p = 0.01). In conclusion, CS appears as an important prognostic factor of major events after TAVI with first generation valves but not with new generation devices. CS remains associated with AR only with new generation self-expandable Evolut R devices.

0022 : Transcatheter aortic valve implantation without intensive care unit admission

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

0486: Aortic valve calcium score evaluated with CT scan predicts outcome after TAVI

Background The clinical risk scores usually used for surgical valve replacement failed to accurately predict outcomes after TAVI and alternative risk parameters are lacking. We proposed to determine the prognostic value of aortic valve calcifications evaluated with CT-scan on outcome after TAVI. Methods This prospective monocentric study included 118 patients referred for TAVI for severe symptomatic aortic stenosis. The procedure was performed via transfemoral route using a balloon expandable (n=61) or a self expandable (n=57) valve. Pre-intervention non enhanced, ECG-gated, multislice CT-scan was done in all patients. Aortic valve calcifications were evaluated using the Agatston calcium score (CS). Procedure-related complications were evaluated and clinical outcome was analysed using a composite criteria (mortality, stroke, myocardial infarction, heart failure) at 30-day follow-up. Results Mean CS was 4092±2176. At 30-day follow-up, mortality was 6.8% (n=8) and 28 patients (23%) have presented the composite criteria. On univariate analysis (table), CS appears to be the best predictor of adverse outcome after TAVI, significantly higher in patients who have presented the composite criteria (5785 vs 3565 p 6000 (OR 106; IC95 15,5-727,6). During the follow-up, the 5 patients who have developped a moderate to severe aortic regurgitation had a significantly higher CS than those who developped none or mild regurgitation (10121 vs 3809, p Conclusion High degree of calcification of aortic valve, easily quantifiable on the pre-operative CT-scan appears to be an important prognostic parameter which should be considered by the Heart Team in the decision making. Abstract 0486 – Table: Predictors of adverse outcome after TAVI Presence of composite criteria n=28 Absence of composite criteria n=90 p EuroScore 1 (%) 24,96±11,48 18,55±10,99 0,013 Dislipidemia n(%) 12 (43) 23 (26) 0,08 Body mass index (BMI) n(%) 24,21±4,01 27,33±5,51 0,01 CoreValve prothesis n(%) 18 (64) 39 (43) 0,056 Calcium score 5875,71±3285,84 3565,78±1331,18