Esther M.A. Wiegerinck

Predictors and Prognostic Value of Myocardial Injury During Transcatheter Aortic Valve Implantation

Background— Myocardial injury is a common complication during cardiac surgery and percutaneous coronary intervention and is associated with postprocedural cardiovascular morbidity and mortality. Limited data have been reported about the occurrence of myocardial damage associated with transcatheter aortic valve implantation (TAVI). Therefore, our purpose was to investigate the incidence, predictors, and prognostic value of myocardial injury during TAVI. Methods and Results— We studied 119 patients (aged 81±8 years; 47 male) who had undergone a TAVI with the Medtronic-CoreValve bioprosthesis. Serum creatine kinase-MB (CK-MB) and cardiac troponin T (cTnT) levels were measured before and after the procedure. Myocardial injury was defined as a postprocedural increase of CK-MB and/or cTnT level >5 times the upper reference limit. After TAVI, the incidence of myocardial injury was 17%, which was independently predicted by procedural duration (in minutes) (odds ratio [OR], 1.04; 95% CI, 1.01–1.06), preprocedural &bgr;-blocker use (OR, 0.12; 95% CI, 0.03–0.45), peripheral arterial disease (OR, 6.36; 95% CI, 1.56–25.87), and prosthesis depth (in millimeters) (OR, 1.31; 95% CI, 1.08–1.59). The 30-day mortality after TAVI was 13% and was independently predicted by myocardial injury (OR, 8.54; 95% CI, 2.17–33.52), preprocedural hospitalization (OR, 9.36; 95% CI, 2.55–34.38), and left ventricular mass index (in g/m2) (OR, 1.02; 95% CI, 1.00–1.03). Conclusions— After transcatheter aortic valve implantation, serum levels of both CK-MB and cTnT increase, reflecting the occurrence of periprocedural myocardial injury. A longer procedural duration, the absence of &bgr;-blocker use, peripheral arterial disease, and a deeper prosthesis insertion are associated with myocardial injury. Together with preprocedural hospitalization and left ventricular mass, myocardial injury is an independent predictor for 30-day mortality after TAVI.

Antiplatelet therapy following transcatheter aortic valve implantation

Objective There is limited evidence to support decision making on antiplatelet therapy following transcatheter aortic valve implantation (TAVI). Our aim was to assess the efficacy and safety of aspirin-only (ASA) versus dual antiplatelet therapy (DAPT) following TAVI. Methods We performed a systematic review and pooled analysis of individual patient data from 672 participants comparing single versus DAPT following TAVI. Primary endpoint was defined as the composite of net adverse clinical and cerebral events (NACE) at 1 month, including all-cause mortality, acute coronary syndrome (ACS), stroke, life-threatening and major bleeding. Results At 30 days a NACE rate of 13% was observed in the ASA-only and in 15% of the DAPT group (OR 0.83, 95% CI 0.48 to 1.43, p=0.50). A tendency towards less life-threatening and major bleeding was observed in patients treated with ASA (OR 0.56, 95% CI 0.28 to 1.11, p=0.09). Also, ASA was not associated with an increased all-cause mortality (OR 0.91, 95% CI 0.36 to 2.27, p=0.83), ACS (OR 0.5, 95% CI 0.05 to 5.51, p=0.57) or stroke (OR 1.21; 95% CI 0.36 to 4.03, p=0.75). Conclusions No difference in 30-day NACE rate was observed between ASA-only or DAPT following TAVI. Moreover, a trend towards less life-threatening and major bleeding was observed in favour of ASA. Consequently the additive value of clopidogrel warrants further investigation.

Predictors and Permanency of Cardiac Conduction Disorders and Necessity of Pacing after Transcatheter Aortic Valve Implantation

Transcatheter aortic valve implantation (TAVI) with the Medtronic‐CoreValve bioprosthesis (CoreValve Inc., Irvine, CA, USA) is associated with a high incidence of new‐onset left bundle branch block (LBBB) and cardiac conduction disorders (CCDs) requiring permanent pacemaker (PPM) implantation. Our objective was to investigate the predictors and permanency of CCDs after TAVI and specifically to evaluate the necessity for pacing.

Towards minimally invasiveness: transcatheter aortic valve implantation under local analgesia exclusively

Background: Both, general anaesthesia (GA) and local analgesia (LA) with or without sedation are options for periprocedural anaesthetic management of transfemoral transcatheter aortic valve implantation (TAVI). We report the safety and feasibility of TAVI under LA and provide our own experience in the largest cohort so far reported. Methods: A total of 178 consecutive patients planned for transfemoral TAVI were included in this study. Patients were treated with the Medtronic Core Valve (n=77) or the Edwards Sapien (n=101) at operators’ discretion. Periprocedural anaesthetic management, procedural characteristics, and outcomes were assessed. Results: Of the 178 patients (34% male), 4 (2.2%) needed a conversion to general anaesthesia (prosthesis embolism, 2 complicated peripheral vasculature puncture/closures, restlessness). Periprocedural transoesophageal echocardiography was not necessary. Premedication included temazepam, lorazepam, or midazolam in 76% of patients. In total 115 patients (66%) received conscious sedation, 34% received sedative medications. Only nine patients developed a delirium during admission (5%). All-cause 30day-mortality was 9 (5%). NYHAclass decreased significantly from 3±0.6 to 1±0.9 (p=0.04). Conclusion: Transfemoral TAVI using exclusively local analgesia and fluoroscopic guidance is safe and feasible with a very low rate of conversion. The fragile TAVI-population may benefit from this anaesthetic management. 14745_SEberl_BW.indd 30 25-07-17 12:43 31 TRANSCATHETER AORTIC VALVE IMPLANTATION UNDER LOCAL ANALGESIA EXCLUSIVELY 3 Transcatheter Aortic Valve Implantation (TAVI) was started in most centres using general anaesthesia (GA) and the same monitoring standard as for patients scheduled for open surgical aortic valve replacement. After gaining experience, few centres switched to local anaesthesia (LA) with or without sedation. Currently both, GA and LA (with or without sedation) are options for the anaesthetic management of TAVI patients. Whether LA is superior to GA has not been addressed in randomised trials before and no consensus upon the preferable method has been reached yet. We report on safety and feasibility of TAVI under LA and present our own experiences in the largest cohort so far reported. At our institution, transfemoral TAVI procedures started in 2007 under GA (n=55). In an effort to minimise invasiveness in this fragile patient population, LA became the standard method for transfemoral TAVI`s beginning October 2010. We included consecutive patients who were planned for TAVI under LA between October 2010 and May 2013. All patients were rejected for surgical treatment due to anticipated high surgical risk by our heart team. Patients signed written informed consent for the procedure, data collection and utilisation according the ethical guidelines of our institute. All patients received pre-procedural consultation by both, the operator as well as the anaesthesiologist. Premedication and use of conscious sedation were left at the discretion of the cardioanaesthesiologist. A total of 40 cc lidocaine 1% mixed with bupivacaine 0.5% (T 1/2 =2.7h) was injected in the percutaneous femoral access site for local wound analgesia. Appropriate valve positioning was achieved by fluoroscopy and aortography without the use of transoesophageal echocardiography (TOE). Results and complications were assessed based on direct patient contact, haemodynamics, angiography, and transthoracic echocardiography (TTE). A cardiovascular anaesthesiologist was constantly present to monitor the patient, stabilise haemodynamics, or perform GA if necessary. All patients treated under LA were postprocedurally observed on the Cardiac Care Unit (CCU) instead of being transported to the Intensive Care Unit (ICU) as is it standard after GA. For the clinical endpoint definitions the criteria of the Valve Academic Research Consortium were used. A comparison was made between the group of patients treated under LA and conscious sedation and the group under LA without conscious sedation. Differences of continuous variables between two groups were analysed with a two-tailed student’s t-test or Mann– Whitney U test where appropriate. Of the 178 patients included, 4 patients (2.2%) needed a conversion to GA (1 conversion to surgery due to prosthesis embolism, 2 complicated peripheral vasculature puncture/ 14745_SEberl_BW.indd 31 25-07-17 12:43

Impact of Aortic Valve Stenosis on Coronary Hemodynamics and the Instantaneous Effect of Transcatheter Aortic Valve Implantation

Background—Aortic valve stenosis (AS) induces compensatory alterations in left ventricular hemodynamics, leading to physiological and pathological alterations in coronary hemodynamics. Relief of AS by transcatheter aortic valve implantation (TAVI) decreases ventricular afterload and is expected to improve microvascular function immediately. We evaluated the effect of AS on coronary hemodynamics and the immediate effect of TAVI. Methods and Results—Intracoronary pressure and flow velocity were simultaneously assessed at rest and at maximal hyperemia in an unobstructed coronary artery in 27 patients with AS before and immediately after TAVI and in 28 patients without AS. Baseline flow velocity was higher and baseline microvascular resistance was lower in patients with AS as compared with controls, which remained unaltered post-TAVI. In patients with AS, hyperemic flow velocity was significantly lower as compared with controls (44.5±14.5 versus 54.3±18.6 cm/s; P=0.04). Hyperemic microvascular resistance (expressed in mm Hg·cm·s−1) was 2.10±0.69 in patients with AS as compared with 1.80±0.60 in controls (P=0.096). Coronary flow velocity reserve in patients with AS was lower, 1.9±0.5 versus 2.7±0.7 in controls (P<0.001). Improvement in coronary hemodynamics after TAVI was most pronounced in patients without post-TAVI aortic regurgitation. In these patients (n=20), hyperemic flow velocity increased significantly from 46.24±15.47 pre-TAVI to 56.56±17.44 cm/s post-TAVI (P=0.003). Hyperemic microvascular resistance decreased from 2.03±0.71 to 1.66±0.45 (P=0.050). Coronary flow velocity reserve increased significantly from 1.9±0.4 to 2.2±0.6 (P=0.009). Conclusions—The vasodilatory reserve capacity of the coronary circulation is reduced in AS. TAVI induces an immediate decrease in hyperemic microvascular resistance and a concomitant increase in hyperemic flow velocity, resulting in immediate improvement in coronary vasodilatory reserve.

Predictors of outcome in patients undergoing MitraClip implantation: An aid to improve patient selection.

BACKGROUND MitraClip implantation (MCI) reduces mitral regurgitation (MR) and symptoms in patients considered inoperable or with high-surgical risk. Data to determine the benefit from MCI for an individual patient are limited. The aim of this study is to determine predictors associated with the prognosis after MCI to improve the patient selection for this procedure. METHODS We included 84 consecutive patients (age: 76 ± 10 years, 51% male) who underwent MCI in our institution for symptomatic severe MR. All patients underwent transthoracic echocardiography before MCI; clinical and echocardiographic follow-up was obtained after MCI. RESULTS The 2-year survival was 81%. Predictors for two-year mortality in multi-variate analysis were baseline NT-proBNP ≥ 5000 μg/L (HR: 5.4, 95% CI: 1.8-16.2), previous valve surgery (HR: 4.5, 95% CI: 1.7-12.2), tricuspid regurgitation (TR)≥ grade 3 prior to MCI (HR: 2.8, 95% CI: 1.2-6.8) and absence of MR reduction after MCI (HR: 2.1, 95% CI: 1.2-3.8). The 2-year survival of patients with 0, 1 or ≥ 2 of these predictors was: 87%; 78% and 38% respectively (log-rank p < 0.001). The functional class at 1 month and mid-term follow-up was worse in patients with two or more of these predictors present at baseline compared to patients with zero or one of these predictors (1 month: p = 0.007 and mid-term: p < 0.001). CONCLUSION Heart failure, previous valve surgery, co-presence of TR and the degree of MR reduction after MCI are the independent predictors of survival and functional status after MCI in high risk patients. The pre-procedural characteristics may be used to optimize patient selection, while maximal MR reduction should be attempted to optimize the outcome of MCI.

Hybrid coronary artery bypass grafting and transaortic transcatheter aortic valve implantation

Evolving less-invasive surgical techniques potentially minimize surgical trauma and reduce the risk of cardiac valve surgery. Transcatheter aortic valve implantation (TAVI) has emerged as an alternative for patients facing high or even prohibitive risk with conventional aortic valve replacement (AVR). Concomitant coronary artery disease (CAD) is a well-known comorbidity in degenerative aortic valve stenosis and has been identified as an independent factor for increased mortality in patients undergoing AVR. The presence of CAD in patients undergoing TAVI is estimated to be as great as 75.6%. Simultaneous percutaneous coronary intervention (PCI) has been reported although TAVI is currently considered a stand-alone procedure. Significant coexisting CAD requires preprocedural PCI. In patients with significant complex CAD, rendering them ineligible for PCI, revascularization ideally consists of coronary artery bypass grafting (CABG). According to the current guidelines, patients undergoing CABG with at least moderate aortic stenosis should undergo concomitant AVR. Combining CABG and AVR increases procedural duration and is considered to increase operative mortality. High-risk patients with significant CAD who are ineligible for PCI could undergo surgical revascularization in a hybrid procedure with TAVI, reducing the duration of aortic crossclamping and cardiopulmonary bypass or even eliminating them entirely, thus decreasing surgical risk. Limited data are available regarding combined TAVI and surgical revascularization. We report TAVI through a transaortic approach during surgical revascularization in 5 high-risk patients with severe symptomatic aortic valve stenosis and significant CAD (Table 1).

Transcatheter Replacement of Stenotic Aortic Valve Normalizes Cardiac–Coronary Interaction by Restoration of Systolic Coronary Flow Dynamics as Assessed by Wave Intensity Analysis

Background—Aortic valve stenosis (AS) can cause angina despite unobstructed coronary arteries, which may be related to increased compression of the intramural microcirculation, especially at the subendocardium. We assessed coronary wave intensity and phasic flow velocity patterns to unravel changes in cardiac–coronary interaction because of transcatheter aortic valve implantation (TAVI). Methods and Results—Intracoronary pressure and flow velocity were measured at rest and maximal hyperemia in undiseased vessels in 15 patients with AS before and after TAVI and in 12 control patients. Coronary flow reserve, systolic and diastolic velocity time integrals, and the energies of forward (aorta-originating) and backward (microcirculatory-originating) coronary waves were determined. Coronary flow reserve was 2.8±0.2 (mean±SEM) in control and 1.8±0.1 in AS (P<0.005) and was not restored by TAVI. Compared with control, the resting backward expansion wave was 45% higher in AS. The peak of the systolic forward compression wave was delayed in AS, consistent with a delayed peak aortic pressure, which was partially restored after TAVI. The energy of forward waves doubled after TAVI, whereas the backward expansion wave increased by >30%. The increase in forward compression wave with TAVI was related to an increase in systolic velocity time integral. AS or TAVI did not alter diastolic velocity time integral. Conclusions—Reduced coronary forward wave energy and systolic velocity time integral imply a compromised systolic flow velocity with AS that is restored after TAVI, suggesting an acute relief of excess compression in systole that likely benefits subendocardial perfusion. Vasodilation is observed to be a major determinant of backward waves.

Troubleshooting in transatrial tricuspid valve-in-valve implantation.

The established treatment for degenerated stenotic tricuspid bioprostheses is reoperation. Recently, transcatheter tricuspid valve implantation has been reported as an alternative option. This case report describes a complex transcatheter tricuspid valve implantation in a degenerated Medtronic intact 31 mm bioprosthesis. Implantation of a 26 mm Edwards Sapien valve failed, subsequent transcatheter implantation of a 29 mm Edwards Sapien valve was successful.

An up-to-date overview of the most recent transcatheter implantable aortic valve prostheses

Over the past decade transcatheter aortic valve implantation (TAVI) has evolved towards the routine therapy for high-risk patients with severe aortic valve stenosis. Technical refinements in TAVI are rapidly evolving with a simultaneous expansion of the number of available devices. This review will present an overview of the current status of development of TAVI-prostheses; describes the technical features and applicability of each device and the clinical data available.