Gintautas Bieliauskas

Natural history of subclinical leaflet thrombosis affecting motion in bioprosthetic aortic valves

Aims Four-dimensional volume-rendered computed tomography (4DCT) has demonstrated instances of hypo-attenuating leaflet thickening (HALT) with or without hypo-attenuation affecting motion (HAM) after transcatheter and surgical aortic valve implantation (TAVI, SAVR). The temporal pattern of evolution of these phenomena is uncertain. Methods and results The SAVORY registry enrolled patients treated by TAVI (n = 75) or SAVR (n = 30) with two 4DCT scans fully interpretable for HALT and HAM as well as unchanged anti-thrombotic medication between the scans. Logistic regression analysis was performed to examine the evolution of HALT and HAM while accounting for demographic and baseline variables, timing of both CT scans, valve type and antithrombotic therapy. The analysis population consisted of 84 patients, in whom first and second CT scans were performed at 140 ± 152 days and 298 ± 141 days after valve implantation, respectively. Hypo-attenuating leaflet thickening was noted in 32 patients (38.1%), with HAM in 17 (20.2%). Both findings were dynamic, showing progression in 13 (15.5%) and regression and 9 (10.7%) patients. Compared with antiplatelet therapy, progression was less likely among patients on oral anticoagulation with vitamin-K antagonists or non-VKA oral anticoagulants (odds ratio: 0.014, P = 0.036). Maintenance on chronic oral anticoagulation was not a significant predictor of regression. These findings were similar for both transcatheter and surgical bioprosthetic aortic valves. No patients developed symptoms of valve dysfunction and leaflet thickening was not clearly associated with any clinical events. Conclusions Subclinical leaflet thrombosis is a common finding after TAVI and SAVR, and may progress from normal leaflet over HALT to the more severe HAM. The phenomenon can develop and regress at variable intervals after valve implantation. Anticoagulants may have a protective effect against the development of HALT, but HALT can also regress without anticoagulation therapy. Registered at ClinicalTrials.gov NCT02426307.

A comparative study of different imaging modalities for successful percutaneous left atrial appendage closure

Objectives Accurate sizing of the left atrial appendage (LAA) is essential when performing percutaneous LAA closure. This study aimed to compare different LAA imaging modalities and sizing methods in order to obtain successful LAA closure. Background Percutaneous LAA closure is an increasingly used treatment strategy to prevent stroke in patients with atrial fibrillation. LAA sizing has typically been done by 2D-transoesophageal echocardiography (TEE). Methods Patients who had a preprocedural TEE and preprocedural and postprocedural multislice CT (MSCT) were identified. Preprocedural measurements of LAA ostia and landing zones by 2D-TEE, MSCT and angiography were collected and analysed for those patients with successful LAA closure - i.e. with no contrast leakage at 3-month follow-up MSCT. Results The study population (n=67) had a mean CHA2DS2-VASc score of 3.0 and HAS-BLED score of 2.7. Fifty-eight patients (87%) were identified to have successful LAA closure. Based on MSCT, 48 LAA sizings (83%) resulted in a correct LAA closure device size selection, whereas with 2D-TEE sizing, only 33 measurements (57%) would have resulted in a correct device size selection (p<0.01). Using adapted Bland-Altman method, MSCT-based perimeter-derived mean diameter was shown to be the best parameter to guide LAA device size selection for ‘closed-end’ devices (Amulet, WatchmanFLX), whereas the maximal diameter was the best parameter for the ‘open-end’ Watchman device. Conclusions Preprocedural MSCT-based LAA closure device size selection proves to be a more accurate method than conventional 2D-TEE-based sizing. Depending on the LAA closure device design, perimeter-derived mean diameter or maximal diameter could be the better sizing method.

Subclinical leaflet thickening and stent frame geometry in self-expanding transcatheter heart valves

AIMS This study aimed to assess the potential relationship between subclinical leaflet thickening and stent frame geometry in patients who underwent aortic valve replacement with a self-expanding transcatheter heart valve (THV). METHODS AND RESULTS Seventy-five patients with a self-expanding THV were studied with 4D-computed tomography and analysed for leaflet thickening. There was no difference in THV size, overall THV expansion, eccentricity or implantation depth between patients with and those without leaflet thickening. Moderate-to-severe regional THV underexpansion (≤90°) more frequently occurred at the non-coronary and right coronary cusps with a significantly higher incidence of leaflet thickening than in cases of full regional THV expansion (24% vs. 3%, p<0.01). Regional THV underexpansion at the inflow level more often translated into the same issue at the valvular level in THV with intra-annular as compared to supra-annular valve position (54% vs. 17%; p=0.04). In case of post-dilatation, regional THV underexpansion occurred less frequently as compared to THV that were not post-dilated (18% vs. 43%, p=0.028). A similar but non-significant trend was found for leaflet thickening. CONCLUSIONS Regional THV stent frame underexpansion is associated with an increased risk of leaflet thickening. Post-dilatation of self-expanding THV as well as a supra-annular valve position seem to reduce the occurrence of this phenomenon.

Use of 3-Dimensional Models to Optimize Pre-Procedural Planning of Percutaneous Left Atrial Appendage Closure

Percutaneous left atrial appendage closure (LAAC) has become the treatment of choice for patients with nonvalvular atrial fibrillation at high risk for stroke and contraindications to oral anticoagulant therapy. The ultimate goal of LAAC is to minimize long-term stroke and bleeding risks while

Coronary artery disease, revascularization, and clinical outcomes in transcatheter aortic valve replacement: Real‐world results from the East Denmark Heart Registry

Transcatheter aortic valve replacement (TAVR) has become an established therapeutic option for patients with symptomatic, severe aortic stenosis. The optimal treatment strategy for concomitant coronary artery disease (CAD) has not been tested prospectively in a randomized clinical trial. This study aimed to describe the degree of CAD, revascularization strategies, and long‐term clinical outcomes in a large‐scale all‐comers TAVR‐population. Nine hundred and forty‐four consecutive patients underwent TAVR. Obstructive CAD was reported in 224 patients (23.7%)—of these, 150 (66.9%) presented with one‐vessel disease (1‐VD), 51 (22.8%) with 2‐VD, and 23 (10.3%) with 3‐VD. Two‐thirds underwent coronary revascularization before TAVR; half of those patients with 1‐VD and only one‐third of those with multivessel disease were completely revascularized. In general, borderline stenoses (50%–70%) were more frequently revascularized in proximal coronary segments than in more distal segments. Long‐term survival rates by Kaplan–Meier analysis of the total TAVR population at 5 and 9 years were 64.7% and 54.1%, respectively. A diagnostic coronary angiography was performed in 16.5% of patients within 5 years after TAVR; only 4.8% underwent consequent percutaneous coronary intervention (PCI). There was no difference in survival and need for revascularization post‐TAVR between those patients with or without obstructive CAD ± revascularization. Neither was there a survival difference between those with or without previous CABG and/or chronic total occlusion(s). In conclusion, CAD is prevalent in TAVR patients and pre‐TAVR coronary revascularization is typically focused on treating proximal and high‐grade stenosis. A selective pre‐TAVR PCI strategy results in favorable clinical outcomes with very low rates of post‐TAVR coronary revascularization.

Pre-Procedural Imaging Modalities for Device Size Selection and Adaptive Nature of the Appendage in Patients Undergoing Percutaneous Left Atrial Appendage Closure

ABSTRACT Background: This study aimed to compare different pre-procedural left atrial appendage (LAA) imaging modalities and analyze the anatomical adaptation of the LAA to the closure device at 3-month multi-slice computed tomography (MSCT). LAA closure device sizing is crucial to optimize immediate and long-term outcomes. Methods: Patients who underwent percutaneous LAA closure and had pre-procedural transesophageal echocardiography (TEE) and MSCT were identified. Devices used were AmuletTM (Abbott, USA), WatchmanTM, and WatchmanFLXTM (Boston Scientific, USA). LAA ostium and landing zone were measured according to the instructions for use at 2D-TEE, as well as at MSCT and X-ray angiography. Post-procedural MSCT was used to assess LAA ellipticity and closure. Results: A total of 67 patients (44 AmuletTM, 11 WatchmanTM, 12 WatchmanFLXTM) were included. Mean age was 74 ± 7 years, CHA2DS2-VASc-score 3.0 ± 1.6 and HAS-BLED-score 2.7 ± 0.9. Bland-Altman analysis for the maximum LAA diameter at MSCT (CTmax) and TEE (TEEmax) showed a mean difference of +4.8 mm with a limit of agreement (LoA) of 9.6 mm (p < 0.01). Maximum LAA diameters at TEE (TEEmax) and X-ray angiography (XAmax) showed a mean difference of +1.3 mm with LoA of 7.6 mm (p = 0.839). The mean difference between CTmean and TEEmax was +2.1 mm with LoA of 8.4 mm (p < 0.05). In addition, LAA ellipticity ratio decreased from 1.48 to 1.05 while overall LAA area only expanded 3% after device implantation. Conclusion: Of the three imaging modalities, MSCT provides the largest LAA measurements, followed by TEE and angiography. At follow-up MSCT, the elliptical LAA conforms to the circular shape of the closure device; however, overall LAA expansion is only minimal.

Economical cost of percutaneous vascular closure with ProGlide™ and Prostar™ XL following transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) has become an established therapeutic option for patients with symptomatic, severe aortic valve stenosis (AS) who are at increased risk for conventional cardiac surgery. In recent years, the TAVR technology is also increasingly used to treat patients with a lower risk profile —this practice has mainly led to a strong increase in the number of TAVR performed by transfemoral (TF) approach. In the early days of TAVR, vascular access site complications were a frequent complication with an important negative impact on overall procedural outcome. Nowadays, with better preprocedural imaging and increased operator experience, major or lifethreatening vascular complications are exceptional. As a result, the majority of TAVR cases are currently performed by true percutaneous TF approach. With new vascular closure devices for large bore femoral arteriotomies in development and soon commercially available, the aim of this study was to determine the average use of devices and cost per patient to obtain a successful percutaneous closure following TAVR. Between March 1 2017 and February 28 2018, 308 patients were treated by TAVR at Rigshospitalet, Copenhagen (Denmark) and, of these, 292 (95%) were performed by true percutaneous TF approach. Percutaneous closure of the large bore arteriotomy was obtained by use of the commercially available ProstarTM XL (n = 60; US

Leaflet Thrombosis after TAVI

524) or ProGlideTM (n = 232; US

Commissural Alignment of Bioprosthetic Aortic Valve and Native Aortic Valve Following Surgical and Transcatheter Aortic Valve Replacement and its Impact on Valvular Function and Coronary Filling

258) vascular preclosure devices (Abbott Vascular, IL, USA). In case of use of ProstarTM XL, one device was routinely used. When using ProGlideTM, typically two devices with an additional AngioSealTM (St. Jude Medical, MN, USA; US

Transcatheter aortic valve implantation with the self-expanding Portico valve system in an all-comers population: procedural and clinical outcomes

163) were used. The choice between ProstarTM XL or ProGlideTM was not related to access vessel morphology but operator-dependent. In case of incomplete vascular closure or vascular closure device failure, additional endovascular devices were used such as a TyshakTM balloon (NuMed, NY, USA; US