Javier Castrodeza

Mitral Regurgitation After Transcatheter Aortic Valve Replacement: Prognosis, Imaging Predictors, and Potential Management

OBJECTIVESnThis study sought to analyze the clinical impact of the degree and improvement of mitral regurgitation in TAVR recipients, validate the main imaging determinants of this improvement, and assess the potential candidates for double valve repair with percutaneous techniques.nnnBACKGROUNDnMany patients with severe aortic stenosis present with concomitant mitral regurgitation (MR). Cardiac imaging plays a key role in identifying prognostic factors of MR persistence after transcatheter aortic valve replacement (TAVR) and for planning its treatment.nnnMETHODSnA total of 1,110 patients with severe aortic stenosis from 6 centers who underwent TAVR were included. In-hospital to 6-month follow-up clinical outcomes according to the degree of baseline MR were evaluated. Off-line analysis of echocardiographic and multidetector computed tomography images was performed to determine predictors of improvement, clinical outcomes, and potential percutaneous alternatives to treat persistent MR.nnnRESULTSnCompared with patients without significant pre-TAVR MR, 177 patients (16%) presented with significant pre-TAVR MR, experiencing a 3-fold increase in 6-month mortality (35.0% vs. 10.2%; pxa0< 0.001). After TAVR, the degree of MR improved in 60% of them. A mitral annular diameter of >35.5 mm (odds ratio: 9.0; 95% confidence interval: 3.2 to 25.3; pxa0<xa00.001) and calcification of the mitral apparatus by multidetector computed tomography (odds ratio: 11.2; 95% confidence interval: 4.03 to 31.3; pxa0< 0.001) were independent predictors of persistent MR. At least 14 patients (1.3% of the entire cohort, 13.1% of patients with persistent MR) met criteria for percutaneous mitral repair with either MitraClip (9.3%) or a balloon-expandable valve (3.8%).nnnCONCLUSIONSnSignificant MR is not uncommon in TAVR recipients and associates with greater mortality. In more than one-half of patients, the degree of MR improves after TAVR, which can be predicted by characterizing the mitral apparatus with multidetector computed tomography. According to standardized imaging criteria, at least 1 in 10 patients whose MR persists after TAVR could benefit from percutaneous mitral procedures, and even more could be treated with MitraClip after dedicated pre-imaging evaluation.

Impact of aortic valve closure on adverse events and outcomes with the HeartWare ventricular assist device

BACKGROUNDnThis study examined whether aortic valve opening (AVO) and other echocardiographic parameters influence outcomes in patients on left ventricular (LV) assist device (LVAD) support. Pump thrombosis (PT) and ischemic stroke (IS) are known complications of LVAD, but mechanisms that could influence them are not completely understood.nnnMETHODSnThis was a retrospective analysis of 147 patients who received a HeartWare Ventricular Assist Device ( HeartWare International) as a bridge to transplant or to candidacy between July 2009 and August 2015, of whom 126 had at least 30 days of follow-up before the first event (30-days-out cohort). Outcomes included survival, PT, IS, and PT+IS (combined thrombotic event; CTE).nnnRESULTSnMedian time on support was 518 days. Of the 30-days-out cohort, 29% had a first PT and 19% a first IS. AVO was associated with longer survival on device (1,081 vs 723 days; p = 0.01) in the entire cohort. In the 30-days-out cohort, the aortic valve was more frequently closed in patients with lower ejection fractions on support (14% ± 6% vs 18% ± 9%; p = 0.009), more dilated pre-event echocardiogram (LV end-diastolic diameter, 66 ± 12 mm vs 62 ± 10 mm; p = 0.04), and pre-implant LV end-diastolic diameter (70 ± 10 mm vs 66 ± 9 mm; p = 0.06). CTE-free survival on the device was lower with a closed aortic valve (897 vs 1,314 days; p = 0.003) as was PT-free survival on the device (1,070 vs 1,457 days; p = 0.02). Cox regression analysis showed that AVO was an independent predictor of CTE (p = 0.03) CONCLUSIONS: Thrombotic events are relatively frequent in patients on long-term LVAD support. A closed aortic valve was associated with decreased overall survival, thrombosis-free survival, and poorer LV function on support. These are high-risk patients, so whether they require more intense anti-coagulation or prioritizing for transplantation requires further research.

Transcatheter Aortic Valve Implantation in Patients With Previous Mitral Prostheses

Transcatheter aortic valve implantation (TAVI) is an established intervention with a growing number of indications. TAVI is increasingly used in patients with a history of heart surgery because of the high estimated cardiovascular risk in this patient subgroup. An especially interesting situation is presented by patients with a previous mitral prosthesis (PMP). The potential for interaction between the TAVI device and the PMP increases procedural complexity, and it is therefore very important from a clinical standpoint to evaluate the experience accumulated to date with these patients. The aim of this systematic review was to examine all published evidence on TAVI in patients with a PMP. An exhaustive literature search was conducted of PUBMED, EMBASE, and the Cochrane Library using the following search terms: ‘‘transcatheter’’, ‘‘percutaneous’’, ‘‘aortic valve intervention’’ and/ or ‘‘replacement’’ and ‘‘previous mitral intervention’’, ‘‘surgery’’,

Arrhythmic Burden as Determined by Ambulatory Continuous Cardiac Monitoring in Patients With New-Onset Persistent Left Bundle Branch Block Following Transcatheter Aortic Valve Replacement: The MARE Study

OBJECTIVESnThe authors sought to determine: 1) the global arrhythmic burden; 2) the rate of arrhythmias leading to a treatment change; and 3) the incidence of high-degree atrioventricular block (HAVB) at 12-month follow-up in patients with new-onset persistent left bundle branch block (LBBB) following transcatheter aortic valve replacement (TAVR).nnnBACKGROUNDnControversial data exist on the occurrence of significant arrhythmias in patients with LBBB post-TAVR.nnnMETHODSnThis was a multicenter prospective study including 103 consecutive patients with new-onset persistent LBBB post-TAVR with the balloon-expandable SAPIEN XT/3 valve (nxa0= 53), or the self-expanding CoreValve/Evolut R system (nxa0= 50). An implantable cardiac monitor (Reveal XT, Reveal Linq) was implanted at 4 (3 to 6) days post-TAVR, and patients had continuous electrocardiogram monitoring for 12 months. All arrhythmic events were adjudicated in a central electrocardiography core lab. Primary endpoints were the incidence of arrhythmias leading to a treatment change, and the incidence of HAVB at 12-month follow-up.nnnRESULTSnA total of 1,553 new arrhythmic events were detected in 44 patients (1,443 episodes of tachyarrhythmia in 26 patients [atrial fibrillation/flutter/atrial tachycardia: 1,427, ventricular tachycardia 16]; 110 episodes of bradyarrhythmia in 21 patients [HAVB 54, severe bradycardia 56]). All arrhythmic events were silent in 34 patients (77%), the arrhythmic event led to a treatment change in 19 patients (18%), and 11 patients (11%) required pacemaker or implantable cardioverter-defibrillator implantation (due to HAVB, severe bradycardia, or ventricular tachycardia episodes in 9, 1, and 1 patient, respectively). A total of 12 patients died at 1-year follow-up, 1 from sudden death.nnnCONCLUSIONSnA high incidence of arrhythmic events was observed at 1-year follow-up in close to one-half of the patients with LBBB post-TAVR. Significant bradyarrhythmias occurred in one-fifth of the patients, and PPMxa0was required in nearly one-half of them. These data support the use of a cardiac monitoring device for closexa0follow-up and expediting the initiation of treatment in this challenging group of patients. (Ambulatory Electrocardiographic Monitoring for the Detection of High-Degree Atrio-Ventricular Block in Patients With New-onset PeRsistent LEftxa0Bundle Branch Block After Transcatheter Aortic Valve Implantation [MARE study]: NCT02153307).

Transubclavian approach: A competitive access for transcatheter aortic valve implantation as compared to transfemoral

Empirically, transfemoral (TF) approach is the first choice for transcatheter aortic valve implantation (TAVI). We aimed to investigate whether transubclavian (TSc) and TF approaches present comparable major outcomes according to current evidence.

Tricuspid but not Mitral Regurgitation Determines Mortality After TAVI in Patients With Nonsevere Mitral Regurgitation

INTRODUCTION AND OBJECTIVESnMany patients undergoing transcatheter aortic valve implantation (TAVI) have concomitant mitral regurgitation (MR) of moderate grade or less. The impact of coexistent tricuspid regurgitation (TR) remains to be determined. We sought to analyze the impact of moderate vs none-to-mild MR and its trend after TAVI, as well as the impact of concomitant TR and its interaction with MR.nnnMETHODSnMulticenter retrospective study of 813 TAVI patients treated through the transfemoral approach with MR ≤ 2 between 2007 and 2015.nnnRESULTSnThe mean age was 81 ± 7 years and the mean Society of Thoracic Surgeons score was 6.9% ± 5.1%. Moderate MR was present in 37.3% of the patients, with similar in-hospital outcomes and 6-month follow-up mortality to those with MR < 2 (11.9% vs 9.4%; P = .257). However, they experienced more rehospitalizations and worse New York Heart Association class (P = .008 and .001, respectively). Few patients (3.8%) showed an increase in the MR grade to > 2 post-TAVI. The presence of concomitant moderate/severe TR was associated with in-hospital and follow-up mortality rates of 13% and 34.1%, respectively, regardless of MR grade. Moderate-severe TR was independently associated with mortality (HR, 18.4; 95%CI, 10.2-33.3; P < .001).nnnCONCLUSIONSnThe presence of moderate MR seemed not to impact short- and mid-term mortality post-TAVI, but was associated with more rehospitalizations. The presence of moderate or severe TR was associated with higher mortality. This suggests that a thorough evaluation of the mechanisms underlying concomitant mitral and tricuspid valve regurgitation should be performed to determine the best strategy for avoiding TAVI-related futility.

Proyección supraesternal y drenaje venoso pulmonar anómalo

Mujer de 59 años de edad que fue remitida por fibrilación auricular paroxı́stica. En la exploración fı́sica presentó una ligera elevación de la presión venosa central y cianosis de la parte distal de las falanges de los dedos, sin evidencia de clubbing. En la radiografı́a de tórax se evidenció dilatación de las cavidades derechas. Se realizó un ecocardiograma transtorácico bidimensional que confirmó dicha dilatación (vı́deo 1 del material suplementario), con un Qp:Qs de 1,3 y una presión sistólica en la arteria pulmonar de 85 mmHg. El tabique interauricular estaba ı́ntegro. En la proyección supraesternal (vı́deo 2 del material suplementario y figura A) se observó una aceleración del flujo, tanto sistólico como diastólico (Doppler pulsado, figura B), justo en la zona posterior al cayado, detrás de la arteria subclavia izquierda. Se sospechó la existencia de un drenaje venoso pulmonar anómalo con presencia de una vena vertical drenando en la vena innominada. El hallazgo se confirmó por tomografı́a computarizada cardiaca [figura C, tomografı́a computarizada bidimensional (TC reconstrucción multiplanar), y figura D, tomografı́a computarizada tridimensional (TC volumen completo)]. El drenaje venoso parcial de las venas pulmonares a través de la vena vertical es una condición inusual, que se observa en el 0,5% de las autopsias realizadas y ocurre en un 10% de los drenajes anómalos de las venas pulmonares izquierdas. Dada su escasa expresividad clı́nica, suele estar infradiagnosticado hasta edades adultas. Este caso pone de manifiesto que un estudio ecocardiográfico meticuloso, incluyendo una proyección supraesternal, puede diagnosticar esta condición. Posteriormente debe considerarse la realización de una tomografı́a computarizada cardiaca como método de elección para confirmar el diagnóstico. Esta figura se muestra a todo color solo en la versión electrónica del artı́culo.

Suprasternal Notch View and Anomalous Pulmonary Drainage

A 59-year-old woman was referred for paroxysmal atrial fibrillation. The physical examination revealed slightly elevated central venous pressure and cyanosis in the distal part of the phalanges, with no evidence of clubbing. Dilatation of the right cavities was observed in the chest X-ray. Two-dimensional transthoracic echocardiography confirmed this dilatation (video 1 of the supplementary material), with Qp:Qs of 1.3 and systolic pulmonary artery pressure of 85 mmHg. The atrial septum was intact. In the suprasternal notch view (video 2 of the supplementary material and Figure A), systolic and diastolic flow acceleration was observed (pulsed Doppler, Figure B) in the region posterior to the aortic arch, behind the left subclavian artery. We suspected anomalous pulmonary venous drainage with the presence of a vertical vein draining into the brachiocephalic vein. The finding was confirmed by cardiac computed tomography (Figure C, multiplanar reconstructed computed tomography, and Figure D, total volume computed tomography). Partial venous drainage of the pulmonary veins via the vertical vein is an uncommon condition that is observed in 0.5% of autopsies and occurs in 10% of anomalous drainage of left pulmonary veins. Given the limited clinical expression, this abnormality is underdiagnosed until adulthood. This case shows that a meticulous echocardiography study, including a suprasternal notch view, may lead to diagnosis of this condition. Subsequently, cardiac computed tomography should be considered the method of choice to confirm the diagnosis.

TCT-752 Transcatheter Aortic Valve Replacement in Patients with Previous Mitral Surgery - A Multicentre Study.

TCT-752 Transcatheter Aortic Valve Replacement in Patients with Previous Mitral Surgery – A Multicentre Study Ignacio Amat-Santos, Carlos Cortes, Antonio Munoz, Jose Suarez De Lezo, Luis Nombela-Franco, Enrique Gutiérrez, Raul Moreno, Vicente Serra, Jose M. de la Torre Hernandez, Javier Castrodeza, Javier Tobar, Jose A. San Roman Institute of heart science, Valladolid, Spain; Hospital Clinico Universitario De Valladolid, Madrid, Spain; Unknown, Malaga, Spain; Hospital Universitario Reina Sofia, Cordoba, Spain; Quebec City, Quebec, Canada; Hospital Universitario Gregorio Marañón, Madrid; University Hospital La Paz, Madrid, Spain; H. Vall d’Hebron, sant cugat del valles, Spain; Hospital Universitario Marques de Valdecilla, Santander, Spain; Hospital Clínico Universitario de Valladolid, Spain; Hospital Clínico Universitario de Valladolid, Spain; Hospital Clínico Universitario de Valladolid, Spain

Undescribed Anatomical Predictors of Vascular Injury after Fully-Percutaneous Trans Femoral Trans Catheter Aortic Valve Implantation

Abstract nBackground: nVascular injury (VI) remains frequent after trans catheter aortic valve implantation (TAVI). We aimed to assess the incidence, predictive factors, and the impact of early VI after fully-percutaneous (FP) TAVI. nMethod: We included a total of 139 consecutive patients who underwent FP transfemoral TAVI in our institution with 14 to 18Fr sheath systems, through right (119, 85.6%) or left (20, 14.4%) femoral arteries. VI was classified as mayor or minor according to VARC-2 definitions. In hospital data were prospectively collected. Follow-up was available for all patients. Reassessment of femoral artery anatomy as determined by computed tomography was performed including lumen diameters, calcification, tortuosity, height of femoral bifurcation and marked collateral circulation around common femoral artery. nResults: Mean age was 81 ± 6.5, 54% were men, logEuroSCORE were 13.9 ± 7.9 and STS-score was 6.3 ± 4.9. Balloon-expandable and self-expandable devices were used in 14 (10.1%) and 125 patients (89.9%), respectively. Mayor and minor VI were observed in 25 (18%) and in 20 patients (14.3%) respectively, 20 of them due to suboptimal femoral closure (80% of major VI occurring in the first half of the learning curve). Lower platelet count (p=0.043), higher calcification of aortic valve (p=0.049), presence of femoral collaterals (OR=4.5, [95% CI: 1.6-12.9], p=0.005), height of femoral bifurcation (OR=14.5, [95% CI: 5.0-42.1], p<0.001), and failed femoral closure (OR=21.3, [95% CI: 4.5-101.4], p<0.001) were associated to higher rate of VI. The median length of hospitalization was 11.6 days [IQR: 7-14], (15.7 days [IQR: 8-19] in the VI cohort, p<0.001). VI was associated to higher in hospital mortality (13.3 vs. 2.1%, p=0.014). nConclusion: In patients who underwent FP TAVI, the rate of VI is still high and associated to worse outcomes. A high common femoral artery bifurcation and the presence of collaterals, especially if associated to other concomitant predisposing factors for VI, should be handled with special care and surgical access may be considered.