Karol Zbroński

Outcome prediction following transcatheter aortic valve implantation: Multiple risk scores comparison.

BACKGROUND The aim of the study was to compare 7 available risk models in the prediction of 30-day mortality following transcatheter aortic valve implantation (TAVI). Heart team decision supported by different risk score calculations is advisable to estimate the individual procedural risk before TAVI. METHODS One hundred and fifty-six consecutive patients (n = 156, 48% female, mean age 80.03 ± 8.18 years) who underwent TAVI between March 2010 and October 2014 were in-cluded in the study. Thirty-day follow-up was performed and available in each patient. Base-line risk was calculated according to EuroSCORE I, EuroSCORE II, STS, ACEF, Amblers, OBSERVANT and SURTAVI scores. RESULTS In receiver operating characteristics analysis, neither of the investigated scales was able to distinguish between patients with or without an endpoint with areas under the curve (AUC) not exceeding 0.6, as follows: EuroSCORE I, AUC 0.55; 95% confidence intervals (CI) 0.47-0.63, p = 0.59; EuroSCORE II, AUC 0.59; 95% CI 0.51-0.67, p = 0.23; STS, AUC 0.55; 95% CI 0.47-0.63, p = 0.52; ACEF, AUC 0.54; 95% CI 0.46-0.62, p = 0.69; Amblers, AUC 0.54; 95% CI 0.46-0.62, p = 0.70; OBSERVANT, AUC 0.597; 95% CI 0.52-0.67, p = 0.21; SURTAVI, AUC 0.535; 95% CI 0.45-0.62, p = 0.65. SURTAVI model was calibrated best in high-risk patients showing coherence between expected and observed mortality (10.8% vs. 9.4%, p = 0.982). ACEF demonstrated best classification accuracy (17.5% vs. 6.9%, p = 0.053, observed mortality in high vs. non-high-risk cohort, respectively). CONCLUSIONS None of the investigated risk scales proved to be optimal in predicting 30-day mortality in unselected, real-life population with aortic stenosis referred to TAVI. This data supports primary role of heart team in decision process of selecting patients for TAVI.

Platelet distribution width predicts left ventricular dysfunction in patients with acute coronary syndromes treated with percutaneous coronary intervention.

BACKGROUND The role of platelets in the pathophysiology of acute coronary syndromes (ACS) is undeniable, but precise relationships between platelet activity and treatment outcomes are a matter of continuant investigation. Among platelet indices, mean platelet volume (MPV) has proven to be a valuable predicting factor in cardiac patients. However, platelet distribution width (PDW) is reported to be a more specific marker of platelet reactivity. Thus, application of PDW in risk stratification of ACS treatment is an up-to-date subject of research. PDW values in the assessment of left ventricular (LV) function have not been previously studied. AIM The aim of the study was to evaluate whether admission PDW can predict LV systolic function in patients with ACS treated with stent implantation. METHODS On-admission PDW was measured in 278 consecutive patients with diagnosis of ACS, who underwent stent(s) implantation. Echocardiogram with LV ejection fraction (LVEF) estimation was performed within 24 h of percutaneous coronary intervention. Additionally, patients were under one-year follow-up, and one-year all-cause mortality was assessed. RESULTS According to receiver-operating characteristics (ROC) analysis, a PDW value greater than 12.8 fL could predict LVEF ≤ 35% with sensitivity of 81% and specificity of 39% (AUC 0.614; p = 0.0177). Only a trend was noted in ROC for PDW and one-year mortality (AUC 0.608; p = 0.0815). Multivariate logistic regression analysis has shown that the PDW parameter correlates independently with both systolic heart failure with LVEF ≤ 35% (PDW cut-off: 12.8 fL, OR 2.8107, CI 1.1401-6.9293, p = 0.0248) and one-year mortality (PDW cut-off: 16 fL, OR 2.6750, CI 1.0190-7.0225, p = 0.0457). CONCLUSIONS Admission PDW may serve as a simple and widely available predictor of impaired LV function in patients with ACS. Association between PDW and mortality needs to be confirmed in larger studies.

Thromboelastography for predicting bleeding in patients with aortic stenosis treated with transcatheter aortic valve implantation

BACKGROUND Bleeding complications are frequent and independently impact mortality after transcatheter aortic valve implantation (TAVI). Thromboelastography (TEG) measures viscoelastic properties of clot formation and is currently best known for perioperative management to reduce blood transfusion in cardiac surgery. AIM We sought to determine whether TEG may be predictive of bleeding in patients treated with TAVI. METHODS AND RESULTS Overall, 54 consecutive patients with severe aortic stenosis treated with TAVI were prospectively included. In all patients, two blood samples were obtained for TEG measurement (the first - 12 h prior to procedure tested with citrated kaolin [CK] TEG assay, and the second - immediately after prosthesis deployment tested with CK and citrated heparinised kaolin assay [CHK]). Major or life-threatening bleeding (MLTB) was diagnosed in 13 (24%) patients. In receiver-operating characteristic (ROC) curve analysis the only TEG parameters showing significant sensitivity and specific-ity for predicting MLTB were those obtained in the CK sample at the end of the procedure: R value (reaction time, time to initiation of clot formation) area under the curve (AUC) 0.69, 95% confidence interval (CI) 0.49-0.88, p = 0.04; angle (the rate of clot formation), AUC 0.75, 95% CI 0.59-0.92, p = 0.007, and maximum amplitude (MA, ultimate strength of fibrin clot), AUC 0.77, 95% CI 0.62-0.93, p = 0.003. After controlling for confounding factors on multivariate logistic regression, MA remained as the only TEG parameter that significantly correlated with bleeding after TAVI, both as a continuous variable (p = 0.004; 95% CI 0.92-0.98; odds ratio [OR] 0.95 per 1 mm increment) and after using the cut-off value derived from ROC analysis; MA < 46.6 mm (OR 10.4; 95% CI 2.1-51.8; p = 0.004). CONCLUSIONS Low strength of fibrin clot measured by TEG immediately after TAVI may serve as an independent predictor of short-term major and life-threatening bleeding complications.

Augmented reality in left atrial appendage occlusion

Augmented reality (AR) is gaining practicality with the increasing number of applications it offers combined with modern hardware and software. It is becoming a credible tool for peri-procedural assessment in interventional cardiology. We present two cases of left atrial appendage occlusion (LAAO) in patients with atrial fibrillation (AF) and contraindications to oral anticoagulants (OAC) performed with assistance of holograms and AR. The first patient is an 84-year-old woman with a history of heart failure with preserved ejection fraction (HFpEF), stable coronary artery disease (sCAD), paroxysmal AF, and hypertension. Based on high risk of stroke (CHA2DS2-VASc score 6), the patient was administered OAC; however, due to gastrointestinal bleeding without an overt source and anaemia, anticoagulants were stopped and the patient was referred for LAAO. Because of chest angina aggravation, a coronary angiography was performed revealing a significant lesion in proximal left anterior descending artery, which was subsequently treated with coronary angioplasty. A transoesophageal echocardiography (TEE) and cardiac computed tomography (cCT) were performed in order to exclude thrombus in the left atrium and to assess the morphology and anatomy of the appendage. Based on the perimeter-derived diameter of the landing-zone from cCT (20 mm) and three-dimensional (3D) reconstructions, a 20 mm Amplatzer Amulet® device was selected and successfully implanted. A transthoracic echocardiography (TTE) performed on the following day showed no signs of pericardial effusion, and a control TEE was scheduled for three months later. Three days after the procedure the patient was discharged. The second patient is an 87-year-old man with a history of paroxysmal AF, HFpEF, sCAD, hypertension, and angiodysplasia of the duodenum and large intestine causing chronic gastrointestinal bleeding. Due to high risk of stroke (CHA2DS2-VASc score 5) and contraindications to OAC the patient was referred for LAAO. Again, TEE and cCT were performed. According to the perimeter-derived diameter of the LAA landing zone (24 mm), a 25-mm Amplatzer Amulet® device was selected and, with the assistance of holograms, successfully implanted. A TTE on the following day revealed correct implant position and no cardiac effusion. The patient was discharged three days later and a TEE was scheduled for three months after the procedure. In both cases, in order to facilitate the pre-procedural assessment, cCTs were processed and holographic reconstructions obtained. Next, 3D images were analysed before and during interventions through a set of AR goggles (Microsoft HoloLens®) with a variety of gestures and voice commands to allow rotation, magnification, slicing, and partitioning (Fig. 1). Models were created and managed using Carnalife Holo® (MedApp S.A., Cracow, Poland) software. A thorough assessment of the LAA and the adjoining structures such as the pulmonary artery and the circumflex artery is essential before LAAO. A 3D reconstruction of the heart accessible via a set of goggles with gestures and voice commands for analysis proved to be a useful enhancement.

Concomitant coronary artery disease and its management in patients referred to transcatheter aortic valve implantation

Coronary artery disease (CAD) and degenerative aortic stenosis often coexist. However, the impact of CAD and its management on the prognosis after transcatheter aortic valve implantation (TAVI) remains uncertain. We sought to evaluate the impact of obstructive CAD, SYNTAX score (Ss), and percutaneous coronary intervention (PCI) prior to TAVI on short‐term outcome.

Simultaneous acute closure of the right coronary artery and left anterior descending artery in a young male.

A 28-year-old man with no cardiovascular history or cardiovascular risk factors, who denied cigarette smoking or taking any medications, drugs, supplements or steroids, was referred to the cardiology department after an outof-hospital cardiac arrest preceded by a four-hour angina episode. The initial rhythm (ventricular fibrillation) was successfully defibrillated. Subsequently, the electrocardiogram suggested inferior and inferobasal ST-elevation myocardial infarction (Figure 1). The coronary angiogram showed simultaneous acute thrombosis of the right coronary artery (RCA) (Figure 2a) and of the left anterior descending (LAD) artery (Figure 3a). Initially, to visualize suspected plaque rupture and to aid the decision whether to implant stents, multiple aspiration thrombectomies were performed, resulting in removal of substantial amounts of thrombotic material (Figure 4). After intravenous and intracoronary admin-

Patient-prosthesis mismatch in patients treated with transcatheter aortic valve implantation – predictors, incidence and impact on clinical efficacy. A preliminary study

Introduction Patient-prosthesis mismatch (PPM) is relatively frequent after surgical aortic valve replacement (SAVR) and negatively impacts prognosis. Aim We sought to determine the frequency and clinical effects of PPM after transcatheter aortic valve implantation (TAVI). Material and methods Overall, 238 patients who underwent TAVI were screened. Moderate PPM was defined as indexed effective orifice area (EOAi) between 0.65 and 0.85 cm2/m2, and severe PPM as < 0.65 cm2/m2. All-cause mortality and the Valve Academic Research Consortium 2 (VARC-2) defined composite of clinical efficacy at 1 year were the primary endpoints. Results Finally, 201 patients were included (mean age: 79.6 ±7.4 years, 52% females). The femoral artery served as the delivery route in 79% and most of the prostheses were self-expanding (68%). Any PPM was present in 48 (24%) subjects, and only 7 (3.5%) had severe PPM. Body surface area (BSA) independently predicted any PPM (OR = 16.9, p < 0.001) whereas post-dilation tended to protect against PPM (OR = 0.46, p = 0.09). All-cause mortality was similar in patients with moderate or severe PPM as compared to those with no PPM (14.6% vs. 14.3% vs. 13.1%, respectively, log-rank p = 0.98). Neither moderate (OR = 1.6, 95% CI: 0.8–3.2, p = 0.16) nor severe PPM (OR = 1.67, 95% CI: 0.36–7.7, p = 0.51) had a significant impact on composite endpoint, or its elements, with the exception of transvalvular pressure gradient > 20 mm Hg. Conclusions Severe PPM after TAVI is rare, can be predicted by larger BSA and does not seem to affect mid-term mortality or composite clinical outcome. Larger studies are needed to find different independent predictors of PPM and elucidate its impact in terms of device durability and long-term clinical efficacy.

Left ventricular remodelling pattern and its relation to clinical outcomes in patients with severe aortic stenosis treated with transcatheter aortic valve implantation

Introduction Left ventricular hypertrophy (LVH) is a common compensating process in the pressure overload mechanism of aortic stenosis (AS). Aim To identify a group of patients with a LVH pattern which may alter periprocedural and 1-year outcomes after transcatheter aortic valve implantation (TAVI). Material and methods Echocardiographic examinations of 226 patients with severe AS treated with TAVI between March 2010 and February 2016 were retrospectively analysed and correlated with echocardiographic parameters and clinical outcomes in the study group. Ultimately 208 patients were enrolled in the study. Based on left ventricular mass index (LVMI) and relative wall thickness (RWT) patients were divided into three categories: concentric remodelling (CR), concentric hypertrophy (CH) and eccentric hypertrophy (EH). Most of the patients with severe AS referred for TAVI were found to have CH (n = 150, 72.8%), then EH (n = 33, 16%) and CR (n = 16, 7.8%). Results There were no significant differences between groups in terms of periprocedural outcomes or complications. After a mean observation time of 561.8 ±239.0 days, the observed all-cause mortality rate was 19.9%. After multivariable adjustment, CR remained associated with a higher risk of mortality (HR = 4.31; 95% CI: 1.607–11.538; p = 0.004). Conclusions Left ventricular hypertrophy is common in patients with severe AS prior to TAVI. The LVH pattern does not affect TAVI-related complications. In patients with severe AS referred for TAVI, CR seems to be the least favourable geometry of LVH, increasing the risk of 1-year all-cause death.

TCT-651 Impact of preprocedural coronary artery disease assessed by SYNTAX score on TAVI outcome

nos: 647 760

Prosthetic valve endocarditis after transcatheter CoreValve Evolut R bioprosthesis implantation

Prosthetic valve endocarditis (PVE) affects 1–6% of prosthetic valve recipients and in patients treated with transcatheter aortic valve implantation (TAVI) has an incidence of 0.3–2.3% per patient-year [1–3].