Masahiko Asami

Transcatheter Mitral Valve Replacement for Degenerated Bioprosthetic Valves and Failed Annuloplasty Rings

BACKGROUNDnLimited data exist regarding transcatheter mitral valve replacement (TMVR) for patients with failed mitral valve replacement and repair.nnnOBJECTIVESnThis study sought to evaluate the outcomes of TMVR in patients with failed mitral bioprosthetic valves (valve-in-valve [ViV]) and annuloplasty rings (valve-in-ring [ViR]).nnnMETHODSnFrom the TMVR multicenter registry, procedural and clinical outcomes of mitral ViV and ViR were compared according to Mitral Valve Academic Research Consortium criteria.nnnRESULTSnA total of 248 patients with mean Society of Thoracic Surgeons score of 8.9 ± 6.8% underwent TMVR. Transseptal access and the balloon-expandable valve were used in 33.1% and 89.9%, respectively. Compared with 176xa0patients undergoing ViV, 72 patients undergoing ViR had lower left ventricular ejection fraction (45.6 ± 17.4% vs. 55.3 ± 11.1%; pxa0< 0.001). Overall technical and device success rates were acceptable, at 92.3% and 85.5%, respectively. However, compared with the ViV group, the ViR group had lower technical success (83.3% vs. 96.0%; pxa0=xa00.001) due to more frequent second valve implantation (11.1% vs. 2.8%; pxa0=xa00.008), and lower device success (76.4% vs. 89.2%; pxa0=xa00.009) due to more frequent reintervention (16.7% vs. 7.4%; pxa0=xa00.03). Mean mitral valve gradients were similar between groups (6.4 ± 2.3xa0mmxa0Hg vs. 5.8 ± 2.7xa0mmxa0Hg; pxa0=xa00.17), whereas the ViR group had more frequent post-procedural mitral regurgitation moderate or higher (19.4% vs. 6.8%; pxa0=xa00.003). Furthermore, the ViR group had more frequent life-threatening bleeding (8.3% vs. 2.3%; pxa0=xa00.03), acute kidney injury (11.1% vs. 4.0%; pxa0=xa00.03), and subsequent lower procedural success (58.3% vs. 79.5%; pxa0=xa00.001). The 1-year all-cause mortality rate was significantly higher in the ViR group compared with the ViV group (28.7% vs. 12.6%; log-rank test, pxa0=xa00.01). On multivariable analysis, failed annuloplasty ring was independently associated with all-cause mortality (hazard ratio: 2.70; 95% confidence interval: 1.34 to 5.43; pxa0=xa00.005).nnnCONCLUSIONSnThe TMVR procedure provided acceptable outcomes in high-risk patients with degenerated bioprostheses or failed annuloplasty rings, but mitral ViR was associated with higher rates of procedural complications and mid-term mortality compared with mitral ViV.

Frequency, Timing, and Impact of Access-Site and Non–Access-Site Bleeding on Mortality Among Patients Undergoing Transcatheter Aortic Valve Replacement

OBJECTIVESnThe aim of this study was to examine the frequency, timing, and association of access-site and non-access-site bleeding with mortality in the setting of transcatheter aortic valve replacement (TAVR) during long-term follow-up.nnnBACKGROUNDnBleeding is frequent and associated with impaired prognosis in patients undergoing TAVR. It is currently unknown whether the site of bleeding differentially influences the outcomes of TAVR patients.nnnMETHODSnIn total, 926 consecutive patients undergoing TAVR from 2007 through 2014 were evaluated. Bleeding was assessed according to the Valve Academic Research Consortium 2 criteria. The primary outcome of interest was all-cause mortality up to 5 years of follow-up.nnnRESULTSnA total of 285 patients (30.7%) experienced at least 1 (minor, major, or life-threatening) bleeding event up to 5 years. Compared with patients not experiencing bleeding, the adjusted risk for all-cause mortality was significantly increased among patients with access-site (hazard ratio: 1.34; 95% confidence interval: 1.01 to 1.76; pxa0= 0.04) and non-access-site bleeding (hazard ratio: 2.08; 95% confidence interval: 1.60 to 2.71; pxa0< 0.001). However, non-access-site bleeding conferred a significantly higher risk for mortality compared with access-site bleeding (hazard ratio: 1.56; 95% confidence interval: 1.12 to 2.18; pxa0= 0.009). At multivariate analysis, female sex was a significant correlate of access-site bleeding, whereas chronic kidney disease and the Society of Thoracic Surgeons score were significantly associated with non-access-site bleeding.nnnCONCLUSIONSnAmong patients with severe aortic stenosis undergoing TAVR, access-site and non-access-site bleeding were independently associated with an increased risk for mortality, with the greatest risk related to non-access-site bleeding during long-term follow-up.

Early versus newer generation devices for transcatheter aortic valve implantation in routine clinical practice: a propensity score matched analysis

Aim Contemporary data comparing early versus newer generation transcatheter heart valve (THV) devices in routine clinical practice are lacking. We sought to compare the safety and efficacy of early versus newer generation THVs in unselected patients undergoing transcatheter aortic valve implantation (TAVI). Methods and results We performed a propensity score matched analysis of patients undergoing transfemoral TAVI at a single centre with early versus newer generation devices between 2007 and 2016. Patients were matched for balloon-expandable versus self-expandable valves and Society of Thoracic Surgeons score. The primary end point was the Valve Academic Research Consortium (VARC)-2 early safety composite end point at 30 days. Among the 391 matched pairs, no differences between early (21.2%) and newer generation (20.8%) THVs regarding the early safety composite end point (HR 0.98, 95%u2009CI 0.72 to 1.33, P=0.88) were observed. The rates of valve embolisation (0.8% vs 4.2%, P=0.005), bleeding events (24.8% vs 32.0%, P=0.028) and moderate-to-severe paravalvular regurgitation (PVR) (3.1% vs 12.1%, P<0.001) were lower among patients receiving newer generation devices. Conversely, patients treated with early generation THVs less frequently experienced annulus rupture (0% vs 2.0%, P=0.008). Conclusion Newer compared with early generation THV devices were associated with a lower rate of valve embolisation, PVR and bleeding events.

The Impact of Left Ventricular Diastolic Dysfunction on Clinical Outcomes After Transcatheter Aortic Valve Replacement

OBJECTIVESnThis study sought to determine the impact of left ventricular diastolic dysfunction (LVDD) on clinical outcomes in patients undergoing transcatheter aortic valve replacement (TAVR).nnnBACKGROUNDnLeft ventricular (LV) hypertrophy in response to afterload increase promotes the development of LVDD and represents an early stage in the progression to valvular heart failure.nnnMETHODSnIn a consecutive cohort of 777 aortic stenosis patients undergoing TAVR, LVDD was categorized according to the latest guidelines. The primary endpoint was 1-year all-cause mortality.nnnRESULTSnThere were 545 (70.1%) patients with LVDD. Ninety-eight (18.0%), 198 (36.3%), and 104 (19.1%) patients were classified as LVDD grades I, II, and III, respectively. In 145 (26.6%) patients, LVDD grade could not be determined because of only 1 or 2 discrepant variables. One-year all-cause mortality was higher in patients with LVDD grades I (16.3%; adjusted hazard ratio [HR]adj: 2.32; 95% confidence interval [CI]: 1.15 to 4.66), II (17.9%; HRadj: 2.58; 95% CI: 1.43 to 4.67), and III (27.6%; HRadj: 4.21; 95% CI: 2.25 to 7.86) than in those with normal diastolic function (6.9%). The difference in clinical outcome emerged within 30 days, was driven by cardiovascular death, and maintained in a sensitivity analysis of patients with normal systolic LV function. Furthermore, LVDD grades I (HRadj: 2.36; 95% CI: 1.17 to 4.74), II (HRadj: 2.58; 95% CI: 1.42 to 4.66), and IIIxa0(HRadj: 4.41; 95% CI: 2.37 to 8.20) were independent predictors of 1-year mortality.nnnCONCLUSIONSnAdvancing stages of LVDD are associated with an incremental risk of all-cause mortality afterxa0TAVR,xa0driven by cardiovascular death and taking effect as early as 30 days after the intervention.

Transcatheter aortic valve thrombosis: incidence, clinical presentation and long-term outcomes

AimsnTo assess the incidence, management and long-term outcomes of transcatheter heart valve thrombosis (THVT).nnnMethods and resultsnBetween August 2007 and February 2016, 1396 patients were included in the Bern TAVI Registry and prospectively followed-up through echocardiographic and clinical evaluation. THVT was suspected in case of: (i) a mean transvalvular pressure gradient greater than 20u2009mmHg at transthoracic echocardiography, or (ii) an increase of more than 50% of the mean transvalvular pressure gradient compared with previous measurements or (iii) new symptoms or signs of heart failure with the presence of thrombus documented by transoesophageal echocardiography or multi-slice computed tomography. THVT occurred in 10 patients (0.71%) at variable time points after TAVI. Increased transvalvular pressure gradients were recorded in all patients and 7 out of 10 patients were symptomatic. Oral anticoagulant therapy (with vitamin K antagonists or non-Vitamin K antagonists) was initiated in all but two patients and resulted in normalization of transvalvular pressure gradients and amelioration of clinical status within 1u2009month. At long-term follow-up (between 10 and 25u2009months after valve thrombosis), echocardiographic findings were stable and no adverse events were reported.nnnConclusionnTHVT is rarely detected at routine clinical and echocardiographic evaluation after TAVI. Oral anticoagulation appears effective to normalize transvalvular gradients in the majority of cases with stable clinical and haemodynamic evolution during long-term follow-up.

Prognostic impact of invasive haemodynamic measurements in combination with clinical and echocardiographic characteristics on two-year clinical outcomes of patients undergoing transcatheter aortic valve implantation

AIMSnThe aim of the study was to evaluate the prognostic utility of right heart catheterisation (RHC)-derived measures among patients undergoing transcatheter aortic valve implantation (TAVI).nnnMETHODS AND RESULTSnData of 469 patients included in the Bern TAVI Registry between August 2007 and December 2012 and undergoing preoperative RHC were analysed. The relationship between haemodynamic parameters and survival was evaluated with Cox proportional hazards models. At two-year follow-up, 118 patients had died (25.1%). At multivariable analysis, diabetes (hazard ratio [HR] 1.95, 95% confidence interval [CI]: 1.28-2.96, p=0.001), transapical access (HR 1.66, 95% CI: 1.07-2.56, p=0.02), and moderate or severe mitral regurgitation (HR 1.55, 95% CI: 1.00-2.39, p=0.04) were independent predictors of two-year mortality, whereas no correlation between RHC-derived measures and mortality was found. Furthermore, the addition of haemodynamic variables did not significantly improve the prognostic power of a model incorporating clinical and echocardiographic data (Harrells C-index: 0.667, 95% CI: 0.615-0.719 vs. 0.662, 95% CI: 0.612-0.713, p=0.47).nnnCONCLUSIONSnOn the basis of a comprehensive clinical and echocardiographic evaluation, RHC performed prior to TAVI does not add incremental prognostic value.

Prognostic Value of Right Ventricular Dysfunction on Clinical Outcomes After Transcatheter Aortic Valve Replacement

OBJECTIVESnThe purpose of this study was to investigate the association between right ventricular dysfunction (RVD) and cardiovascular death after transcatheter aortic valve replacement (TAVR).nnnBACKGROUNDnThere is conflicting evidence on the effect of RVD on clinical outcomes after TAVR.nnnMETHODSnA total of 1,116 TAVR patients (age 82 ± 6 years; 51% female) who were consecutively enrolled into a prospective registry underwent detailed pre-operative assessment of right ventricular (RV) function and were dichotomized into 2 groups for the purposes of the present retrospective analysis. RVD was assessed using fractional area change (<35%), tricuspid annular plane systolic excursion (<1.7 cm), and systolic movement of the RV lateral wall by tissue Doppler imaging (<9.5xa0cm/s). RVD was found in 325 (29.1%) patients. The primary outcome was cardiovascular death at 1 year.nnnRESULTSnAfter adjustment for comorbidities, patients with RVD had a higher risk of cardiovascular death at 1 year compared with patients with normal RV function (20.1% vs. 7.1%; adjusted hazard ratio [HRadj]: 2.94; 95% confidence interval [CI]: 2.02 to 4.27; pxa0< 0.001). The difference emerged within the first 30 days after TAVR (9.0% vs. 2.2%; HRadj: 4.62; 95% CI: 2.51 to 8.50; pxa0< 0.001). Normalization of RV function after TAVR was found in 57.4% of patients with RVD at baseline. There was a gradient of increasing risk of cardiovascular death among patients with normal RV function, RVD recovery (HRadj: 2.16; 95% CI: 1.16 to 4.02), new RVD (HRadj: 3.93; 95% CI: 2.09 to 7.39), and maintained RVD (HRadj: 8.74; 95% CI: 5.33 to 14.3), respectively.nnnCONCLUSIONSnRVD at baseline was associated with a more than 2-fold increased risk of cardiovascular death at 1xa0year after TAVR, with a gradient of risk according to RVD recovery. (Swiss TAVI Registry; NCT01368250).

Effects of coronary artery disease in patients undergoing transcatheter aortic valve implantation: A study of age- and gender-matched cohorts

BACKGROUNDnThe prognostic role of concomitant coronary artery disease (CAD) among patients undergoing transcatheter aortic valve implantation (TAVI) is still uncertain.nnnMETHODSnData from the Bern TAVI Registry and the Bern PCI Registry were analyzed. Patients with concomitant CAD undergoing TAVI (TAVI+CAD) were age- and gender-matched to the following two cohorts: patients without CAD undergoing TAVI (TAVI-noCAD) and patients with stable CAD undergoing percutaneous coronary intervention (CAD-noAS). Major adverse cardiovascular and cerebrovascular events (MACCE), defined as the composite of cardiovascular death, myocardial infarction, or cerebrovascular events, represented the primary endpoint at 1-year.nnnRESULTSnOut of 9478 procedures performed between 2007 and 2013 (807 TAVI; 8671 PCI), three cohorts, each including 248 subjects, were derived. At 1-year, MACCE were significantly increased among TAVI+CAD compared with TAVI-noCAD (16.8% vs. 9.8%, hazard ratio, HR, 1.75, 95% confidence intervals, CI, 1.06-2.89, p=0.030) and CAD-noAS patients (16.8% vs. 9.5%, HR 1.85, 95%CI 1.11-3.09, p=0.018) whereas no difference was found between TAVI-noCAD and CAD-noAS patients. The higher rate of MACCE among TAVI+CAD patients was mainly driven by an increased risk of cardiovascular mortality compared with the TAVI-noCAD (HR 1.86, 95%CI 1.03-3.36, p=0.040) and CAD-noAS cohorts (HR 2.29, 95%CI 1.22-4.30, p=0.010). The 1-year rate of MACCE was similar between TAVI-noCAD and CAD-noAS patients (9.8% vs. 9.5%, HR 1.05, 95%CI 0.59-1.87, p=0.86).nnnCONCLUSIONSnConcomitant CAD in the setting of TAVI conveyed an increased risk of ischemic events and cardiovascular mortality at 1-year follow-up.

IMPACT OF?3/6 POLYUNSATURATED FATTY ACIDS RATIO ON THE PREVALENCE OF CORONARY ARTERY DISEASE ASSESSED BY 320-ROW CT CORONARY ANGIOGRAPHY

Previous studies have shown that eicosapentaenoic acid (EPA)/ arachidonic acid (AA) may be a marker of coronary artery disease (CAD). However, there have been few studies to assess the association of plasma EPA/AA ratio on the prevalence of CAD by using a computed tomography coronary angiography (

CRT-700.27 Valvular Resistance and Bleeding Events Among Patients Undergoing Transcatheter Aortic Valve Replacement

Stenosis-induced shear stress in patients with aortic stenosis is considered as one of the causes of bleeding tendency, and aortic valvular resistance (VR) may be a potential marker of it. The aim of the present study is to assess the relationship between VR and bleeding events in patients