Olaf Wendler

Device-dependent association between paravalvar aortic regurgitation and outcome after TAVI

Objective The aim of the current study was to identify predictors of paraprosthetic aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI) and examine its influence on short/medium-term mortality using the UK TAVI Registry. TAVI is an effective treatment for high-risk patients with severe symptomatic aortic stenosis (AS), but paraprosthetic AR has been associated with increased in-hospital and mid-term mortality. Methods Between January 2007 and December 2011, 2584 TAVI procedures were performed in the UK. Patients undergoing ‘valve-in-valve’ procedures, patients with aortic regurgitation as the primary pathology and with no recorded severity of AR were excluded from this analysis (n=144). In total, therefore, 2440 patients were included. Balloon-expandable and self-expanding devices were implanted in 52.7 and 47.2%, respectively, using either transfemoral (67.7%) or non-transfemoral, surgical access (32.3%). Results Postprocedural AR was observed in 68%, mild AR in 57% and moderate-severe in 10%. A large aortic annulus, high preprocedural transaortic gradient, and use of self-expanding valve were independent predictors of moderate-severe AR. Moderate-severe (but not mild) AR was associated with increased mortality, and this relationship appeared significant for the balloon-expandable but not the self-expanding device. Conclusions Our data suggest that a large aortic annulus, high preprocedural transaortic gradient, and use of the self-expanding valve predict moderate-severe AR after TAVI. Such a degree of AR is associated with a significantly worse outcome with the balloon-expandable, but not with the self-expanding valve. Further studies are needed to verify this and explore potential mechanisms.

Transcatheter Aortic Valve Implantation in the UK: Temporal Trends, Predictors of Outcome and 6 Year Follow Up: A Report from the UK TAVI Registry 2007 to 2012

Background— We assessed trends in the performance of transcatheter aortic valve implantation in the United Kingdom from the first case in 2007 to the end of 2012. We analyzed changes in case mix, complications, outcomes to 6 years, and predictors of mortality. Methods and Results— Annual cohorts were examined. Mortality outcomes were analyzed in the 92% of patients from England and Wales for whom independent mortality tracking was available. A total of 3980 transcatheter aortic valve implantation procedures were performed. In successive years, there was an increase in frequency of impaired left ventricular function, but there was no change in Logistic EuroSCORE. Overall 30-day mortality was 6.3%; it was highest in the first cohort (2007–2008), after which there were no further significant changes. One-year survival was 81.7%, falling to 37.3% at 6 years. Discharge by day 5 rose from 16.7% in 2007 and 2008 to 28% in 2012. The only multivariate preprocedural predictor of 30-day mortality was Logistic EuroSCORE ≥40. During long-term follow-up, multivariate predictors of mortality were preprocedural atrial fibrillation, chronic obstructive pulmonary disease, creatinine >200 μmol/L, diabetes mellitus, and coronary artery disease. The strongest independent procedural predictor of long-term mortality was periprocedural stroke (hazard ratio=3.00; P <0.0001). Nonfemoral access and postprocedural aortic regurgitation were also significant predictors of adverse outcome. Conclusions— We analyzed transcatheter aortic valve implantation in an entire country, with follow-up over 6 years. Although clinical profiles of enrolled patients remained unchanged, longer-term outcomes improved, and patients were discharged earlier. Periprocedural stroke, nonfemoral access, and postprocedural aortic regurgitation are predictors of adverse outcome, along with intrinsic patient risk factors. # CLINICAL PERSPECTIVE {#article-title-29}Background— We assessed trends in the performance of transcatheter aortic valve implantation in the United Kingdom from the first case in 2007 to the end of 2012. We analyzed changes in case mix, complications, outcomes to 6 years, and predictors of mortality. Methods and Results— Annual cohorts were examined. Mortality outcomes were analyzed in the 92% of patients from England and Wales for whom independent mortality tracking was available. A total of 3980 transcatheter aortic valve implantation procedures were performed. In successive years, there was an increase in frequency of impaired left ventricular function, but there was no change in Logistic EuroSCORE. Overall 30-day mortality was 6.3%; it was highest in the first cohort (2007–2008), after which there were no further significant changes. One-year survival was 81.7%, falling to 37.3% at 6 years. Discharge by day 5 rose from 16.7% in 2007 and 2008 to 28% in 2012. The only multivariate preprocedural predictor of 30-day mortality was Logistic EuroSCORE ≥40. During long-term follow-up, multivariate predictors of mortality were preprocedural atrial fibrillation, chronic obstructive pulmonary disease, creatinine >200 &mgr;mol/L, diabetes mellitus, and coronary artery disease. The strongest independent procedural predictor of long-term mortality was periprocedural stroke (hazard ratio=3.00; P<0.0001). Nonfemoral access and postprocedural aortic regurgitation were also significant predictors of adverse outcome. Conclusions— We analyzed transcatheter aortic valve implantation in an entire country, with follow-up over 6 years. Although clinical profiles of enrolled patients remained unchanged, longer-term outcomes improved, and patients were discharged earlier. Periprocedural stroke, nonfemoral access, and postprocedural aortic regurgitation are predictors of adverse outcome, along with intrinsic patient risk factors.

A rare case of an aberrant anterior mitral valve chord resulting in severe mitral regurgitation

A 49 year old female presented with severe dyspnoea due to mitral regurgitation. Echocardiography revealed an aberrant mitral valve chord causing severe mitral regurgitation. The aberrant chord extended between the anterior mitral valve leaflet (AMVL) and the atrial septum causing AMVL prolapse. Resection of the aberrant chord and correction of the AMVL using synthetic Gore-Tex sutures was performed. The patient made an uneventful recovery with post-op echocardiography demonstrating normal mitral valve function.

164 Early haemodynamic changes and myocardial injury after transfemoral transcatheter aortic valve implantation (TAVI)

Purpose Transfemoral (TF) TAVI is a novel procedure for the treatment of severe aortic stenosis, without the need for thoracotomy or cardiopulmonary bypass. The procedure results in almost instantaneous normalisation of transvalvular gradients, but little is yet known about the periprocedural haemodynamic effects. We aimed to describe these effects using 3D and tissue Doppler (tD) transthoracic echocardiography (TTE) and Cardiac Output monitoring. Methods In 16 patients undergoing TF TAVI haemodynamics were characterised with a number of tD and 3D TTE measurements. These were taken at multiple time points (baseline, 6 and 24 hours post procedure). Calculated volumetric parameters included 3D end-diastolic volume (EDV) and end-systolic volume (ESV), stroke volume (SV) and 3D LA volume (LAV). Diastolic function was monitored using the indices mean E:E′ and systolic function/contractility was measured with dP/dt max and early peak systolic velocity (S′). The FloTrac system (consisting of the Vigileo monitor and sensor), uses a clinically validated algorithm to provide continuous cardiac output (CO), stroke volume (SV) and systemic vascular resistance in real-time. Results TAVI resulted in an immediate increase in cardiac output (3.7 (baseline), 4.6 (6 h) 4.5 l/min (24 h), p<0.5 baseline vs 6 h and 24 h) with no significant change in systemic vascular resistance (1162, 1292 and 1367 dyn*s/cm5). However, 6 h post-TAVI there was a significant decrease in systolic function as measured by dP/dt max/EDV (see Abstract 164 figure 1A) and co-existent impairment of diastolic function as indicated by medial E:E′ values (see Abstract 164 figure 1B), which was associated with an appropriate increase in LA volume (70.3, 82.6 and 72.8 ml, p<0.05 baseline vs 6 h). Following this, there was a recovery of both systolic and diastolic indices. In addition, another marker of systolic function, S′ increased after 24 h (6.4, 6.6, 8.2 cm/s, p<0.05 baseline vs 24 h and 6 h vs 24 h). Concurrent with this recovery, we observed a significant decrease in EDV and ESV at 24 h post-TAVI (EDV: 94.9 to 83.4 ml (p<0.05); ESV 41.9 to 33.5 ml (p<0.05)). These changes in haemodynamics were associated with significant increase of troponin I levels at 24 h and increase in CK-MB at 6 h after the procedure (troponin: 0.06 vs 1.19 μg/l, p<0.05; CK-MB 1.6 vs 6.6 μg/l, p<0.05).Abstract 164 Figure 1 Conclusion Successful TF TAVI results in an immediate improvement in cardiac output. However, overlying this, within the first 24 h both systolic and diastolic dysfunction occurs. The rise in the markers of myocardial injury suggest this may be due to myocardial stunning and/or some periprocedural myocardial damage. Recovery of contractility is observed after 24 hours.

Circumflex Artery-Superior Vena Cava Fistula.

A 49-year-old male with a history of atrial fibrillation presented with dyspnea on exertion. A computed tomogram and transesophageal echocardiogram (TEE) showed a fistula between the circumflex artery and the superior vena cava (SVC) (Fig. 1A, C, E). A median sternotomy was performed and the patient was placed on cardiopulmonary bypass. The ascending aorta was retracted revealing the fistulous communication (Fig. 1B). The fistula was ligated and a follow-up TEE showed no flow in the SVC (Fig. 1D, F). The patient tolerated the procedure well and had an uncomplicated postoperative course. DISCLOSURE

100 Multi-disciplinary Clinic: Next Step In “heart Team” Approach For Tavi

Introduction The “Heart team” approach is considered to be the most appropriate method for assessing patients for consideration of Transcatheter Aortic Valve Implantation (TAVI) in severe aortic stenosis. Thus far, the approach has involved the discussion of patients in a multi-disciplinary meeting (MDM) involving interventional cardiologists, imaging specialists, surgeons, anaesthetists and elderly care physicians. The disadvantage of this approach is that the patients are often reviewed remotely by a single specialist. We have developed a unique model of multi-disciplinary clinic (MDC) for assessing patients for TAVI; in this model the patients are reviewed by an interventional cardiologist, cardiac surgeon and anaesthetist in the same clinic. We report the first 8 months data of patients reviewed in this clinic and the outcomes. Methods The TAVI MDC at King’s College hospital has run twice a month since January 2013. Data for all patients who attended this clinic were collected and analysed. For those who attended the clinic more than once, the decision made during the first visit was included for analysis. We compared this with that taken from MDM patient discussions (n = 71) undertaken in the 8 months prior to the inception of the clinic. Results During the study period, 64 appointment slots were made in the clinic. 48 patients (83 ± 6 yrs, 22 female) were reviewed in the clinic 57 times (7 patients seen twice, one patient seen three times). The outcome of clinic decisions for these patients is shown in Figure 1. This was compared with the outcome for patients discussed in the preceding 8 months. (Table 1)TAVI work-up was completed prior to clinic appointment in 15 patients (31.3%) compared to 62 patients (87.3%, p < 0.0001) in the MDM group. A total of 13 patients in the MDC group and 28 patients in the MDM group finally underwent TAVI. In those who finally underwent TAVI, the time interval between clinic/discussion to TAVI was shorter in the MDC group when compared to the MDM group (median 54, IQR 36–88 days vs 130, 64–171 days, p = 0.01). The TAVI ‘turn-down’ rate was also higher when patients were reviewed in MDC when compared to MDM discussion (35.4% vs 16.9%, p = 0.03). Abstract 100 Figure 1 Conclusion This is the first report of the live “Heart team” clinic data. TAVI decline rate was higher when patients were seen earlier in the process by the team, thereby avoiding unnecessary costs of TAVI work-up investigations. Patients underwent TAVI quicker when seen and accepted in the MDC. This model offers the potential for a more effective method of multidisciplinary assessment, but does require significant resource allocation. Abstract 100 Table 1 n (%) MDM clinic(n = 48) MDM discussion(n = 71) P value TAVI Work-up completed prior to clinic/discussion 15 (31) 62 (87.3) <0.0001 No severe AS 3 (6.3) 4 (5.6) 1.0 TAVI declined/not suitable 17 (35.4) 12 (16.9) 0.03 For surgical AVR 5 (10.4) 14 (19.7) 0.2 Accepted (provisionally, for those without work-up) 14 (29.2) 29 (40.8) 0.2 Patient/family to decide after discussion 4 (8.3) NA NA Need further assessment 5 (10.4) 12 (16.9) 0.4 TAVI performed 13 (27.1) 28 (39.4) 0.2

OPCABG using right internal mammary artery and sequential saphenous vein graft in reverse sequence) in a PT with right pneumonectomy with compensatory hyperexpansion of the left lung

Case report 77 years old male with worsening angina and shortness of breath and diagnosed with 3 vessel disease and history of right pneumonectomy was referred for coronary artery bypass grafting.Other co morbidities included hypercholesterolemia, exsmoking, recurrent pneumonia, colorectal resection and chemotherapy for cancer and also had gastric ulcers and could not tolerate aspirin (hence not an ideal candidate for PCI). CT chest was performed which showed heart to be deviated to the right side with tracheal deviation due to compensatory hyperexpansion of left lung. Initial plan was to perform on pump CABG in view of single lung. However after midline sternotomy it was clear that the left lung dominated the chestand the heart lay posteriorly in the right hemi-thorax with slight rotation to theright. This made on-pump surgery difficult as there was no access to the right atrium and majority of the aorta lay behind the Pulmonary artery. Femoral venous cannulation would havebeen risky due to the right atrial shift at the level of the diaphragm. Decision was made to perform the procedure without cardiopulmonary bypass. The Right internal mammary artery was harvested in semi-skeletonised fashion and was anastomosed to the mid LAD. There was enough aorta accessible to place a single vein sequentially on the OM2 and PDA performing the top end to the aorta first and then OM2 anastomoses in side to side fashion followed by PDA anastomosesas end to side anastomosis. There were no periods of instability. The postoperative course was uneventful apart from patient going into atrial fibrillation which was treated with amiodarone. Patient was discharged home on 6 postoperative day.