Omar Aldalati

Is Mitral Valve Repair Superior to Mitral Valve Replacement in Elderly Patients? Comparison of Short‐ and Long‐Term Outcomes in a Propensity‐Matched Cohort

Background Because of demographic changes, a growing number of elderly patients present with mitral valve (MV) disease. Although mitral valve repair (MV‐repair) is the “gold standard” treatment for MV disease, in elderly patients, there is controversy about whether MV‐repair is superior to mitral valve replacement. We reviewed results after MV surgery in elderly patients treated over the past 20 years. Methods and Results Our in‐hospital database was explored for patients who underwent MV surgery between 1994 and 2015. Survival data, obtained from the National Health Service central register, were complete for all patients. Of 1776 patients with MV disease, 341 were aged ≥75 years. Patients with repeat cardiac surgery, endocarditis, and concomitant aortic valve replacement were excluded. This yielded 221 MV‐repair and 120 mitral valve replacement patients. Concomitant procedures included coronary artery bypass grafting in 135 patients (39.6%) and tricuspid valve surgery in 50 patients (14.7%). Thirty‐day mortality was 5.4% (MV‐repair) versus 9.2% (mitral valve replacement, P=0.26). Overall 1‐ and 5‐year survival was 90.7%, 74.2% versus 81.3%, 61.0% (P<0.01). Median survival after MV‐repair was 7.8 years, close to 8.5 years (95% CI: 8.2–9.4) in the age‐matched UK population (ratio 0.9). Rate of re‐operation for MV‐dysfunction was 2.3% versus 2.5% (mitral valve replacement, P=1.0). After propensity matching, patients after MV‐repair still had improved survival at 1, 2, and 5 years (93.4%, 91.6%, 76.9% versus 77.2%, 75.2%, 58.7%, P=0.03). Conclusions Excellent outcomes can be achieved after MV surgery in elderly patients. Long‐term survival is superior after MV‐repair and the re‐operation rate is low. MV‐repair should be the preferred surgical approach in elderly patients.

Dynamic transcatheter mitral valve repair: a new concept to treat functional mitral regurgitation using an adjustable spacer

We report the first-in-man implantation of the Mitra-Spacer. The device was implanted transapically. FMR was reduced to moderate. At two months, while in NYHA Class II, LVEF had improved, but FMR increased and 2 mL was added, reducing FMR to mild. Despite anticoagulation, thrombi developed around the device and the valve was replaced at eight months. The Mitra-Spacer successfully bridged this patient to surgery after LVEF had recovered.

Comparison of general anaesthesia and non-general anaesthesia approach in transfemoral transcatheter aortic valve implantation

Objective Performing transfemoral transcatheter aortic valve implantation (TAVI) without general anaesthesia (GA) has been increasingly adopted. We sought to study the impact of GA and non-GA approaches on procedural outcome and 30-day and 1-year mortality in transfemoral TAVI. Methods The UK TAVI registry holds information for every TAVI procedure in the UK. We analysed the data for patients implanted during 2013–2014 using either an Edwards Sapien or a Medtronic CoreValve prosthesis. Propensity score-matching analysis was performed to adjust for confounding factors. Results 2243 patients were studied (aged 81.4±7.5 years, 1195 males). 1816 (81%) underwent TAVI with GA and 427 (19%) without GA. Transoesophageal echocardiography (TOE) was used in 92.3% of GA and 12.4% of non-GA cases (p<0.001). There was no significant difference in the rate of successful valve deployment (GA 97.2% vs non-GA 95.7%, p=0.104) and in the incidence of more than mild aortic regurgitation (AR) at the end of the procedure (GA 5.6% vs non-GA 7.0%, p=0.295). However, procedure time was longer (131±60 vs 121±60mins, p=0.002) and length of stay was greater (8.0±13.5 vs 5.7±5.5 days, p<0.001) for GA cases. 30-day and 1-year mortality rates did not differ between the GA and non-GA cases. After propensity matching, these results remained unchanged. A second propensity analysis (adjusted for mode of anaesthesia) did not show an association between use of TOE and rate of successful valve deployment or frequency of significant AR. Neither was TOE associated with a longer procedural time or greater length of stay. Conclusion Procedure outcome, and 30-day and 1-year mortality are not influenced by mode of anaesthesia. However, GA is associated with longer procedure duration and greater length of stay.

46 The Impact of Pulmonary Artery Systolic Pressure on New York Heart Association Functional Status After Transcatheter Aortic Valve Implantation

Introduction Transcatheter aortic valve implantation (TAVI) is a therapeutic option for high surgical risk patients with symptomatic aortic stenosis. While improvements in pulmonary artery systolic pressure (PASP) following TAVI have been reported, data regarding the effect of changes in PASP on patient functional status are limited. Methods We performed a retrospective analysis of all consecutive TAVI procedures recorded on the UK TAVI registry from our institution between January 2007 and January 2015. Functional status was defined by the New York Heart Association (NYHA) classification and PASP assessed by transthoracic echocardiography. Repeat measures of PASP and NYHA were performed prior to TAVI and at 1-, 6- and 12-– months following TAVI. Linear mixed model for repeated measures analysis was used to detect changes in PASP and NYHA over the three time points following TAVI and to measure their association. Adjusting for traditional risk factors, we subsequently evaluated whether PASP and NYHA predicted 1-year mortality following TAVI. Results Over eight years, 299 patients (48% male, age 84 ± 8 years) underwent TAVI. During a mean follow-up of 775 days, 114 patients died. One month following TAVI, there was a significant reduction in PASP (37.3 ± 1.7 to 32.4 ± 1.7 mm Hg, p < 0.0001), which remained at 6-months (33.7 ± 1.9 mm Hg, p = 0.03), yet at 12-months the pressure had returned to baseline levels (35 ± 2.2 mm Hg). There was a significant decrease in NYHA at 1-month following TAVI (2.3 ± 0.1 to 1.5 ± 0.1, p < 0.0001). The improvement in NYHA persisted both at 6-months (1.5 ± 0.1, p < 0.0001) and at 12-months (1.6 ± 0.1, p < 0.0001) following TAVI. In linear mixed model analysis, after adjusting for left ventricular ejection fraction (LVEF), we observed an association between changes in PASP and NYHA following TAVI (coefficient 0.030 ± 0.01, p < 0.0001). An improvement in NYHA by one functional class was therefore associated with a reduction in PASP by 42 mm Hg. In univariate Cox regression analyses, PASP, NYHA and LVEF, at 1-month following TAVI, all predicted 1-year mortality (p < 0.05). In multivariate analysis, only NYHA at 1-month following TAVI was independently related to 1-year mortality (hazard ratio 1.80, 95% confidence interval 1.21 to 2.69, p = 0.004). Conclusion These data provide evidence that the reduction in PASP observed following TAVI is closely correlated with an improvement in NYHA functional class along with mortality at 1-year. This study will help enable cardiovascular clinicians to identify those patients likely to have a favourable symptomatic response to TAVI based on the echocardiographic PASP estimate post-procedure.

24 Spinal analgesia in patients undergoing transapical aortic valve implantation: improved outcomes in a routine cohort

Introduction Epidural analgesia improves outcomes after transapical aortic valve implantation (TA-AVI). However, it is rarely used due to the risk of complications in patients on antiplatelet or anticoagulant medication. Spinal analgesia (SA) is associated with fewer complications. We used SA in patients undergoing TA-AVI and report on outcomes. Methods All TA-AVI patients received general anaesthesia. Since 2013, additional single-shot SA using a long acting opioid plus local anaesthetic intrathecally was used (n = 26). We compared results to a control group of patients without SA (n = 110). Results Mean age was 79.3 ± 8.8yrs (SA) vs. 82.6 ± 7.1yrs (non-SA, p = 0.04). No SA related complication occurred. Up to 30-days, no patient died in the SA cohort compared to 18 deaths in the non-SA group (16.4%, p = 0.02). Increase in creatinine was lower in the SA group (18.5 ± 36.3mmol/l vs. 53.2 ± 74.7mmol/l, p = 0.02). After SA, no patient required dialysis vs. 10.0% (p = 0.12). No patient had respiratory failure in the SA group vs. 12.7% in non-SA (p = 0.05). New onset of atrial fibrillation occurred in 3.8% in SA vs. 16.4% (p = 0.09). Length of stay on intensive care unit (1.9 ± 1.7 vs. 2.0 ± 2.9, p = 0.88) and NYHA-class at 30 days (NYHA I/II 80.8% vs. 67.3%, p = 0.56) were not different. Conclusion The use of SA in TA-AVI is safe. In addition to the growing experience with TA-AVI and its peri-procedural management, the introduction of SA improved outcomes after TA-AVI, with lower mortality, renal- and pulmonary complications. The use of SA possibly leads to a reduction of inflammatory response.

28 Haemodynamic performance of supra-annular versus intra-annular transcatheter heart valves in failed bioprostheses

Background Transcatheter aortic valve-in-valve implantation (ViV) is increasingly used to treat failed bioprostheses (BP), but elevated gradients remain a challenge. In-vitro studies suggest transcatheter heart valves (THV) with supra-annular position improve haemodynamic results compared to THV with intra-anular position. Methods We compared haemodynamic performance. Methods: Since 2008, 71 patients underwent ViV using the Medtronic CoreValve /Evolut-R (CV) or Edwards Sapien /XT/3 THV (ES). Patients were matched regarding true internal diameter (ID) and mode of degeneration (MoD) (CV=22, ES=19). Results In the total group, CV were implanted into smaller BP than ES (true ID: 19.0 ± 2.1mm vs. 21.4 ± 2.7mm, p < 0.01). After matching, true ID was 19.4 ± 2.0mm in both groups, p = 0.92. MoD, BSA and left ventricular function were not significantly different. Baseline mean gradients (CV: 39.0 ± 17.2mmHg vs. ES: 38.0 ± 19.5mmHg, p = 0.86) and indexed effective orifice areas (iEOA; CV: 0.79 ± 0.11cm²/m² vs. ES: 0.80 ± 0.10cm²/m², p = 0.64) were comparable. At discharge, mean gradients were 22.0 ± 7.7mmHg (CV) vs. 20.0 ± 7.8 (ES, p = 0.43) and iEOA: 0.77 ± 0.14 cm²/m² (CV) vs 0.84 ± 0.21cm²/m² (ES, p = 0.28). In CV, 54.5% had a mean gradient ≥20mmHg, compared to 52.6% in ES, p = 1.0. There was no paravalvular regurgitation >1. Conclusion In retrospect, haemodynamic performance of either CV or ES for ViV was not different and superiority of supra-annular THV remains to be proven. Other factors, such as implantation depth of THV, may be more relevant for haemodynamic outcome and need further investigation.