Philipp Ruile

Early hypo-attenuated leaflet thickening in balloon-expandable transcatheter aortic heart valves

AIMS We sought to evaluate the frequency of early hypo-attenuated leaflet thickening (HALT) of the SAPIEN 3 transcatheter aortic valve (S3). METHODS AND RESULTS Of 249 patients who had undergone S3 implantation, we studied 156 consecutive patients (85 women, median age 82.2 ± 5.5 years) by electrocardiogram (ECG)-triggered dual-source computed tomography angiography (CTA) after a median of 5 days post-transcatheter aortic valve implantation. The prosthesis was assessed for HALT. Apart from heparin, peri-interventional antithrombotic therapy consisted of single- (aspirin 29%) or dual- (aspirin plus clopidogrel 71%) antiplatelet therapy. Hypo-attenuated leaflet thickening was found in 16 patients [10.3% (95% confidence interval (CI) 5.5-15.0%)] of the patients. None of the baseline and procedural variables were significantly associated with HALT, nor did we find a significant association with the antithrombotic regimen, either peri-interventionally or at the time of CTA. Hypo-attenuated leaflet thickening was found in 6 of 45 patients with peri-interventional single-antiplatelet therapy and in 10 of 111 patients with dual-antiplatelet therapy at the time of intervention [13.3% (95% CI 3.4-23.3%) vs. 9% (95% CI 3.7-14.3%), P = 0.42]. Hypo-attenuated leaflet thickening was not associated with clinical symptoms, but a small, albeit significant difference in mean pressure gradient at the time of CTA (11.6 ± 3.4 vs. 14.9 ± 5.3 mmHg, P = 0.026). Full anticoagulation led to almost complete resolution of HALT in 13 patients with follow-up CTA. CONCLUSION Irrespective of the antiplatelet regimen, early HALT occurred in 10% of our patients undergoing transcatheter aortic S3 implantation. Early HALT is clinically inapparent and reversible by full anticoagulation.

Pre-procedural assessment of aortic annulus dimensions for transcatheter aortic valve replacement: comparison of a non-contrast 3D MRA protocol with contrast-enhanced cardiac dual-source CT angiography

AIMS To evaluate the feasibility of a non-contrast three-dimensional (3D)-FLASH magnetic resonance angiography (MRA) protocol for pre-procedural aortic annulus assessment for transcatheter aortic valve replacement (TAVR) in comparison with cardiac dual-source computed tomography angiography (CTA). METHODS AND RESULTS In this prospective study, 69 of 104 consecutive patients (mean age 81.8 ± 5.4 years, 37.7% arrhythmic) with severe aortic stenosis who had undergone pre-TAVR cardiac CTA received a respiratory and ECG-triggered, non-contrast 3D-FLASH MRA at 3 T. Annular area measurements were obtained at mid-diastole for both modalities whereas maximum systolic area was assessed by CTA only. Systolic MRA dimensions were modelled, by adding the relative difference of systolic and diastolic CTA area dimensions as a corrective factor. Hypothetical prosthesis sizing was performed based on systolic CTA, diastolic, and modelled systolic MRA area measurements. MR image quality and degree of annular calcifications were evaluated using 4-point-grading scales. The mean acquisition time was 14 ± 4.2 min. The mean image quality was 3.1 ± 0.9 with only two examinations rated non-diagnostic. The mean degree of calcifications was equal. As assessed by Bland-Altman analysis, there was no relevant systematic difference between area measurements for modelled systolic MRA and systolic CTA [the mean difference -3.1 mm(2) (limits of agreement -44.4 mm(2); 38.2 mm(2))]. Agreement for hypothetical prosthesis sizing was found in 63 of 67 (94%) patients for systolic CTA and modelled systolic MRA. CONCLUSION The employed non-contrast 3D-FLASH MRA protocol allows for reliable assessment of aortic annulus dimensions and calcifications even in the presence of arrhythmias in an all-comers pre-TAVR population. Implementation of this technique appears legitimate in patients at an increased risk for contrast-induced nephropathy.

Hypo-attenuated leaflet thickening of transcatheter aortic valves: jeopardy or epiphenomenon?

HALT has been reported as a mostly incidental finding on multislice computerd tomography (MSCT) angiography. It is characterized by lesions with lower density above the leaflets of the prosthesis and in most cases is associated with restricted leaflet motion. The consistent finding of resolution of HALT under oral anticoagulation suggests thrombosis as the underlying mechanism. Reported incidences of HALT range around 10% after transcatheter aortic valve implantation (TAVI). HALT may occur with any type of transcatheter aortic valve and has also been reported with surgical valve prostheses. In surgically implanted prostheses, valve thrombosis is a dreaded complication. Based on earlier experience in this setting, it is associated with valve dysfunction as well as increased risk of thrombo-embolic events and ultimately death. Yet, unlike HALT that is unusually a chance finding in asymptomatic patients, detection of valve thrombosis in the earlier studies on surgical valves was always triggered by clinical symptoms. Moreover, modern CT technology enables the detection of minute changes in leaflet structure and motion that cannot be detected by any other method and, therefore, is not represented in the earlier literature on surgical valves. Hence, there is reasonable doubt about the clinical relevance of HALT. So far, published data on the clinical course of patients with HALT are limited: the largest data sets by Makkar et al., Pache et al., Hansson et al., and Yanagisawa et al. included only 39, 16, 28, and 10 patients, respectively. Moreover, looking at the impact of antithrombotic treatment, Ruile et al. extended the series of Pache et al. to 51 patients. In the previous studies, clinical follow-up was limited to 1 year. It is the merit of the current study by Vollema et al. to report clinical and echocardiographic follow-up for up to 3 years in 16 patients with HALT out of a subset of 128 patients with MSCT after TAVI. To corroborate their clinical findings in patients with HALT, they also assessed the clinical course of 13 patients who met the echocardiographic criteria for valve thrombosis within the entire cohort of 431 patients with TAVI. When assessing the clinical relevance of HALT, two key issues need to be addressed: the impact of HALT on valve function and the risk of thrombo-embolic events.

Impact of the type of transcatheter heart valve on the incidence of early subclinical leaflet thrombosis

OBJECTIVES The aim of this study was to investigate whether balloon-expandable and self-expandable transcatheter heart valves (THVs) differ in terms of the incidence of early subclinical leaflet thrombosis (LT). METHODS Electrocardiographic-gated cardiac dual-source computed tomography angiography was performed at a median of 5 days after transcatheter aortic valve implantation and assessed for evidence of LT. RESULTS Of the 629 consecutive patients, 538 (86%) received a balloon-expandable THV and 91 (14%) a self-expandable THV. LT was documented in 77 (14%) patients with a balloon-expandable valve and in 16 (18%) with a self-expandable valve (P = 0.42). Similarly, LT was not significantly related to THV size (P = 0.62). Corresponding to a lower rate of atrial fibrillation in the group with LT [25 (27%) vs 222 (41%), P = 0.01], anticoagulation at the time of computed tomography angiography was less frequent in this group [21 (23%) vs 183 (34%), P = 0.03]. Among the other potentially relevant covariables, there was no significant difference in the clinical baseline and the procedural characteristics between patients with and without LT (age 82 ± 6 years vs 82 ± 6 years, P = 0.51; ejection fraction 49 ± 10% vs 50 ± 10%, P = 0.47). In multivariate logistic regression analysis, including potentially relevant covariables, valve type was not significantly associated with LT (P = 0.36). In the univariate and multivariate analyses, only the lack of anticoagulation at the time of computed tomography angiography was predictive of thrombus formation [0.563 (0.335-0.944), P = 0.03; 0.576 (0.343-0.970), P = 0.04]. CONCLUSIONS In this large retrospective study of 629 patients, the type and the size of THV was not predictive of early LT.

Anatomic estimation of aortic stenosis severity vs “fusion” of data from computed tomography and Doppler echocardiography

Two‐dimensional, transthoracic echocardiography does not account for the noncircular anatomy of the left ventricular outflow tract (LVOT) and may therefore underestimate LVOT area. Fusion of computed tomography (CT)‐derived LVOT area and Doppler‐derived flow data has been proposed to improve assessment of aortic valve area (AVA) and classification of aortic stenosis severity. For hemodynamic reasons, effective AVA has to be smaller than anatomic AVA. The aim of the study was to test the “fusion approach” by comparing effective CT‐derived AVA with anatomic AVA from CT planimetry.

Post-TAVI Follow-Up with MDCT of the Valve Prosthesis: Technical Application, Regular Findings and Typical Local Post-Interventional Complications

BACKGROUND  Transcatheter aortic valve implantation (TAVI) has evolved into an alternative procedure to surgical valve replacement for high-risk patients with aortic valve stenosis. Despite technical innovations, there is still a risk of complications during and after the intervention. After a TAVI procedure, ECG-gated multidetector computed tomography (MDCT) plays an important role in the early diagnosis of local complications. In this article, we explain for the first time how the technical acquisition of MDCT in the region of the aortic root is performed as post-interventional control of the TAVI prosthesis. In the second part normal post-interventional findings of different prosthetic valves as well as classic and uncommon complications in the implant area will be illustrated in several case studies. METHODS  In this review the current literature from PubMed about ECG-gated MDCT after TAVI is summarized and structured. It is supplemented by several case studies from our institution. RESULTS AND CONCLUSION  Using retrospectively ECG-gated MDCT, an aortic valve prosthesis after TAVI can be visualized with high spatial resolution in several phases of the cardiac cycle. Images of the implanted aortic valve at all time points of the cardiac cycle enable a functional analysis of prosthetic leaflets similar to echocardiography. MDCT is superior to transthoracic echocardiography with respect to the direct detection of prosthetic leaflet thrombosis. The position of the device in relation to the coronary ostia and correct unfolding of the stent frame need to be evaluated. There are different types of stents carrying the valve leaflets with distinct ideal positions. Any stent should cover the left ventricular outflow tract (LVOT) along its whole circumference. Life-threatening complications in the implant area, such as annulus rupture, can be diagnosed reliably with CT. KEY POINTS   · ECG-gated multidetector CT (MDCT) after transcatheter aortic valve implantation (TAVI) can provide early detection of postinterventional complications of the prosthetic valve and the aortic root.. · MDCT is superior to echocardiography with respect to the direct detection of prosthetic leaflet thrombosis.. · MDCT can also reveal hypokinesia of the thrombotic valve leaflets.. · Correct position of the device und unfolding of the stent frame differ according to the type of prosthesis.. · The integrity of the native aortic root should be carefully assessed.. CITATION FORMAT · Soschynski M, Capilli F, Ruile P et al. Post-TAVI Follow-Up with MDCT of the Valve Prosthesis: Technical Application, Regular Findings and Typical Local Post-Interventional Complications. Fortschr Röntgenstr 2018; 190: 521 - 530.

TCT-79 Course of early subclinical leaflet thrombosis after transcatheter aortic valve replacement with or without oral anticoagulation

nos: 81 84 TCT-81 Clinical and hemodynamic results after direct transcatheter aortic valve replacement versus pre-implantation balloon aortic valvuloplasty. A case-matched analysis Luis Nombela Franco, Carlos Ferrera, Eulogio Garcia, Pilar Jimenez, Corina Biagioni, Nieves Gonzalo, Ivan Nuñez-Gil, Ana Viana, Pablo Salinas, Javier Escaned, Antonio Fernandez-Ortiz, Carlos Macaya Hospital Clínico San Carlos, Madrid, Spain; Hospital Clínico San Carlos; Hospital Clinico San Carlos, Madrid, Spain; Hospital Clinico San Carlos, Madrid, Spain; Hospital Clínico San Carlos; Unknown, Madrid, Spain; Hospital Clínico San Carlos; Unknown, Madrid, Spain; Hospital Clínico San Carlos, Madrid, Spain; Hospital Clínico San Carlos, Madrid, Spain; Hospital Clínico San Carlos; Hospital Clinico de San Carlos, Madrid, Spain BACKGROUND Balloon aortic valvuloplasty (BAV) was considered a routine previous step in transcatheter aortic valve implantation (TAVI). Our aim was to evaluate the feasibility, safety and midterm hemodynamic results of direct TAVI without pre-implantation BAV. METHODS A total of 339 consecutive patients who underwent transfemoral TAVR were prospectively selected. A 1:1 matching was conducted, pairing age, prosthesis type (self-expandable or balloon expandable) and size, and valve calcification grade (48% with moderate to severe valve calcification). Finally, 102 pairs (102 patients with previous BAV and 102 without BAV) were obtained. RESULTS Direct TAVR was feasible in all patients without any crossover to BAV group. Device success was achieved in 91.2% and 90.2% of cases in direct TAVR and pre-BAV groups (p1⁄40.810), respectively, without any differences in balloon postdilation rate and residual aortic regurgitation. The amount of contrast agent, acute kidney injury and myocardial injury was significantly lower in the direct implantation group (p<0.05). No differences were found in 30-day and 1-year mortality between both groups (4.9% versus 9.8%, p1⁄40.177 and 14.0% versus 23.8%, p1⁄40.771, respectively). Hemodynamic parameters remained stable after 1-year follow-up in both groups. CONCLUSION Direct transfemoral TAVR without prior BAV was safe in patients with calcified severe aortic stenosis. Pre-implantation BAV could be omitted in patients undergoing TAVR, without influence in procedure success rate, and subsequent patients’ clinical course and valve hemodynamic performance. CATEGORIES STRUCTURAL: Valvular Disease: Aortic TCT-82 Evaluation of Current Practices in Transcatheter Aortic Valve Replacement: The WRITTEN (WoRldwIde TAVR ExperieNce) Survey Luis Nombela-Franco, Enrico Cerrato, Tamim Nazif, Helene Eltchaninoff, Lars Sondergaard, Henrique Ribeiro, Marco Barbanti, Fabian Nietlispach, Pierfrancesco Agostoni,

BICUSPID AORTIC VALVE STENOSIS: IMPROVED OUTCOMES WITH A NEXT GENERATION TRANSCATHETER HEART VALVE IN A MULTI-CENTER STUDY

A bicuspid aortic stenosis (AS) is often considered a relative contraindication to transcatheter aortic valve replacement (TAVR). While initial reports have demonstrated feasibility using early generation devices outcomes have not matched those seen with tricuspid AS. Paravalvular aortic