The prognostic value of fragmented QRS in patients undergoing transcatheter aortic valve implantation

Background

Although transcatheter aortic valve implantation (TAVI) can successfully correct aortic narrowing, pre-existing pathophysiological alterations in the left ventricle are still a concern in terms of long-term mortality. This study aimed to examine the predictive role of fQRS morphology on long-term prognosis in patients undergoing TAVI due to severe aortic stenosis.

Setting up a transcatheter aortic valve implantation program: Indian perspective

Transcatheter aortic valve implantation (TAVI) has revolutionized the management of elderly patients with symptomatic severe aortic stenosis in the western world. It is a valuable alternative to surgical aortic valve replacement in patients, who are inoperable or at high surgical risk due to co-morbidities. The prevalence of aortic stenosis increases sharply with age after the sixth decade and is expected to have a significant impact on the geriatric health care system of India, given the rapid increase in life expectancy in recent years. Although a decade has passed since the first TAVI implantation, it is yet to penetrate most of the developing countries in a major way. This short review focuses on fundamentals of initiating a TAVI program based on the experience of a high volume TAVI center with a successful program in Germany.     

Preferential short cut or alternative route: the transaxillary access for transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) has gained widespread acceptance as a treatment option for patients at high risk for conventional aortic valve replacement. The most commonly used access site for TAVI is the common femoral artery. Yet, in a significant number of patients the transfemoral access is not suitable due to peripheral vascular disease of the lower extremity. In these cases the transaxillary approach can serve as an alternative implantation route. By considering the anatomical requirements and providing an adequate endovascular “safety-net” during the procedure the transaxillary TAVI approach results in excellent procedural and clinical outcome. However, whether the transaxillary access for TAVI is superior to other non-transfemoral approaches (e.g., transapical or direct aortic) needs to be studied in the future in a prospective randomized trial.     

Recent developments and controversies in transcatheter aortic valve implantation

Interventional cardiology has been revolutionised by transcatheter aortic valve implantation (TAVI), which has become established as the benchmark treatment for severe aortic stenosis in patients at high risk for surgical aortic valve replacement (AVR). Increased procedural familiarity and progression in device technology has enabled improvements to be made in complication rates, which have led to a commensurate expansion in the use of TAVI; it is now a viable alternative to AVR in patients at intermediate surgical risk, and has been used in cohorts such as those with bicuspid aortic valves or pure, severe aortic regurgitation. Given the rapid expansion in the use of TAVI, including cohorts of younger patients with fewer co‐morbidities, attention must be paid to further reducing remaining complications, such as cardiac tamponade or stroke. To this end, novel techniques and devices have been devised and trialled, with varying levels of success. Furthermore, significant work has gone into refining the technique with exploration of alternative imaging modalities, as well as alternative access routes to provide greater options for patients with challenging vascular anatomy. Whilst significant progress has been made with TAVI, areas of uncertainty remain such as the management of concomitant coronary artery disease and the optimum post‐procedure antiplatelet regimen. As such, research in this field continues apace, and is likely to continue as use of TAVI becomes more widespread. This review provides a summary of the existing evidence, as well as an overview of recent developments and contentious issues in the field of TAVI.     

In vitro study of coronary flow occlusion in transcatheter aortic valve implantation

Background

Transcatheter aortic valve implantation (TAVI) has been developed recently for patients with high morbidities and who are believed to be not tolerate standard surgical aortic valve replacement. Nevertheless, the TAVI is associated with complications such as potential obstruction of coronary ostia, mitral valve insufficiency, and stent migration although it seems promising. Impairment of the coronary blood flow after TAVI is catastrophic and it was believed to be associated with the close position of the coronary orifice and the aortic leaflets and valve stent. However, few data was available as to the anatomic relationship between valve stent and aortic root anatomic structures including the coronary arterial ostia, aortic leaflets.

Methods

The aortic roots were observed in 40 hearts specimens. The width of aortic leaflet, height of aortic sinus annulus to the sinutubular junction (STJ), distance between aortic sinus annulus to its corresponding coronary ostia, and coronary arterial ostia to its corresponding STJ level were measured. Moreover, the relationships of valve stent, aortic leaflets and coronary ostia before/post stent implantation and after the open of aorta were evaluated respectively.

Results

Approximate three quarters of the coronary ostia were located below the STJ level. The mean distances from left, right and posterior aortic sinus annulus to the related STJ level was comparable, which was 18.5±2.7, 18.9±2.6, 18.7±2.6 mm, respectively. Meanwhile, the height of left and right aortic sinus annulus to its corresponding coronary ostia was 16.6±2.8 and 17.2±3.1 mm for left and right side respectively.

Conclusions

Most of the coronary ostia were located below the STJ level and could be covered by the leaflets. This highlights the need of modified stents to prevent occlusion of coronary flow after TAVI.     

超声心动图在主动脉瓣狭窄经导管主动脉瓣植入术中的应用价值

目的探讨超声心动图在主动脉瓣狭窄患者经导管主动脉瓣植入术中的作用。方法3例重度主动脉瓣瓣膜狭窄患者接受经导管主动脉瓣人工瓣膜植入术。使用PhilipS iE33型彩色多普勒超声诊断仪,配备经胸探头S5—1和经食道探头S7—2,X7—2t。超声观察内容包括明确主动脉瓣膜病变范围和程度,测量主动脉瓣环前后径,人工瓣膜植入术后瓣膜功能等。结果3例患者经导管主动脉瓣植入术均取得了成功,人工瓣膜位置稳定,常规超声心动图3例患者术前经胸超声心动图与术中经食管超声心动图诊断相符,跨瓣压差较术前明显下降,主动脉瓣瓣上流速明显下降,瓣周漏瞬时反流量平均约1．2mL。结论经导管主动脉瓣人工瓣膜植入术在治疗严重主动脉瓣瓣膜狭窄中方法可行,效果良好;超声心动图在这项工作中具有重要的辅助作用。     

Clinical and prognostic implications of atrial fibrillation in patients undergoing transcatheter aortic valve implantation

AIM: To study a cohort of consecutive patients under-going transcatheter aortic valve implantation (TAVI) and compare the outcomes of atrial fibrillation (AF) patients vs patients in sinus rhythm (SR). METHODS: All consecutive patients undergoing TAVI in our hospital were included. The AF group comprised patients in AF at the time of TAVI or with history of AF, and were compared with the SR group. Procedural, echocardiographic and follow-up variables were compared. Likewise, the CHA 2 DS 2-VASC stroke risk score and HAS-BLED bleeding risk score and antithrombotic treatment at discharge in AF patients were compared with that in SR patients. RESULTS: From a total of 34 patients undergoing TAVI, 17 (50%) were allocated to the AF group, of whom 15 (88%) were under chronic oral anticoagulation. Patients in the AF group were similar to those in the SR group except for a trend (P = 0.07) for a higher logistic EuroSCORE (28% vs 19%), and a higher prevalence of hypertension (82% vs 53%) and chronic renal failure (17% vs 0%). Risk of both stroke and bleeding was high in the AF group (mean CHA 2 DS 2-VASC 4.3, mean HAS-BLED 2.9). In the AF group, treatment at discharge included chronic oral anticoagulation in all except one case, and in association with an antiplatelet drug in 57% of patients. During a mean follow-up of 11 mo (maximum 32), there were only two strokes, none of them during the peri-procedural period: one in the AF group at 30 mo and one in the SR group at 3 mo. There were no statistical differences in procedural success, and clinical outcome (survival at 1 year 81% vs 74% in AF and SR groups, respectively, P = NS). CONCLUSION: Patients in AF undergoing TAVI show a trend to a higher surgical risk. However, in our cohort, patients in AF did not have a higher stroke rate compared to the SR group, and the prognosis was similar in both groups.     

Effect of transcatheter aortic valve implantation on QT dispersion in patients with aortic stenosis

Background QT dispersion （QTd） is a predictor of ventricular arrhythmia. Ventricular arrhythmia is an important factor influencing morbidity and mortality in patients with aortic stenosis. Surgical aortic valve replacement reduced the QTd in this patients group. However, the effect of transcatheter aortic valve implantation （TAVI） on QTd in patients with aortic stenosis is unknown. The aim of this study was to investigate the effect of TAVI on QTd in patients with aortic stenosis. Methods Patients with severe aortic stenosis, who were not candi-dates for surgical aortic valve replacement due to contraindications or high surgical risk, were included in the study. All patients underwent electrocardiographic and echocardiographic evaluation before, and at the 6th month after TAVI, computed QTd and left ventricular mass index （LVMI）. Results A total 30 patients were admitted to the study （mean age 83.2 ± 1.0 years, female 21 and male 9, mean valve area 0.7 ± 3 mm2）. Edwards SAPIEN heart valves, 23 mm （21 patients） and 26 mm （9 patients）, by the transfemoral approach were used in the TAVI procedures. All TAVI procedures were successful. Both QTd and LVMI at the 6th month after TAVI were significantly reduced com-pared with baseline values of QTd and LVMI before TAVI （73.8 ± 4 ms vs. 68 ± 2 ms, P=0.001 and 198 ± 51 g/m2 vs. 184 ± 40 g/m2, P=0.04, respectively）. There was a significant correlation between QTd and LVMI （r=0.646, P〈0.001）. Conclusions QTd, which malign ventricular arrhythmia marker, and LVMI were significantly reduced after TAVI procedure. TAVI may decrease the possibility of ventricu-lar arrhythmia in patients with aortic stenosis.     

Outcome of transcatheter aortic valve implantation in high risk patients with severe aortic stenosis

Aim

To assess outcome of TAVI in high risk patients with severe symptomatic aortic stenosis.

心房颤动患者经导管主动脉瓣植入术后1年随访结果

目的:探讨经导管主动脉瓣植入（TAVI）术前合并心房颤动（房颤）是否会对患者的预后产生影响。方法:本研究为单中心回顾性研究。入选2016年5月至2020年11月于北部战区总医院住院并成功接受TAVI治疗且顺利出院的重度主动脉瓣狭窄患者115例。根据入选患者是否合并房颤将其分为房颤组（21例）及非房颤组（94例）。随访纳...     

Evolution of non-invasive myocardial work variables after transcatheter aortic valve implantation in patients with severe aortic stenosis

IntroductionGuidelines recommend aortic valve replacement in patients with severe aortic stenosis who present with symptoms or left ventricular ejection fraction < 50%, both conditions representing a late stage of the disease. Whereas global longitudinal strain is load dependent, but interesting for assessing prognosis, myocardial work has emerged.AimTo evaluate acute changes in myocardial work occurring in patients undergoing transcatheter aortic valve implantation (TAVI).MethodsPatients who underwent TAVI were evaluated before and after by echocardiography. Complete echocardiographies were considered. Myocardial work indices (global work index, global constructive work, global work efficiency, global wasted work) were calculated integrating mean transaortic pressure gradient and brachial cuff systolic pressure.ResultsOne hundred and twenty-five patients underwent successful TAVI, with a significant decrease in mean transaortic gradient (from 52.5 ± 16.1 to 12.2 ± 5.0; P < 0.0001). There was no significant change in left ventricular ejection fraction after TAVI. Myocardial work data after TAVI showed a significant reduction in global work index (1389 ± 537 vs. 2014 ± 714; P < 0.0001), global constructive work (1693 ± 543 vs. 2379 ± 761; P < 0.0001) and global work efficiency (85.0 ± 7.06 vs. 87.1 ± 5.98; P = 0.0034). The decrease in global work index and global constructive work after TAVI was homogeneous among different subgroups, based on global longitudinal strain, left ventricular ejection fraction and New York Heart Association status before TAVI. We observed a significant association between global work index and global constructive work before TAVI, and global longitudinal strain degradation after TAVI.ConclusionsMyocardial work variables show promising potential in best understanding the left ventricular myocardial consequences of aortic stenosis and its correction. Given their ability to discriminate between New York Heart Association status and global longitudinal strain evolution, we can hypothesize about their clinical value.     

Development of transcatheter aortic valve implantation (TAVI): A heart-warming adventure

The development of transcatheter aortic valve implantation (TAVI) spearheaded by our group has been a great adventure since we validated the concept in the early 1990s in aortic stenosis (AS) postmortem studies. We first tested prototypes in animal models before performing the daring first-in-man implantation in 2002. Prospective compassionate use series followed, accompanied by ongoing technological innovation of devices and of delivery systems. High surgical risk patients were enrolled in feasibility studies, which led to the Conformité Européenne (CE) mark being granted in 2007. Data from post-marketing registries involving thousands of patients have shown remarkable results and increasingly smaller complication rates, as a result of growing experience and improved technology. Survival and quality of life results from the landmark randomized PARTNER Edwards SAPIEN study have confirmed the important place of TAVI in non-operable and high surgical risk patients. To date, more than 50,000 patients have benefited from TAVI worldwide. TAVI is now recommended in the European Society of Cardiology (ESC), the European Association for Cardio-Thoracic Surgery (EACTS) guidelines, and by the Food and Drug Administration in the United States for the treatment of AS patients who are not suitable or at high risk for surgery, as assessed by a multidisciplinary heart team, and in whom a less invasive approach is favored. Multidisciplinary heart teams are critical in patient selection and in successful procedures. In future, TAVI may be extended to use in lower risk patients, although further clinical investigation is necessary. Just over 10 years after the first-in-man case, TAVI has quickly become an established AS treatment option.     

Acute kidney injury following transcatheter aortic valve implantation: incidence,predictors and clinical outcome

Background

Limited data exist on renal complications of transcatheter aortic valve implantation (TAVI) within a comprehensive program using different valves with transfemoral, transapical, and trans-subclavian approach.

Methods

Prospective single-center registry of 102 consecutive patients undergoing TAVI using both approved bioprostheses and different access routes. The main objective was to assess the incidence, predictors and the clinical impact of acute kidney injury (AKI). AKI was defined according to the valve academic research consortium (VARC) indications.

Results

Mean age was 83.7 ± 5.3 years, logistic EuroSCORE 22.6 ± 12.4%, and STS score 8.2 ± 4.1%. Chronic kidney disease at baseline was present in 87.3%. Periprocedural AKI developed in 42 patients (41.7%): 32.4% stage 1, 4.9% stage 2 and 3.9% stage 3. The incidence of AKI was 66.7% in transapical, 30.3% in transfemoral, and 50% in trans-subclavian procedures. The only independent predictor of AKI was transapical access, with a hazard ratio (HR) between 4.57 and 5.18 based on the model used. Cumulative 1-year survival was 88.2%. At Cox regression analysis, the only independent predictor of 30-day mortality was diabetes mellitus (HR 7.05, 95% CI 1.07–46.32; p = 0.042), whilst the independent predictors of 1-year death were baseline glomerular filtration rate < 30 mL/min (HR 5.74, 95% CI 1.42–23.26; p = 0.014) and post-procedural AKI 3 (HR 8.59, 95% CI 1.61–45.86, p = 0.012).

Conclusions

TAVI is associated with a high incidence of AKI. Although in the majority of the cases AKI is of mild entity and reversible, AKI 3 holds a strong negative impact on 1-year survival. The incidence of AKI is higher with transapical access.