Atrioventricular Conduction After Transcatheter Aortic Valve Implantation and Surgical Aortic Valve Replacement

AV Conduction After TAVI and SAVR . Introduction: Atrioventricular conduction abnormalities (AVCA) may complicate transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR). The aim of this study was to prospectively evaluate AVCA after TAVI and SAVR. Methods and Results: Among 50 patients undergoing TAVI and 25 patients undergoing SAVR a continuous 7‐day Holter electrocardiogram (ECG) was recorded after the procedure. ECGs during TAVI and 12‐lead ECGs before and 1 and 7 days after TAVI and SAVR were analyzed. At baseline, TAVI patients were older (mean 82.1 vs 75.4, P < 0.001), had a longer PR interval (median 200 milliseconds vs 175 milliseconds, P = 0.004) and broader QRS width (median 100 milliseconds vs 80 milliseconds, P = 0.007) than SAVR patients. New AVCA were observed among 29 TAVI patients (58%), mostly new left bundle branch block (76%). Predilatation induced new AVCA in 14 TAVI patients (28%). New AVCA resolved within 24 hours in 15 TAVI patients (30%), and persisted in 14 TAVI (28%) and 3 SAVR patients (12%, P = 0.12). Among patients with persistent QRS width <120 milliseconds during the first 24 hours after TAVI, QRS width remained stable during the remainder of the observation period. During Holter monitoring complete AV block was observed in 4 TAVI patients (8%) and 3 SAVR patients (12%; P = 0.68). Conclusions: Almost half of AVCA during TAVI are induced by predilatation, but half of them resolve within 24 hours. Persistent AVCA are more frequently observed after TAVI than SAVR. If QRS width is below 120 milliseconds the first day after TAVI, the risk of late AVCA seems low. (J Cardiovasc Electrophysiol, Vol. 23 pp. 1115‐1122, October 2012)     

Transcatheter Aortic Valve Implantation

Severe aortic stenosis (AS) is a life-threatening condition when left untreated. Aortic valve replacement (AVR) is the gold standard treatment for the majority of patients; however, transcatheter aortic valve implantation/replacement (TAVI/TAVR) has emerged as the preferred treatment for high-risk or inoperable patients. The concept of transcatheter heart valves originated in the 1960s and has evolved into the current Edwards Sapien and Medtronic CoreValve platforms available for clinical use. Complications following TAVI, including cerebrovascular events, perivalvular regurgitation, vascular injury, and heart block have decreased with experience and evolving technology, such that ongoing trials studying TAVI in lower risk patients have become tenable. The multidisciplinary team involving the cardiac surgeon and cardiologist plays an essential role in patient selection, procedural conduct, and perioperative care.     

经导管主动脉瓣置入术临床应用

经导管主动脉瓣膜置入术是近年来出现一种治疗主动脉瓣狭窄的新兴技术,可以通过微创的方法治疗心脏瓣膜病。主动脉瓣狭窄传统治疗需要外科手术换瓣治疗,尤其合并左心功能不全的老年患者风险很大,且有些患者存在手术禁忌证。经导管置换主动脉瓣会给患者带来巨大的利益,其主要优点是体现在微创、避免体外循环及输血、缩短住院时间等方面。     

Incomplete Functional Revascularization Is Associated With Adverse Clinical Outcomes After Transcatheter Aortic Valve Implantation

Background and purposeWhether incomplete functional revascularization has an impact on the clinical outcome of patients treated with transcatheter aortic valve implantation (TAVI) is still unknown. We aim to assess the prognostic value of residual functional SYNTAX score (rFSS) in a cohort of patients undergoing TAVI.Methods and resultsOne-hundred-twenty-four patients (229 lesions) with severe aortic stenosis and coronary artery disease (CAD) underwent fractional flow reserve (FFR)-guided revascularization. The primary endpoint of the study was the composite of cardiac death, myocardial infarction, and revascularization at the last available follow-up after TAVI. Median SYNTAX score (SS) and Functional SYNTAX score (FSS) at baseline were 7 (range 5–12) and 0 (range 0–7) respectively. After revascularization or deferral according to FFR, residual SS (rSS) and rFSS were 5 (range 0–8) and 0 (range 0–0) respectively. Angiographic incomplete revascularization (rSS > 0) was not associated with the primary endpoint (HR 1.2; 95% CI 0.4–3.9; p = 0.69), whereas functional incomplete revascularization (rFSS>0) was associated with worse event-free survival at follow up after adjusting for clinical confounders (HR 3.7; 95% CI 1.0–13.7; p = 0.04).ConclusionIncomplete functional revascularization is associated with adverse clinical outcomes after TAVI. Residual functional SYNTAX score may be regarded as a treatment goal for patients with CAD undergoing TAVI. Further studies are warranted to confirm our hypothesis.     

Aortic Valve Calcium Volume Predicts Paravalvular Regurgitation and the Need for Balloon Post‐Dilatation After Transcatheter Aortic Valve Implantation

Objective

This study sought to evaluate the impact of aortic valve (AV) and left ventricle outflow tract (LVOT) calcium on paravalvular regurgitation (PVR) and need for balloon post‐dilatation (BPD) during transcatheter aortic valve implantation (TAVI).

Methods

The overall study population comprised 152 patients. Calcium mass and volume of AV and LVOT were estimated from contrast‐enhanced multislice computed tomography imaging, using 3 thresholds for calcium detection [650, 850, and 1,050 Hounsfield units (HU)].

Results

A self‐expandable prosthesis was implanted in 67.8% of patients and a balloon‐expandable prosthesis in the remaining. Eleven patients required BPD and 82 patients presented post‐procedural PVR, which was mild in 44.1% and moderate in 9.9%. The greatest discriminatory value for PVR ≥ mild was seen for calcium volume using 850 HU threshold, with an area under the curve of 0.72 (95%CI 0.64–0.80, P < 0.001) for AV and of 0.63 (95%CI 0.54–0.72, P = 0.008) for LVOT. For 850 HU threshold, the calcium volume cut‐off with the highest sum of sensitivity and specificity for PVR was 157 mm³ for AV and 0.6 mm³ for LVOT. In multivariate logistic regression analysis, the presence of AV calcium ≥157 mm³ (OR 3.83, 95%CI 1.81–8.10, P < 0.001) and ≥267 mm³ (OR 11.3, 95%CI 1.2–103.1, P = 0.03) were the only independent predictors of PVR and BPD, respectively.

Conclusions

AV calcium volume was an independent predictor of PVR and BPD in patients submitted to TAVI. Our results support a systematic assessment of AV calcium volume to identify patients at increased risk of post‐procedural PVR. (J Interven Cardiol 2016;29:117–123)