Imaging‐based predictors of permanent pacemaker implantation after transcatheter aortic valve replacement

1 Background

Cardiac conduction abnormalities requiring permanent pacemaker (PPM) implantation are major complications of transcatheter aortic valve replacement (TAVR). We aimed to investigate whether the relationship between prosthetic valve size and cardiac‐gated computed tomography (CT)‐based aortic root complex measurements can aid in recognizing patients at risk for PPM implantation post‐TAVR.

2 Methods

We included 83 of 114 consecutive patients who underwent TAVR with the Edwards Sapien valve (Edwards Lifesciences, Irving, CA, USA) at our institution. We excluded patients with preexisting PPM, patients who required conversion to an open surgical procedure, and patients without CT data. We assessed the significance of various potential predictors of PPM placement post‐TAVR.

3 Results

Following TAVR, eight patients (9.6%) required PPM. Prosthetic valve to sinus of Valsalva (SOV) index was significantly higher in those patients requiring a PPM post‐TAVR (84.1 ± 9.3 vs 76.8 ± 7.1, P  =  0.009).

4 Conclusions

The prosthetic valve size to diameter of SOV index was identified as a novel predictor of PPM implantation after TAVR.     

Incidence and predictors of transcatheter aortic valve replacement device emboligenic matter detected by transesophageal echocardiography

The International Journal of Cardiovascular Imaging - During transfemoral (TF) or transcatheter aortic valve replacement (TAVR), transesophageal echocardiography (TEE) sometimes reveals an...     

Immediate aortic dissection after transcatheter aortic valve replacement: A case report and review of the literature

‐Aortic dissection of descending aorta was detected by intraoperative TEE in a case of 67‐year‐old man with symptomatic severe aortic stenosis after TAVR.‐Transesophageal echocardiogram after TAVR procedure is helpful to detect this rare complication.     

Frailty assessment and impact of frailty on outcomes after transcatheter aortic valve replacement

Introduction: Certain frail patients fail to achieve adequate functional or mortality benefit despite successful transcatheter aortic valve replacement (TAVR). Therefore, frailty assessment methods are becoming an important tool to identify and intervene on this high-risk patient subset for improving clinical outcomes.

Areas covered: The authors provide an overview of frailty and frailty assessment tools being used in clinical practice and discuss the impact of frailty on the cardiac patients, particularly among the TAVR population.

Expert commentary: Available evidence suggests that frailty assessment is critical for identifying patients at high risk of morbidity and mortality after TAVR procedures. However, there is lack of consensus for the best methodology to determine frailty and its optimal management in TAVR populations. Although, physical exercise is a commonly employed intervention to reduce frailty, a greater attention towards improving nutrition may convey more benefit than either intervention alone. Ongoing studies are investigating the benefits of a multicomponent approach to improve clinical outcomes in frail patients undergoing TAVR.     

Dynamic changes in aortic impedance after transcatheter aortic valve replacement and its impact on exploratory outcome

Valvulo-arterial impedance (Zva) has been shown to predict worse outcome in medically managed aortic stenosis (AS) patients. We aimed to investigate the association between Zva and left ventricular (LV) adaptation and to explore the predictive value of Zva for cardiac functional recovery and outcome after transcatheter aortic valve replacement (TAVR). We prospectively enrolled 128 patients with AS who underwent TAVR. Zva was calculated as: (systolic blood pressure?+?mean transaortic gradient)/stroke volume index). Echocardiographic assessment occurred at baseline, 1-month and 1-year after TAVR. The primary endpoints were to investigate associations between Zva and global longitudinal strain (GLS) at baseline as well as GLS change after TAVR. The secondary was to compare all-cause mortality after TAVR between patients with pre-defined Zva (=5 mmHg m²/ml), stroke volume index (=35 ml/m²), and GLS (=?15%) cutoffs. The mean GLS was reduced (?13.0?±?3.2%). The mean Zva was 5.2?±?1.6 mmHg*m²/ml with 55% of values ≥5.0 mmHg*m²/ml, considered to be abnormally high. Higher Zva correlated with worse GLS (r?=??0.33, p?<?0.001). After TAVR, Zva decreased significantly (5.1?±?1.6 vs. 4.5?±?1.6 mmHg*m²/ml, p?=?0.001). A reduction of Zva at 1-month was associated with GLS improvement at 1-month (r?=??0.31, p?=?0.001) and at 1-year (r?=??0.36 and p?=?0.001). By Kaplan–Meier analysis, patients with higher Zva at baseline had higher mortality (Log-rank p?=?0.046), while stroke volume index and GLS did not differentiate outcome (Log-rank p?=?0.09 and 0.25, respectively). As a conclusion, Zva is correlated with GLS in AS as well as GLS improvement after TAVR. Furthermore, a high baseline Zva may have an additional impact to traditional parameters on predicting worse mortality after TAVR.     

Perceval sutureless aortic valve replacement after ascending aortic replacement

In patients with a narrow sinotubular junction, small sinus of Valsalva, or extensibility loss in the aortic root, aortic valve replacement (AVR) with a standard valve is challenging due to limited surgical field. Detailed preoperative measurements of the aortic root render performing AVR using the Perceval valve easy.     

超声心动图在经导管主动脉瓣置换术中的应用价值

目的探讨超声心动图在主动脉瓣膜病变患者经导管主动脉瓣置换术(TAVR)的术前评估、术中监测及术后随访中的应用价值。方法回顾性分析我院收治的32例行TAVR的主动脉瓣膜病变患者的临床资料,分为单纯主动脉狭窄患者13例(Ⅰ组),单纯主动脉瓣反流患者6例(Ⅱ组),主动脉瓣狭窄合并反流患者13例(Ⅲ组)。分析各组术前多层计算机断层扫描(MSCT)对主动脉根部结构测值、术前及术后1个月超声心动图参数的差异,以及术中情况、术后并发症发生情况。结果32例患者术中均经股动脉植入瓣膜,并应用经食管超声心动图(TEE)监测,其中2例于TEE引导下行房间隔穿刺逆行跨主动脉瓣,4例采用瓣中瓣手术。术前实时三维经食管超声心动图(RT-3D TEE)与MSCT测得的主动脉瓣环最大径、最小径、面积、周长,以及左、右冠状动脉开口高度比较,差异均无统计学意义。术后即刻TEE评估:少至中量瓣周漏4例,少量瓣周漏9例,微量瓣周漏5例,无瓣周漏14例。经胸超声心动图结果显示,与术前比较,Ⅰ组术后1个月主动脉瓣峰值流速(AV Vmax)、主动脉瓣平均跨瓣压差(AVPGmean)、室间隔厚度(IVST)、左室后壁厚度(PWT)均减小,左室射血分数(LVEF)增大,差异均有统计学意义(均P<0.05);Ⅱ组术后1个月主动脉瓣反流面积(AR area)、主动脉瓣缩流径(AR width)及左室舒张末期内径(LVEDD)均减小,差异均有统计学意义(均P<0.05);Ⅲ组术后1个月AV Vmax、AVPGmean、AR area、AR width、IVST、PWT、LVEDD均减小,LVEF增大,差异均有统计学意义(均P<0.05)。术后随访死亡1例,行永久起搏器植入4例。结论超声心动图在不同类型的主动脉瓣膜病变患者TAVR的术前评估、术中监测及术后随访中均具有重要作用,可为TAVR的疗效评估及预后判断提供依据。     

经心尖途径经导管主动脉瓣置换术救治单纯性主动脉瓣重度反流1例

目的 探讨经心尖途径经导管主动脉瓣置换术治疗单纯性主动脉瓣关闭不全的可行性.方法 回顾性分析2016年9月8日浙江大学医学院附属第二医院心脏中心开展的浙江省首例经心尖途径经导管主动脉瓣置换术的术前评估、术中操作以及患者术后情况.结果 患者严格进行术前评估,术中行全身麻醉、气管插管,透视下定位后第五肋间小切口进胸,打开心包,选择心尖裸区预置荷包,穿刺后导入超滑泥鳅导丝跨过主动脉瓣到达降主动脉,导入J-Valve输送系统逐步释放,经食道超声心动图评估主动脉瓣反流从术前的大量到瓣膜释放后无反流,撤出瓣膜输送系统,手术成功结束.术后患者症状明显缓解,出现Ⅰ度房室传导阻滞,未发生死亡、心肌梗死、心包填塞、动脉夹层等并发症.结论 经心尖途径经导管主动脉瓣置换术是安全可行的,患者的远期预后还有待进一步观察.     

Fungal endocarditis after transcatheter aortic valve replacement (TAVR): Case report and review of literature

The reported number of transcatheter aortic valve replacement-associated infective endocarditis (TAVR-IE) cases has been increasing worldwide, but information about the incidence and clinical features of fungal TAVR-IE is quite limited. We present a patient who acquired TAVR-IE caused by Candida parapsilosis four month after TAVR, who was successfully treated redo-aortic valve replacement and prolonged antifungal therapy.     

Changes in cerebral oxygen saturation during transcatheter aortic valve replacement

Cerebral oxygen saturation (rSO₂) is a non-invasive monitor used to monitor cerebral oxygen balance and perfusion. Decreases in rSO₂ >20 % from baseline have been associated with cerebral ischemia and increased perioperative morbidity. During transcatheter aortic valve replacement (TAVR), hemodynamic manipulation with ventricular pacing up to 180 beats per minute is necessary for valve deployment. The magnitude and duration of rSO₂ change during this manipulation is unclear. In this small case series, changes in rSO₂ in patients undergoing TAVR are investigated. Ten ASA IV patients undergoing TAVR with general anesthesia at a university hospital were prospectively observed. Cerebral oximetry values were analyzed at four points: pre-procedure (baseline), after tracheal intubation, during valve deployment, and at procedure end. Baseline rSO₂ values were 54.5 ± 6.9 %. After induction of general anesthesia, rSO₂ increased to a mean of 66.0 ± 6.7 %. During valve deployment, the mean rSO₂ decreased <20 % below baseline to 48.5 ± 13.4 %. In two patients, rSO₂ decreased >20 % of baseline. Cerebral oxygenation returned to post-induction values in all patients 13 ± 10 min after valve deployment. At procedure end, the mean rSO₂ was 67.6 ± 8.1 %. As expected, rapid ventricular pacing resulting in the desired decrease in cardiac output during valve deployment was associated with a significant decrease in rSO₂ compared to post-induction values. However, despite increased post-induction values in all patients, whether related to increased inspired oxygen fraction or reduced cerebral oxygen consumption under anesthesia, two patients experienced a significant decrease in rSO₂ compared to baseline. Recovery to baseline was not immediate, and took up to 20 min in three patients. Furthermore, baseline rSO₂ in this population was at the lower limit of the published normal range. Significant cerebral desaturation during valve deployment may potentially be limited by maximizing rSO₂ after anesthetic induction. Future studies should attempt to correlate recovery in rSO₂ with recovery of hemodynamics and cardiac function, provide detailed neurological assessments pre and post procedure, determine the most effective method of maximizing rSO₂ prior to hemodynamic manipulation, and provide the most rapid method of recovery of rSO₂ following valve deployment.