Outcomes in patients with electrocardiographic left ventricular dyssynchrony following transcatheter aortic valve replacement

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Clinical value of regression of electrocardiographic left ventricular hypertrophy after aortic valve replacement

Electrocardiographic left ventricular hypertrophy (ECG-LVH) gradually regressed after aortic valve replacement (AVR) in patients with severe aortic stenosis. Sokolow–Lyon voltage (SV₁ + RV_5/6) is possibly the most widely used criterion for ECG-LVH. The aim of this study was to determine whether decrease in Sokolow–Lyon voltage reflects left ventricular reverse remodeling detected by echocardiography after AVR. Of 129 consecutive patients who underwent AVR for severe aortic stenosis, 38 patients with preoperative ECG-LVH, defined by SV₁ + RV_5/6 of ≥3.5 mV, were enrolled in this study. Electrocardiography and echocardiography were performed preoperatively and 1 year postoperatively. The patients were divided into ECG-LVH regression group (n = 19) and non-regression group (n = 19) according to the median value of the absolute regression in SV₁ + RV_5/6. Multivariate logistic regression analysis was performed to assess determinants of ECG-LVH regression among echocardiographic indices. ECG-LVH regression group showed significantly greater decrease in left ventricular mass index and left ventricular dimensions than Non-regression group. ECG-LVH regression was independently determined by decrease in the left ventricular mass index [odds ratio (OR) 1.28, 95 % confidence interval (CI) 1.03–1.69, p = 0.048], left ventricular end-diastolic dimension (OR 1.18, 95 % CI 1.03–1.41, p = 0.014), and left ventricular end-systolic dimension (OR 1.24, 95 % CI 1.06–1.52, p = 0.0047). ECG-LVH regression could be a marker of the effect of AVR on both reducing the left ventricular mass index and left ventricular dimensions. The effect of AVR on reverse remodeling can be estimated, at least in part, by regression of ECG-LVH.     

Prognostic impact of permanent pacemaker implantation after transcatheter aortic valve replacement

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Development of left ventricular function following aortic valve replacement

Changes in left ventricular function were evaluated in twelve patients with aortic valve stenosis and in eleven patients with aortic valve regurgitation in order to find out whether the results obtained soon after aortic valve replacement persisted over a long period. All patients had been provided with a St-Jude Medical valve. Evaluation included electrocardiography, radiography of the chest, phonocarotidography and echocardiography and was performed preoperatively, then three months and five years on average in each patient after surgery. In patients with aortic valve stenosis, the left ventricular mass clearly regressed during the first three months (p less than 0.01) and continued to regress, albeit not significantly, over five years. In patients with aortic valve regurgitation, the left ventricular volume and mass regressed significantly during the first three months and remained normal for five years. No significant variation in systolic performance was observed in both groups. In spite of good overall results, 26 p. 100 of the patients had an unfavourable long-term outcome as they developed major left ventricular dilatation. Nos prosthesis dysfunction was observed, and the St Jude Medical valve caused little obstruction. Thus, with this little obstructive prosthesis the postoperative improvement obtained persisted for five years in most cases of aortic valve stenosis or regurgitation.     

Time course of regression of left ventricular hypertrophy after aortic valve replacement

To assess the time course and extent of regression of myocardial hypertrophy after removal of the inciting hemodynamic stress, 21 patients with either aortic stenosis or aortic insufficiency were studied preoperatively, after an intermediate period (1.6 +/- 0.5 years), and late (8.1 +/- 2.9 years) after aortic valve replacement, and results were compared with those in 11 control patients. After aortic valve replacement there was significant hemodynamic improvement, with a fall in the left ventricular end-diastolic volume index (164 +/- 73 to 105 +/- 35 ml/m2, p less than .01), a fall in left heart filling pressure (19 +/- 9 to 12 +/- 5 mm Hg, p less than .01), and maintenance of the cardiac index (3.3 +/- 0.8 to 3.5 +/- 0.8 liters/min/m2, NS) and left ventricular ejection fraction (60 +/- 13% to 64 +/- 10%, NS). By the late study the cardiac index (4.0 +/- 0.6 liters/min/m2, p less than .01) and left ventricular ejection fraction (66 +/- 15%, p less than .05) had further increased and were significantly greater than before surgery. For the group as a whole, the left ventricular muscle mass index fell 31% after surgery by the time of the intermediate postoperative study (174 +/- 38 vs 120 +/- 29 g/m2, p less than .01), and a further 13% from the intermediate to the late study (105 +/- 32 g/m2, p less than .05). At the preoperative study left ventricular muscle mass index was greatest in those patients with aortic insufficiency (191 +/- 36 g/m2), and greater in those with aortic stenosis (158 +/- 33 g/m2) than in control subjects (85 +/- 9 g/m2, p less than .05). At the intermediate postoperative study left ventricular muscle mass index remained significantly higher in both those with preoperative aortic insufficiency (128 +/- 29 g/m2) and those with stenosis (114 +/- 27 g/m2) than in the control subjects (p less than .01). By the time of the late postoperative study there were no longer any significant differences in left ventricular muscle mass index. Thus, the regression of myocardial hypertrophy is a process that occurs over many years after correction of the primary hemodynamic abnormality. As this process of myocardial remodeling occurs, continued improvement in cardiac function may occur, and the improvement occurring between the intermediate and late postoperative studies at a slight but constant afterload excess (inherent in the relative stenosis of the aortic prosthesis) suggests that the hypertrophied myocardium is operating at a reduced level compared with normal myocardium.     

Prognostic indices of the normalization of left ventricular function in chronic aortic insufficiency following valve replacement

The aim of this study of 31 patients was to identify M mode echocardiographic parameters predictive of normalisation of left ventricular function after valvular replacement for chronic aortic incompetence in order to determine the optimal time for surgery. Only patients with chronic, pure aortic incompetence (ventriculo-aortic pressure gradient less than or equal to 30 mmHG) were considered. At the time of investigation 4 patients were in functional Class I, 6 in Class II, 10 in Class III and 11 in Class IV (NYHA). M mode echocardiography was performed on an Echovideorex or an Irex System II echocardiograph. The following measurements were made and corrected for body surface area according to the recommendations of the American Society of Echocardiography; end systolic and end diastolic dimensions (mm), fractional shortening (%), end systolic and end diastolic wall thickness (mm), diastolic radius to wall thickness ratio, short axis myocardial surface area (cme), wall stress, end systolic stress (mmHg). The study comprised pre and postoperative studies with an interval of 22.7 +/- 12.5 months (range 5 to 46 months); the data obtained was compared with a control group of 10 normal subjects. The results showed that preoperative fractional shortening less than 28% was associated with an increased risk of persistent postoperative left ventricular dysfunction.     

Assessing the impact of transcatheter aortic valve replacement on myocardial work indices and left ventricular diastolic function in aortic valve stenosis patients

Background

Aortic valve stenosis (AS) is the most common valvular heart disease worldwide. When timely intervention is performed, aortic valve replacement can improve patients' quality and duration of life. Load-independent left ventricular (LV) functional assessments, such as myocardial work indices (MWIs) and LV diastolic function parameters, could help clinicians decide on the optimal timing of intervention.

Aims

To evaluate the reliability of MWI in AS patients and the changes in MWI and LV diastolic function after transcatheter aortic valve replacement (TAVR).

Methods

We enrolled 53 consecutive patients with severe AS undergoing TAVR admitted between March 2021 and November 2021. MWIs and LV diastolic function were assessed before and after TAVR for each patient.

Results

All MWIs and LV diastolic function indices improved after TAVR. The degree of MWIs improvement was higher in patients with lower prior-TAVR MWI values, while the more severe the impairment of diastolic function, the greater the post-TAVR benefit.

Conclusion

The introduction of myocardial work parameters into the routine assessment of patients with AS could improve our understanding of cardiac performance and aid in identifying the optimal timing for surgical or percutaneous treatment.     

Subclinical leaflet thrombosis following transcatheter aortic valve replacement

Since the inception of transcatheter aortic valve replacement (TAVR), there have been significant reductions in complications due to improvements of transcatheter heart valve (THV) designs and technologies. Given expanding TAVR applications, reducing complications further and better understanding THV durability has become a focus within the structural heart space. Recently, dedicated cardiac computed tomographic angiography (CTA) performed at 1 month post‐TAVR has identified subclinical leaflet thrombosis (SLT), with rates as high as 40%. From the SLT imaging hallmarks of hypoattenuated leaflet thickening (HALT) to hypoattenuation affecting motion (HAM), a postulated timeline of THV thrombosis advancing to clinical symptoms can be recognized. This review article focuses on leaflet thrombosis particularly following TAVR explaining the spectrum of this disease process, its diagnosis, current treatment options, and future directions in the field.

     

Leaflet length and left main coronary artery occlusion following transcatheter aortic valve replacement

Coronary artery occlusion during transcatheter aortic valve replacement is a rare complication. However, it is a very severe and life‐threatening event. Although there are some possible causes of this phenomenon, definite etiologies and predictors are unknown because of the small number. We describe one case of left main coronary artery occlusion immediately after deployment of a prosthetic valve. The patient became hypotensive and developed cardiopulmonary arrest. However, the coronary artery was successfully stented with a help of cardiopulmonary bypass and he recovered well. In this case, pre‐procedural computed tomography (CT) showed the adequately high coronary height and no other significant conventional predictor for coronary occlusion. The examinations were retrospectively reviewed and the CT showed a long leaflet compared to the coronary sinus complex. The fluoroscopy appeared to show the long leaflet covering the left main coronary artery ostium immediately after the valve deployment. The height of the coronary artery ostium from the aortic annulus appeared sufficiently high in this case and did not explain the coronary compromise; leaflet length in relation to the coronary sinus dimension seemed more relevant. The ratio between leaflet length and curved coronary sinus height (L/C) may be one novel predictor for coronary artery occlusion. © 2013 Wiley Periodicals, Inc.     

Emergent use of retrograde left ventricular support in patients after transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) is currently a therapeutic alternative to open aortic valve replacement for high‐risk patients with severe symptomatic aortic valve stenosis. The procedure is associated with some life‐threatening complications including circulatory collapse which may require temporary hemodynamic support. We describe our experience with the use of the Impella 2.5 system to provide emergent left ventricular support in cases of hemodynamic collapse after TAVR with the Edwards SAPIEN prosthesis.© 2012 Wiley Periodicals, Inc.     

Multimodality imaging of left ventricular apical pseudoaneurysm after apical approach transcatheter aortic valve replacement

Left ventricular pseudoaneurysm formation is a rare complication of transapical approach transcatheter aortic valve replacement. It can cause chest pain and shortness of breath or remain asymptomatic. Mortality rate is high, and therefore, timely diagnosis and management are essential. Different imaging modalities can provide anatomic or functional information and are essential for the primary diagnosis or during follow-up.     

The problem of delirium following transcatheter aortic valve replacement

• Delirium is a common condition among elderly patients, particularly those hospitalized following surgical procedures.
• A study indicates that delirium occurs in 1 out of 5 patients following TAVR and it was found to be associated with diminished survival, prolonged hospitalization, and increased healthcare utilization.
• Delirium is potentially preventable and treatable clinical syndrome.

     

Rare complication of ventricular septal defect in three patients following transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) is a highly‐effective but technically challenging procedure. Despite improvement in device technology and operator techniques, complications are common and previously unknown procedural‐related complications continue to arise. In this report, we present a case series of three patients with acquired perimembranous ventricular septal defects following transfemoral TAVR with an Edwards SAPIEN prosthesis. © 2013 Wiley Periodicals, Inc.