One-year results of transcatheter aortic valve implantation in severe symptomatic aortic valve stenosis

Transcatheter aortic valve implantation (TAVI) is an alternative therapy for symptomatic severe aortic valve stenosis in high-risk patients with several co-morbidities. We evaluated the 1-year effects of TAVI on quality of life, exercise capacity, neurohormonal activation, and myocardial hypertrophy. From June 2008 to October 2009, consecutive patients aged ≥75 years with symptomatic severe aortic valve stenosis (area <1 cm(2)) and a logistic euroSCORE ≥15% or aged >60 years with additional specified risk factors underwent TAVI. An aortic valve prosthesis (CoreValve) was inserted in a retrograde fashion. Examinations were performed before and 30 days and 1 year after TAVI. An assessment of the quality of life (Minnesota Living with Heart Failure Questionnaire), a 6-minute walking test, measurement of B-type natriuretic peptide, and echocardiography were performed. In 51 patients (mean age 78 ± 6.6 years, mean left ventricular ejection fraction 58.4 ± 12.2%), the follow-up examinations were performed after TAVI. The 1-year follow-up visit after TAVI revealed significantly improved quality of life (baseline Minnesota Living with Heart Failure Questionnaire score 39.6 ± 19 vs 26.1 ± 18, p <0.001) and more distance covered in the 6-minute walking test (baseline 185 ± 106 vs 266 ± 118 m, p <0.001). The B-type natriuretic peptide level had decreased (baseline 642 ± 634 vs 323 ± 266 pg/ml, p <0.001), and the left ventricular mass index had decreased (156 ± 45 vs 130 ± 42 g/m(2), p <0.001). The left ventricular diameter and ejection fraction remained unchanged. In conclusion, TAVI leads to significantly reduced neurohormonal activation, regression of myocardial hypertrophy, and lasting enhancement of quality of life and exercise capacity in patients with symptomatic and severe aortic stenosis 1 year after intervention.     

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.

Aortic valve annulus diameter in Chinese patients with severe calcific aortic valve stenosis: implications for transcatheter aortic valve implantation

Objectives : The objective of the study was to describe the distribution and determine the predictors of aortic valve annulus diameter (AVAD) in Chinese patients with severe calcific aortic valve stenosis (CAS). Background : AVAD in Chinese patients with CAS has not been reported. Predictors of AVAD in patients with CAS are unclear. Methods : One hundred elderly patients (≥60 years) with severe CAS were included in the study. AVAD in all patients was measured by transthoracic echocardiograph (AVAD‐TTE) and in 74 patients of them was measured intra‐operatively (AVAD‐intra). Results : The intraclass correlation coefficient (ICC) between AVAD‐TTE and AVAD‐intra was 0.81 (95% CI: 0.72–0.88). The differences between AVAD‐TTE and AVAD‐intra ranged from ?3 to 3 mm and were ≤≤ 2mm in 91.9% (68/74) of patients. The intra‐observer ICC for TTE was 0.87 (95% CI: 0.74–0.94). Mean AVAD in the whole population was 21.80 ± 2.09 (17–27) mm. 11% of cases had an AVAD < 20 mm, 78% had an AVAD between 20 and 24 mm, and 11% had an AVAD between 25 and 27 mm. The correlation between AVAD and height (r = 0.476, P < 0.001) was stronger than that between AVAD and weight (r = 0.215, P = 0.034) or body surface area (BSA) (r = 0.358, P < 0.001). Multivariate regression showed that height, sex, and age but not BSA were independent predictors of AVAD (all P < 0.05). Conclusion : Most of Chinese patients with CAS can be candidates for transcatheter aortic valve implantation procedure in terms of AVAD, whereas more sizes of prosthetic valves need to be developed. Sex, age, and especially height, but not BAS, are independent predictors of AVAD in patients with CAS. © 2011 Wiley Periodicals, Inc.     

First human transcatheter implantation of an aortic valve prosthesis in a case of severe calcific aortic stenosis

A percutaneous implantable prosthetic heart valve was developed, and after animal studies, the first human case was performed in a 57-year-old man with calcific aortic stenosis with cardiogenic shock. The implantation was performed with the use of an antegrade trans-septal approach after aortic valvuloplasty, and over a follow-up period of 4 months, the valvular function remained satisfactory. However, severe noncardiac complications occurred leading to death 17 weeks after implantation.     

Left ventricular morphological and functional adaptation in severe aortic stenosis after transcatheter aortic valve implantation

Background Transcatheter aortic valve implantation (TAVI) has been confirmed to improve the prognosis of high-risk patients with severe aortic stenosis (AS),sti...     

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.     

Impact of transcatheter aortic valve implantation on circulating von Willebrand factor in patients with severe aortic stenosis

Introduction

Severe aortic stenosis (AS) can lead to degradation of high molecular weight (HMW) von Willebrand factor (VWF) which can result in haemostatic abnormalities. While studies have explored changes in VWF profiles before and after surgical aortic valve replacement (SAVR), the longer-term changes in VWF profiles pre- and post-transcatheter aortic valve implantation (TAVI) are less understood.

Aim

Our primary objective was to identify differences in VWF multimer profiles and VWF function pre-TAVI and 1-month post-TAVI. Our secondary objective was to correlate VWF markers with measures of AS severity.

Methods

Adult patients with severe AS referred for TAVI at our institution were prospectively enrolled in this cohort study. Blood samples were collected for plasma analysis at three time points for all patients: 1 day pre-TAVI, 3 days post-TAVI, and 1-month post-TAVI. VWF antigen, activity, propeptide, collagen binding, multimers, and factor VIII coagulant activity were determined at each time point. Correlations between VWF parameters and severity of AS were assessed.

Results

Twenty participants (15 males, five females) with severe AS were recruited for the study. There was a significant increase in HMW VWF between pre-procedure and 1-month post-TAVI (p < .05). There was a transient increase in VWF antigen levels and activity at 3-days post TAVI that decreased to pre-TAVI levels at 1-month. There were no statistically significant correlations between VWF markers and AS severity.

Conclusions

This is the first study to elucidate longer-term (>1 week) improvements in HMW VWF after a TAVI procedure in severe AS patients.     

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。     

Exercise capacity in patients with severe symptomatic aortic stenosis before and six months after transcatheter aortic valve implantation

Few data exist on the use of the 6-minute walk test (6MWT) to measure the exercise capacity of patients with severe symptomatic aortic stenosis considered at very high surgical risk. The objectives of the present prospective study were (1) to determine the feasibility and safety of the 6MWT as a measure of exercise capacity before and after transcatheter aortic valve implantation (TAVI), and (2) to determine the clinical and hemodynamic parameters associated with the exercise capacity changes in such patients. A total of 64 patients (age 80 ± 8 years, logistic European System for Cardiac Operative Risk Evaluation score 21 ± 15%, Society of Thoracic Surgeons' score 7.5 ± 3.9%) who had undergone successful TAVI were included. The 6MWT was performed within the month before TAVI and at the 6-month follow-up visit. The mean distance walked increased from 165.3 ± 79.7 to 231.7 ± 88.9 m (p <0.0001); however, up to 25% of the patients did not improve or even decreased their exercise capacity. After adjustment for the baseline distance walked, multilinear regression analysis showed that a greater degree of renal dysfunction, as evaluated by the serum creatinine levels (r(2) = 0.05, p = 0.03), lower postprocedural hemoglobin values (r(2) = 0.13, p = 0.0012), and a longer hospitalization length (r(2) = 0.08, p = 0.007) were associated with lower improvement in exercise capacity. In conclusion, exercise capacity, as evaluated by the 6MWT, was very poor in patients with severe symptomatic aortic stenosis considered at very high surgical risk. TAVI was associated with a significant increase in exercise capacity, although no improvement was observed in 1/4 of the patients. A greater degree in renal dysfunction, lower postprocedural hemoglobin values, and longer hospitalization stay were predictors of lower improvement in exercise capacity after TAVI. These results suggest that the 6MWT might become an important tool as a part of the evaluation process for TAVI candidates.     

Outcomes of patients with severe aortic stenosis at high surgical risk evaluated in a trial of transcatheter aortic valve implantation

Recent randomized clinical trials have demonstrated that transcatheter aortic valve implantation (TAVI) reduces mortality in high-risk patients with aortic stenosis who are not candidates for aortic valve replacement (AVR). In similar patients who are acceptable candidates for AVR, TAVI provides equivalent outcomes to AVR. In this study, 900 patients with severe aortic stenosis at high surgical risk were evaluated as possible candidates for TAVI. Of these, 595 (66.1%) had neither TAVI nor AVR and constituted the medical arm. In addition to the best available conservative care, 345 patients (39.3%) in this group had balloon aortic valvuloplasty. The AVR arm consisted of 146 patients (16.2%) and the TAVI arm of 159 patients (17.6%). The AVR group had significantly lower clinical risk compared to the medical and TAVI groups, with lower mean age, Society of Thoracic Surgeons score, and logistic European System for Cardiac Operative Risk Evaluation score. Patients in the medical and balloon aortic valvuloplasty group had significantly higher B-type natriuretic peptide levels compared to those in the AVR and TAVI groups and had, on average, lower ejection fractions. The medical and balloon aortic valvuloplasty group was followed for a median of 206 days; the mortality rate was 46.6% (n = 277). The AVR group was followed for 628 days; 39 patients died (26.7%). In 399 days of follow-up, the mortality rate in the TAVI group was 30.8% (n = 49). In conclusion, patients with severe AS who did not undergo TAVI or AVR had high mortality. In properly selected patients, TAVI and AVR improve outcomes. Renal failure is the strongest correlate for adverse outcomes, irrespective of treatment group.