Transcatheter aortic valve replacement (TAVR) is a relatively new procedure for high-risk patients with severe aortic stenosis. We report a case of a new left ventricular outflow tract ventricular tachycardia following TAVR.
Background: Transcatheter closure of atrial septal defects (ASD) is performed with intracardiac or transesophageal echocardiography (TEE) guidance. ASDs often have an elliptical shape and 2D imaging may underestimate the maximum diameter. Three-dimensional (3D) TEE using reconstructed gated acquisitions in multiple planes is a time-consuming process limited by motion artifact, making it impractical for intra-procedural use. Recently, a matrix array TEE capable of real-time 3D (RT3D) imaging has been developed (Philips Medical Systems). Methods: Two-dimensional, Doppler and RT3D TEE images were acquired in 5 patients undergoing ASD closure. Device selection was based on the maximum diameter of the ASD measured by 2D imaging. RT3D images were analyzed using commercially available software (QLab, Philips). The maximum diameter was measured and compared to 2D. Results: The mean maximum diameter was 1.6 ± 0.8 cm using 2D imaging and 2.0 ± 1.1 cm using RT3D images (p=0.16). In the 3 patients with ASDs >2 cm, the maximum diameter was 2.2 ± 0.1 cm by 2D imaging compared to 2.8 ± 0.3 cm by RT3D imaging (p=0.02), an underestimate of 20.7 ± 12.2 %. In the remaining 2 patients with ASDs <1.2 cm, there was good agreement between 2D and 3D measurements. In the 2 patients with the largest discrepancy between 2D and 3D measurements, the initial device selected was retrieved prior to catheter release, due to significant residual shunting or instability along the septum, requiring placement of a larger device. Conclusion: RT3D TEE during transcatheter ASD closure is feasible and may improve defect sizing and device selection during transcatheter ASD closure.
Background Many patients with severe aortic stenosis (AS) and an indication for aortic valve replacement (AVR) do not undergo treatment. The reasons for this have not been well studied in the transcatheter AVR era. We sought to determine how patient- and process-specific factors affected AVR use in patients with severe AS. Methods and Results We identified ambulatory patients from 2016 to 2018 demonstrating severe AS, defined by aortic valve area [Formula: see text]1.0 cm2. Propensity scoring analysis with inverse probability of treatment weighting was used to evaluate associations between predictors and the odds of undergoing AVR at 365 days and subsequent mortality at 730 days. Of 324 patients with an indication for AVR (79.3±9.7 years, 57.4% men), 140 patients (43.2%) did not undergo AVR. The odds of AVR were reduced in patients aged >90 years (odds ratio [OR], 0.24 [95% CI, 0.08-0.69]; P=0.01), greater comorbid conditions (OR, 0.88 per 1-point increase in Combined Comorbidity Index [95% CI, 0.79-0.97]; P=0.01), low-flow, low-gradient AS with preserved left ventricular ejection fraction (OR, 0.11 [95% CI, 0.06-0.21]), and low-gradient AS with reduced left ventricular ejection fraction (OR, 0.18 [95% CI, 0.08-0.40]) and were increased if the transthoracic echocardiogram ordering provider was a cardiologist (OR, 2.46 [95% CI, 1.38-4.38]). Patients who underwent AVR gained an average of 85.8 days of life (95% CI, 40.9-130.6) at 730 days. Conclusions The proportion of ambulatory patients with severe AS and an indication for AVR who do not receive AVR remains significant. Efforts are needed to maximize the recognition of severe AS, especially low-gradient subtypes, and to encourage patient referral to multidisciplinary heart valve teams.
Background: Impaired left ventricular function is associated with worse prognosis among patients with aortic stenosis treated medically or with surgical aortic valve replacement. It is unclear whether reduced left ventricular ejection fraction (LVEF) is an independent predictor of adverse outcomes after transcatheter aortic valve replacement. Methods and Results: Patients who underwent transcatheter aortic valve replacement in the PARTNER 2 trials (Placement of Aortic Transcatheter Valves) and registries were stratified according to presence of reduced LVEF (<50%) at baseline, and 2-year risk of cardiovascular mortality was compared using Kaplan–Meier methods and multivariable Cox proportional hazards regression. Of 2991 patients, 839 (28%) had reduced LVEF. These patients were younger, more often males, and were more likely to have comorbidities, such as coronary disease, diabetes mellitus, and renal insufficiency. Compared with patients with normal LVEF, patients with low LVEF had higher crude rates of 2-year cardiovascular mortality (19.8% versus 12.0%, P <0.0001) and all-cause mortality (27.4% versus 19.2%, P <0.0001). Mean aortic valve gradient was not associated with clinical outcomes other than heart failure hospitalizations (hazard ratio [HR], 0.99; CI, 0.99–1.00; P =0.03). After multivariable adjustment, patients with reduced versus normal LVEF had significantly higher adjusted risk of cardiovascular death (adjusted HR, 1.42, 95% CI, 1.11–1.81; P =0.005), but not all-cause death (adjusted HR, 1.20; 95% CI, 0.99–1.47; P =0.07). When LVEF was treated as continuous variable, it was associated with increased 2-year risk of both cardiovascular mortality (adjusted HR per 10% decrease in LVEF, 1.16; 95% CI, 1.07–1.27; P =0.0006) and all-cause mortality (adjusted HR, 1.09; 95% CI, 1.01–1.16; P =0.02). Conclusions: In this patient-level pooled analysis of PARTNER 2 patients who underwent transcatheter aortic valve replacement, baseline LVEF was an independent predictor of 2-year cardiovascular mortality. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifiers: NCT01314313, NCT02184442, NCT03222128, and NCT02184441.
Purpose: Paravalvular regurgitation (PVR) after transcatheter aortic valve implantation (TAVI) is an important predictor of short- and long-term mortality. Aortic valve (AV) calcification, as assessed by multidetector computed tomography (MDCT), has been shown to predict the incidence of PVR after TAVI. We hypothesize that the agglomeration (large versus small nodules) of AV calcium specifically will influence the presence and degree of PVR. The aims of this study were to provide a thorough assessment of AV calcification, to explore its relation with PVR after TAVI, and to propose a new composite metric to express and quantify AV calcium burden and agglomeration. Methods: We included 133 patients who underwent contrast-enhanced MDCT prior to TAVI with Edwards SAPIEN valves. Clinical, echocardiographic, MDCT and procedural variables were studied. Total calcium burden of the AV was quantified as total calcium mass (AVCM). Each calcium nodule was characterized, with regards to its location (right, left or non-coronary cusp; and annulus versus leaflet) and its calcium mass. The AV calcium nodule score (AVCNS) was defined as: AVCM x mass of the largest calcium nodule. To assess PVR, follow-up echocardiography at one month was obtained. Logistic regression analysis was conducted to identify predictors of PVR. Results: Mean age was 84.1±7.6 years (56% females, 33% diabetics). Mean left ventricular ejection fraction (LVEF) was 56.7±17.3% (16% had LVEF <35%). TAVI access was transapical in 56% of patients. Procedural success was achieved in 92% of cases. In-hospital mortality was 5%. At one-month follow-up, the prevalence of absent/trace, mild, moderate and severe PVR was 58%, 31%, 11% and 0%, respectively. After adjusting for the potential predictors of PVR identified with unadjusted analyses (including AVCM), multivariable analysis showed that the only predictors of at least mild PVR were: AVCNS (OR 2.27, 95% CI: 1.43 to 3.59; p<0.001), aortic annulus area (OR 1.11, 95% CI 1.01 to 1.22; p=0.03) and the number of calcium nodules on aortic annulus (OR 1.82, 95% CI: 1.14 to 2.92; p=0.01). This model showed an AUC for PVR prediction of 0.84 (95% CI: 0.75 to 0.94). ROC analysis showed that a cut-off value of 337,740 for AVCNS (77th percentile) had sensitivity 61%, specificity 99%, positive predictive value 96% and negative predictive value 80%, for detecting at least mild PVR. Conclusions: AVCNS, a variable that comprises the total burden of AV calcification as well as calcification agglomeration in form of large nodules, is a novel and powerful independent predictor of PVR after TAVI.
