New-onset rhythm and conduction disorders after transcatheter aortic valve replacement

Tableau d'honneur de la Faculté des études supérieures et postdoctorales, 2016-2017La sténose aortique est la cardiopathie valvulaire la plus fréquente retrouvée chez les patients agés. Suite à l’apparition des symptômes, la survie des patients diminue de façon drastique en l’absence d’un remplacement valvulaire aortique. Cependant, une proportion considérable de ces patients n’est pas opérée en raison d'un risque chirurgical élevé, l'âge étant l'une des principales raisons de refus d’un remplacement valvulaire aortique chirurgical. Ce défaut dans la prise en charge des ces patients a favorisé le développement du remplacement valvulaire aortique par cathéter où implantation valvulaire aortique par cathèter (TAVR ou TAVI), qui a représenté une révolution dans le traitement de la sténose aortique. Cette intervention est actuellement un traitement de routine chez les patients à haut risque chirurgical atteints d’une sténose aortique, même si la chirurgie cardiaque n’est pas contre-indiquée. Ces dernières années ont vu un changement de profil des candidats potentiels vers une population à plus faible risque. Cependant, plusieurs préoccupations demeurent. L’une des plus importantes est la survenue des arythmies et de troubles de conduction, notamment le bloc de branche gauche et le bloc auriculo-ventriculaire, qui sont des complications fréquemment associées au TAVR. Malgré l’évolution de la technologie et le développement de nouveaux dispositifs réduisant le taux global de complications, aucune amélioration n’a pas été intégrée pour prévenir l’apparition de telles complications. De plus, l'utilisation de certains dispositifs de nouvelle génération semble être associée à un risque accru de troubles de conduction, et par conséquent, l'incidence de ces complications pourrait augmenter dans le futur. Cependant, L'impact et l'évolution de ces complications sont inconnus. Ce travail de recherche évalue l'incidence et l'évolution des troubles de conduction suite au TAVR et l'impact des blocs de branche gauche de novo et de l'implantation d'un pacemaker sur les résultats cliniques et échocardiographiques.The aortic stenosis is one of the most frequent valvular heart diseases, which is mostly diagnosed in older patients. With the symptoms onset, the lifespan of such patients dramatically decrease unless an aortic valve replacement is performed. However, a considerable proportion of such patients do not undergo cardiac surgery owing to a perceived high risk, being the advanced age one of main reasons to deny surgical aortic valve replacement. Such deficiency in the care of these patients has favoured the development of transcatheter aortic valve replacement or implantation (TAVR or TAVI), which has revolutionized the treatment of aortic stenosis. This treatment is now a routine therapy in high-risk patients with aortic stenosis, even if cardiac surgery is not contraindicated. Indeed, the last years have witnessed a shift in the use of this technology to lower risk populations. TAVR technology has experienced a dramatic evolution to integrate enhanced iterations which have allowed, along with the improvement of the technology, a reduction in the risk of complications associated with this therapy. However, several concerns remain. One of them is the occurrence of arrhythmias and conductions disturbances, in particular left bundle branch block and atrioventricular block, which are frequent complications of TAVR. Despite the evolution of the technology and development of new devices leading to a reduction in the overall rate of complications, no new iterations have been integrated to prevent the occurrence of such complications. Moreover, the use of new-generation devices seems to be associated with an increased risk of such complications, and therefore, its incidence is expected to increase in the next future. Nonetheless, little is known about the impact and evolution of these disorders. This thesis evaluates the incidence and evolution of new-onset arrhythmias and conduction abnormalities after TAVR and the impact of new-onset left bundle branch block and permanent pacemaker implantation on late clinical and echocardiographic outcomes

Left atrial decompression through unidirectional left-to-right interatrial shunt for the treatment of left heart failure : first-inman experience with the V-Wave device

Aims: Elevated filling pressures of the left atrium (LA) are associated with poorer outcomes in patients with chronic heart failure. The V-Wave is a new percutaneously implanted device intended to decrease the LA pressure by the shunting of blood from the LA to the right atrium. This report describes the first-in-man experience with the V-Wave device. Methods and results: A 70-year-old man with a history of heart failure of ischaemic origin, left ventricular dysfunction (LVEF: 35%, pulmonary wedge: 19 mmHg), no right heart dysfunction, NYHA Class III and orthopnoea despite optimal treatment, was accepted for V-Wave device implantation. The device consists of an ePTFE encapsulated nitinol frame that is implanted at the level of the interatrial septum and contains a trileaflet pericardium tissue valve sutured inside which allows a unidirectional LA to right atrium shunt. The procedure was performed through a transfemoral venous approach under fluoroscopic and TEE guidance. The device was successfully implanted and the patient was discharged 24 hours after the procedure with no complications. At three-month follow-up a left-to-right shunt through the device was confirmed by TEE. The patient was in NYHA Class II, without orthopnoea, the Kansas City Cardiomyopathy index was 77.6 (from 39.1 at baseline) and NT-proBNP was 322 ng/mL (from 502 ng/mL at baseline). The QP/QS was 1.17 and the pulmonary wedge was 8 mmHg, with no changes in pulmonary pressure or right ventricular function. Conclusions: Left atrial decompression through a unidirectional left-to-right interatrial shunt represents a new concept for the treatment of patients with left ventricular failure. The present report shows the feasibility of applying this new therapy with the successful and uneventful implantation of the V-Wave device, which was associated with significant improvement in functional, quality of life and haemodynamic parameters at 90 days

Incidence, predictive factors and haemodynamic consequences of acute stent recoil following transcatheter aortic valve implantation with a balloon-expandable valve

Aims: The elastic behaviour (acute recoil) of a valve prosthesis stent following transcatheter aortic valve implantation (TAVI) is unknown. This study sought to determine the occurrence, severity, predictive factors and haemodynamic consequences of acute recoil following TAVI. Methods and results : A prospective angiographic analysis of the stent frame dimensions in 111 consecutive patients who underwent TAVI with a balloon-expandable valve (36 Edwards SAPIEN; 75 SAPIEN XT) was performed. Acute recoil was defined as the difference between minimal lumen diameter (MLD) at full balloon expansion and immediately after balloon deflation. MLD during balloon inflation was significantly larger than MLD after balloon deflation (23.40±2.31 mm vs. 22.29±2.21 mm, p<0.001), which represented an absolute and percent decrease in stent dimension of 1.10±0.40 mm and 4.70±1.76%, respectively. In the multivariate analysis, the predictors of larger recoil were a higher prosthesis/annulus ratio (r²=0.0624, p=0.015) and the SAPIEN XT prosthesis (r²=0.1276, p=0.001). No significant changes in haemodynamic performance were observed at discharge and follow-up in patients with larger recoil. Conclusions : TAVI with a balloon-expandable valve was systematically associated with a certain degree of valve stent recoil after balloon deflation. A higher degree of valve oversizing and the SAPIEN XT prosthesis predicted a larger degree of stent recoil

Myocardial injury following transcatheter aortic valve implantation : insights from delayed-enhancement cardiovascular magnetic resonance

Aims: The aim of this study was to evaluate the presence, localisation and extent of myocardial injury as determined by late gadolinium enhancement (LGE) on cardiovascular magnetic resonance (CMR) imaging in patients undergoing transcatheter aortic valve implantation (TAVI). Methods and results: A total of 37 patients, who underwent successful TAVI with a balloon-expandable valve (transapical [TA], n=11; non-TA, n=26), were included. Cardiac biomarker (CK-MB and cTnT) lev- els were determined at baseline and following TAVI. CMR was performed within a week before and within 30 days following TAVI. Some increase in cardiac biomarkers was detected in 97% of the patients as deter- mined by a rise in cTnT, and in 49% of the patients as determined by a rise in CK-MB. Following TAVI, no new myocardial necrosis defects were observed with the non-TA approach. Nonetheless, all patients who underwent TAVI through the TA approach had new focal myocardial necrosis in the apex, with a median myo-cardial extent and necrotic mass of 5% [2.0-7.0] and 3.5 g [2.3-4.5], respectively. Conclusions: Although some increase in cardiac biomarkers of myocardial injury was systematically detected following TAVI, new myocardial necrosis as evaluated by CMR was observed only in patients undergoing the procedure through the TA approach, involving ~5% of the myocardium in the apex

Incidence, predictive factors, and prognostic value of new-onset atrial fibrillation following transcatheter aortic valve implantation

Objectives: This study sought to evaluate the incidence, predictive factors, and prognostic value of new-onset atrial fibrillation (NOAF) following transcatheter aortic valve implantation (TAVI). Background: Very few data exist on the occurrence of NOAF following TAVI. Methods: A total of 138 consecutive patients with no prior history of atrial fibrillation (AF) underwent TAVI with a balloon-expandable valve. Patients were on continuous electrocardiogram monitoring until hospital discharge, and NOAF was defined as any episode of AF lasting >30 s. All clinical, echocardiographic, procedural, and follow-up data were prospectively collected. Results: NOAF occurred in 44 patients (31.9%) at a median time of 48 h (interquartile range: 0 to 72 h) following TAVI. The predictive factors of NOAF were left atrial (LA) size (odds ratio [OR]: 1.21 for each increase in 1 mm/m2, 95% confidence interval [CI]: 1.09 to 1.34, p < 0.0001) and transapical approach (OR: 4.08, 95% CI: 1.35 to 12.31, p = 0.019). At 30-day follow-up, NOAF was associated with a higher rate of stroke/systemic embolism (13.6% vs. 3.2%, p = 0.021, p = 0.047 after adjustment for baseline differences between groups), with no differences in mortality rate between groups (NOAF: 9.1%, no-NOAF: 6.4%, p = 0.57). At a median follow-up of 12 months (interquartile range: 5 to 20 months), a total of 27 patients (19.6%) had died, with no differences between the NOAF (15.9%) and no-NOAF (21.3%) groups, p = 0.58. The cumulative rate of stroke and stroke/systemic embolism at follow-up were 13.6% and 15.9%, respectively, in the NOAF group versus 3.2% in the no-NOAF group (p = 0.039, adjusted p = 0.037 for stroke; p = 0.020, adjusted p = 0.023 for stroke/systemic embolism). Conclusions: NOAF occurred in about one-third of the patients with no prior history of AF undergoing TAVI and its incidence was increased in patients with larger LA size and those undergoing transapical TAVI. NOAF was associated with a higher rate of stroke/systemic embolism, but not a higher mortality, at 30 days and at 1-year follow-up

Evaluation of length of stay after transfemoral transcatheter aortic valve implantation with SAPIEN 3 prosthesis A French multicentre prospective observational trial

International audienceBACKGROUND:Complications decrease after transfemoral transcatheter aortic valve implantation (TAVI), and early discharge is feasible and safe in selected populations. AIMS:To evaluate length of stay (LOS) and reasons for prolonged hospitalisation after transfemoral TAVI in unselected patients. METHODS:Patients with severe aortic stenosis, who had transfemoral TAVI with the SAPIEN 3 prosthesis using exclusively local anaesthesia, were prospectively and consecutively included at five French high-volume centres. LOS was calculated from TAVI procedure to discharge. Reasons for prolonged hospitalisation (i.e.>3 days) were evaluated. RESULTS:Between 2017 and 2018, 293 patients were included, with a mean age of 82.4±6.5 years and a mean logistic EuroSCORE of 13.7±9.0%. The in-hospital mortality rate was 1.4%. The median LOS was 5 (3-7) days, and varied considerably between centres (from 2 to 7 days). Sixty-four (21.8%) patients were discharged within 3 days after transfemoral TAVI. Reported reasons for prolonged hospitalisation were complications in 62.2%, loss of autonomy in 3.1%, discharge refusal in 2.2% and logistical reasons in 0.9%. In 31.6% of cases, the investigators reported no apparent reasons. CONCLUSIONS:The results of our study suggest that LOS after transfemoral TAVI, using the SAPIEN 3 prosthesis and a minimalist approach, varies considerably between centres. In almost a third of cases, hospitalisation was prolonged without any apparent reason. Efforts should be made to educate centres to reduce LOS

Long-term prognostic value and serial changes of plasma N-terminal prohormone B-type natriuretic peptide in patients undergoing transcatheter aortic valve implantation.

Little is known about the usefulness of evaluating cardiac neurohormones in patients undergoing transcatheter aortic valve implantation (TAVI). The objectives of this study were to evaluate the baseline values and serial changes of N-terminal prohormone B-type natriuretic peptide (NT-proBNP) after TAVI, its related factors, and prognostic value. A total of 333 consecutive patients were included, and baseline, procedural, and follow-up (median 20 months, interquartile range 9 to 36) data were prospectively collected. Systematic NT-proBNP measurements were performed at baseline, hospital discharge, 1, 6, and 12 months, and yearly thereafter. Baseline NT-proBNP values were elevated in 86% of the patients (median 1,692 pg/ml); lower left ventricular ejection fraction and stroke volume index, greater left ventricular mass, and renal dysfunction were associated with greater baseline values (p <0.01 for all). Higher NT-proBNP levels were independently associated with increased long-term overall and cardiovascular mortalities (p <0.001 for both), with a baseline cut-off level of w2,000 pg/ml best predicting worse outcomes (p <0.001). At 6- to 12-month follow-up, NT-proBNP levels had decreased (p <0.001) by 23% and remained stable up to 4-year follow-up. In 39% of the patients, however, there was a lack of NT-proBNP improvement, mainly related to preprocedural chronic atrial fibrillation, lower mean transaortic gradient, and moderate-to-severe mitral regurgitation (p <0.01 for all). In conclusion, most patients undergoing TAVI presented high NT-proBNP levels, and a lack of improvement was observed in >1/3 of the patients after TAVI. Also, higher NT-proBNP levels predicted greater overall and cardiac mortalities at a median follow-up of 2 years. These findings support the implementation of NT-proBNP measurements for the clinical decision-making process and follow-up of patients undergoing TAVI

Predictive factors, efficacy, and safety of balloon post-dilation after transcatheter aortic valve implantation with a balloon-expandable valve

OBJECTIVES: This study sought to evaluate the predictive factors, effects, and safety of balloon post-dilation (BPD) for the treatment of significant paravalvular aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI). BACKGROUND: Very few data exist on BPD after TAVI with a balloon-expandable valve. METHODS: A total of 211 patients who underwent TAVI with a balloon-expandable valve were included. BPD was performed after TAVI if paravalvular AR [Greater-than or equal to] 2 was identified by transesophageal echocardiography. Clinical events and echocardiographic data were prospectively recorded, and median follow-up was 12 (6 to 24) months. RESULTS: BPD was performed in 59 patients (28%), leading to a reduction in at least 1 degree of AR in 71% of patients, with residual AR 2,200 and >3,800 mm(3) best determining the need for and a poor response to BPD, respectively. Patients who underwent BPD had a higher incidence of cerebrovascular events at 30 days (11.9% vs. 2.0%, p = 0.006), with most (83%) events within the 24 h after the procedure occurring in patients who had BPD. No significant changes in valve area or AR degree were observed at follow-up in BPD and no-BPD groups. CONCLUSIONS: BPD was needed in about one-fourth of the patients undergoing TAVI with a balloon-expandable valve and was successful in about one-half of them. A higher degree of valve calcification and transfemoral approach predicted the need for BPD. BPD was not associated with any deleterious effect on valve function at mid-term follow-up, but a higher rate of cerebrovascular events was observed in patients who had BPD

Evolution and prognostic impact of low flow after transcatheter aortic valve replacement

Objective : Low flow (LF), defined as stroke volume index (SVi) <35 mL/m2, prior to the procedure has been recently identified as a powerful independent predictor of early and late mortality in patients undergoing transcatheter aortic valve replacement (TAVR). The objectives of this study were to determine the evolution of SVi following TAVR and to assess the determinants and impact on mortality of early postprocedural SVi (EP-SVi). Methods : We retrospectively analysed the clinical, Doppler echocardiographic and outcome data prospectively collected in 255 patients who underwent TAVR. Echocardiograms were performed before (baseline), within 5 days after procedure (early post procedure) and 6 months to 1 year following TAVR (late post procedure). Results : Patients with EP-SVi <35 mL/m2 (n=138; 54%) had increased mortality (HR 1.97, p=0.003) compared with those with EP-SVi =35 mL/m2 (n=117; 46%). Furthermore, patients with baseline SVi (B-SVi) <35 mL/m2 and EP-SVI =35 mL/m2, that is, normalised flow, had better survival (HR 0.46, p=0.03) than those with both B-SVi and EP-SVi <35 mL/m2, that is, persistent LF, and similar survival compared with those with both B-SVi and EP-SVi =35 mL/m2, that is, maintained normal flow. In a multivariable model analysis, EP-SVi was independently associated with increased risk of mortality (HR 1.41 per 10 mL/m2 decrease, p=0.03). The preprocedural/ intraprocedural factors associated with lower EP-SVi were lower B-SVi (standardised ß [ß] 0.36, p<0.001) atrial fibrillation (ß -0.13, p=0.02) and transapical approach (ß -0.22, p<0.001). Conclusions : The measurement of EP-SVi is useful to assess the immediate haemodynamic benefit of TAVR and to predict the risk of late mortality