Two birds with one stone: transcatheter valve-in-valve treatment of a failed surgical bioprosthesis with concomitant severe stenosis and paravalvular leak

Implantation of bioprosthetic surgical valves has been a common procedure in elderly patients with severe aortic stenosis due to patients´ preferences avoiding anticoagulation therapy. However, this valve presents sometime certain deterioration degree (i.e., dysfunction due to stenosis or regurgitation) or even paravalvular leak. Transcatheter heart valve implantation is a good alternative in high-risk patients. The valve-in-valve procedure has been shown to be a safe and effective procedure. However, the presence of the fixed sewing ring of the surgical bioprosthesis can hamper appropriate expansion of the THV. For this reason, the use of cracking balloon seems to be a safe alternative to increase the effective orifice area. We present a case of a patient with a degenerated previous implanted biological valve and paravalvular leak. We used the treatment strategy of valve-in-valve with post-dilatation with high-pressure balloon, in a way to treat both, the degenerated valve and the paravalvular leak. The use of a single percutaneous procedure was enough and safe to treat both problems without further complications

Comparison of latest generation supra-annular and intra-annular self-expanding transcatheter heart valves

Background This study compares two latest-generation self-expanding transcatheter heart valves (THV), the supra-annular ACURATE neo (Boston Scientific) and the intra-annular Centera THV (Edwards Lifesciences). Methods In this single center observational cohort trial 317 patients treated with the ACURATE neo and 78 patients treated with the Centera TVH were included. The main endpoints were device success and the early safety endpoint at 30 days. Results Besides higher incidence of diabetes mellitus and higher body mass index in patients treated with the ACURATE neo THV, there were no baseline differences between the groups. Device success was similar in both groups (neo: 91.8% vs. Centera: 93.6%; P=0.598), with numerically higher rates of moderate to severe paravalvular leakage in the ACURATE neo group (4.7% vs. 1.3%; P=0.214). At 30 days all-cause mortality rates were low in both groups (0.3% vs. 0%; P=0.620) and no difference occurred in the early safety at 30 days (19.3% vs. 16.7%; P=0.599). However, all-cause stroke rates were significantly higher in patients treated with the Centera THV (6.4 vs. 1.6%; P=0.015). Conclusions The ACURATE neo and the Centera THV show low mortality rates as well as comparable, favorable hemodynamics. The finding of higher stroke rates at 30 days with the repositionable Centera SE-THV needs further assessment

Mitral annular disjunction in patients with severe aortic stenosis: Extent and reproducibility of measurements with computed tomography

Objectives To determine with CT the prevalence and extent of mitral annular disjunction (MAD) in patients undergoing transcatheter aortic valve replacement (TAVR) and its association with mitral valve disease and arrhythmia. Methods We retrospectively evaluated 408 patients (median age, 82 years; 186 females) with severe aortic stenosis undergoing ECG-gated cardiac CT with end-systolic data acquisition. Baseline and follow-up data were collected in the context of a national registry. Two blinded, independent observers evaluated the presence of MAD on multi-planar reformations. Maximum MAD distance (left atrial wall-mitral leaflet junction to left ventricular myocardium) and circumferential extent of MAD were assessed on CT using dedicated post-processing software. Associated mitral valve disease was determined with echocardiography. Results 7.8 % (32/408) of patients with severe aortic stenosis had MAD. The maximum MAD was 3.5 mm (interquartile range: 3.0-4.0 mm). The circumferential extent of MAD comprised 34 ± 15 % of the posterior and 26 ± 12 % of the entire mitral annulus. Intra- and interobserver agreement for the detection of MAD on CT were excellent (kappa: 0.90 ± 0.02 and 0.92 ± 0.02). Mitral regurgitation (p = 1.00) and severe mitral annular calcification (p = 0.29) were similarly prevalent in MAD and non-MAD patients. Significantly more patients with MAD (6/32; 19 %) had mitral valve prolapse compared to those without (6/376; 2 %; p  0.05). Conclusions Using CT, MAD was found in 7.8 % of patients with severe aortic stenosis, with a higher prevalence in patients with mitral valve prolapse. We found no association of MAD with arrhythmia before or after TAVR

Influence of marital status in patients undergoing transcatheter aortic valve implantation

Background Marital status has been described to affect outcome in cardiovascular diseases, however its impact on patients undergoing transcatheter aortic valve implantation (TAVI) is unknown. We therefore aimed to assess the impact of marital status in patients undergoing TAVI. Methods Between 2011 and 2015, 779 patients undergoing transfemoral TAVI with known marital status were included in the analysis. The primary endpoint of the study was the composite of cardiac death and readmission for congestive heart failure (CHF) at one year. Results Mean age was 80.7±5.9 years, 47.8% were female and median logistic EuroScore was 12.7% (8.13-19.39%). Forty-three point three percent of patients were not married. Compared to married patients, unmarried patients were older (82.4±5.5 vs. 79.5±5.8 years; P<0.001), more often female (73.3% vs. 28.3%; P<0.001), presented with a higher logistic EuroScore [13.1% (9.5-21.5%) vs. 11.7% (7.0-18.5%); P<0.001], and more symptomatic with New York Heart Association functional class III/IV (69.7% vs. 60.6%; P=0.009). At one year the incidence of the primary endpoint was higher in unmarried patients (18.7% vs. 12.0%; P=0.011) which was mainly driven by more admissions for CHF (14.1% vs. 7.8%; P=0.007). After multivariable adjustment, marital status was borderline significant regarding CHF (HR 0.61, 95% CI: 0.37-1.02; P=0.06) but not the primary endpoint. Conclusions Unmarried patients undergoing TAVI showed a higher incidence of cardiac death or CHF at one year. Hence, marital status should be taken into account in patients with aortic stenosis subjected to TAVI. Whether closer monitoring and intensified medical follow-up improves outcomes remains to be investigated in future studies

Transcatheter Aortic Valve Replacement With Balloon-Expandable Valves: Comparison of SAPIEN 3 Ultra Versus SAPIEN 3

OBJECTIVES The aim of this study was to compare outcomes after transcatheter aortic valve replacement (TAVR) with the SAPIEN 3 Ultra (Ultra) and SAPIEN 3 (S3) transcatheter heart valves (THVs). BACKGROUND The latest generation balloon-expandable Ultra THV incorporates new technical features and might improve outcomes following TAVR. METHODS This registry included all consecutive patients who underwent TAVR with either the Ultra or S3 between January 2014 and January 2020. One-to-one propensity score matching was performed to account for differences in baseline characteristics. In-hospital and 30-day Valve Academic Research Consortium-2-defined outcomes were investigated. RESULTS A total of 310 patients (n = 155 Ultra, n = 155 S3) were included. There were no significant differences in baseline characteristics after propensity score matching. Procedures were significantly more often performed under conscious sedation with Ultra compared with S3 (97.4% vs. 71.6%; p < 0.001). Pre-dilatation was more frequent with S3 compared with Ultra (85.2% vs. 42.6%; p < 0.001). In-hospital outcomes, including device success (91.6% vs. 95.5%; p = 0.165), major vascular complications (12.3% vs. 11.0%; p = 0.723), and new pacemaker implantation (5.8% vs. 4.5%; p = 0.608), were comparable between S3 and Ultra patients, respectively. Post-procedural mean transprosthetic gradients (13.2 ± 5.7 mm Hg vs. 13.1 ± 4.7 mm Hg; p = 0.829) and rate of moderate or greater paravalvular leakage (PVL) (1.3% vs. 2.7%; p = 0.414) were comparable, whereas mild PVL was more frequent with S3 compared with Ultra (43.0% vs. 18.7%; p < 0.001). CONCLUSIONS Device success rates were high with both balloon-expandable THVs, with overall low rates of adverse events up to 30 days after TAVR. Despite a lower frequency of pre-dilatation, significant reduction of mild PVL confirms improved annular sealing properties of the novel Ultra THV