Conduction Abnormalities After Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) has been established as a therapeutic option for patients with severe symptomatic aortic stenosis who are of intermediate or higher surgical risk. Several periprocedural complications are reduced with newer transcatheter heart valve generations; however, conduction abnormalities and the need for permanent pacemaker implantation have remained unchanged and are the most frequent TAVR complications. The close relationship of the atrioventricular node and left bundle branch to the subaortic region explains these potential conduction abnormalities. This article highlights conduction abnormalities after TAVR with a focus on basic conduction system anatomy in relation to the aortic valve, the mechanism, incidence, predisposing factors for occurrence, impact on mortality and finally, proposed treatment algorithms for management

Impact of COVID-19 Pandemic on TAVR Activity: A Worldwide Registry

Background: The COVID-19 pandemic had a considerable impact on the provision of structural heart intervention worldwide. Our objectives were: 1) to assess the impact of the COVID-19 pandemic on transcatheter aortic valve replacement (TAVR) activity globally; and 2) to determine the differences in the impact according to geographic region and the demographic, development, and economic status of diverse international health care systems. Methods: We developed a multinational registry of global TAVR activity and invited individual TAVR sites to submit TAVR implant data before and during the COVID-19 pandemic. Specifically, the number of TAVR procedures performed monthly from January 2019 to December 2021 was collected. The adaptive measures to maintain TAVR activity by each site were recorded, as was a variety of indices relating to type of health care system and national economic indices. The primary subject of interest was the impact on TAVR activity during each of the pandemic waves (2020 and 2021) compared with the same period pre–COVID-19 (2019). Results: Data were received from 130 centers from 61 countries, with 14 subcontinents and 5 continents participating in the study. Overall, TAVR activity increased by 16.7% (2,337 procedures) between 2018 and 2019 (ie, before the pandemic), but between 2019 and 2020 (ie, first year of the pandemic), there was no significant growth (–0.1%; –10 procedures). In contrast, activity again increased by 18.9% (3,085 procedures) between 2020 and 2021 (ie, second year of the pandemic). During the first pandemic wave, there was a reduction of 18.9% (945 procedures) in TAVR activity among participating sites, while during the second and third waves, there was an increase of 6.7% (489 procedures) and 15.9% (1,042 procedures), respectively. Further analysis and results of this study are ongoing and will be available at the time of the congress. Conclusion: The COVID-19 pandemic initially led to a reduction in the number of patients undergoing TAVR worldwide, although health care systems subsequently adapted, and the number of TAVR recipients continued to grow in subsequent COVID-19 pandemic waves. Categories: STRUCTURAL: Valvular Disease: Aorti

Percutaneous transapical access: current status

Percutaneous transapical access provides a direct route to many cardiac structures difficult to reach with conventional interventional approaches. With recent developments of new technologies in structural heart disease, there has been an increasing interest in the use of transapical access for cardiac interventions. Meticulous planning, careful access and closure techniques are essential. Development of novel imaging technologies and dedicated closure devices are warranted to allow a greater number of operators to successfully adopt percutaneous transapical access and further reduce complication rates. This article is an overview of the current status and utility of percutaneous transapical access with focus on multimodality imaging, technique and potential complications of this approach

Right Coronary Aneurysm with Coronary Arteriovenous Fistula to Right Atrium

<p>A 56-year-old man presented with shortness of breath and palpitations. Workup and evaluation revealed paroxysmal atrial fibrillation, severe tricuspid regurgitation, and a giant right coronary aneurysm with an arteriovenous fistula to the right atrium. An echocardiogram revealed an aneurysm of the proximal right coronary artery. Cardiac catheterization and cardiac magnetic resonance imaging showed the aneurysm coursing between the right pulmonary artery and the ascending aorta. The caliber of the right coronary artery distal to the aneurysm was normal.<br> A median sternotomy was performed and the pericardium was opened to encounter the proximal right coronary aneurysm. The superior vena cava was looped to allow for exclusion of venous return. Direct cannulation of the aorta and percutaneous access of the femoral vein were performed to place the patient on cardiopulmonary bypass. Further dissection revealed the giant aneurysm between the aorta, right pulmonary artery, and superior vena cava, with an apparent arteriovenous fistula between the right coronary aneurysm and the right atrium. The shunted blood flow coursed from the aorta, to the right coronary aneurysm, to the right atrium.<br> After the heart was arrested and the patient placed on cardiopulmonary bypass, the normal right coronary artery distal to the aneurysm was dissected, allowing for a reverse saphenous vein to be grafted. The right coronary artery between the aneurysm and the graft was ligated. The proximal right coronary artery was further identified and ligated at the aorta. Attention was then turned to the right atrium, which was opened to identify the entry of the arteriovenous fistula. Additionally, the proximal right coronary artery aneurysm sac was opened and followed down through the giant aneurysm to the right atrium. A probe was passed to delineate the flow through the fistula. A bovine pericardium patch was sewn from within the right atrium to close the fistula. <br> The severe tricuspid regurgitation discovered during preoperative workup was managed with the placement of a tricuspid annuloplasty ring. A left-sided pulmonary vein maze procedure was performed for the atrial arrhythmia, and was accompanied by the placement of a left atrial appendage clip. The proximal vein graft was then anastomosed to the aorta, and the aortic clamp was released. The right coronary aneurysm sac and giant aneurysm were oversewn. The patient was taken off of cardiopulmonary bypass with restoration of normal anatomic blood flow.<br> In conclusion, this video demonstrates the presentation, diagnosis, and surgical treatment of a large complex right coronary artery aneurysm with an arteriovenous fistula to the right atrium. The surgical treatment was ligation and exclusion of the aneurysm, with coronary artery bypass to the distal right coronary artery, and patch repair of the right atrium. The patient had an uneventful postoperative course with a full recovery.</p

Comparison of outcomes of balloon aortic valvuloplasty plus percutaneous coronary intervention versus percutaneous aortic balloon valvuloplasty alone during the same hospitalization in the United States

The use of percutaneous aortic balloon balvotomy (PABV) in high surgical risk patients has resurged because of development of less invasive endovascular therapies. We compared outcomes of concomitant PABV and percutaneous coronary intervention (PCI) with PABV alone during same hospitalization using nation's largest hospitalization database. We identified patients and determined time trends using the International Classification of Diseases, Ninth Revision, Clinical Modification, procedure code for valvulotomy from Nationwide Inpatient Sample database 1998 to 2010. Only patients >60 years with aortic stenosis were included. Primary outcome included in-hospital mortality, and secondary outcomes included procedural complications, length of stay (LOS), and cost of hospitalization. Total 2,127 PABV procedures were identified, with 247 in PABV + PCI group and 1,880 in the PABV group. Utilization rate of concomitant PABV + PCI during same hospitalization increased by 225% from 5.1% in 1998 to 1999 to 16.6% in 2009 to 2010 (p <0.001). Overall in-hospital mortality rate and complication rates in PABV + PCI group were similar to that of PABV group (10.3% vs 10.5% and 23.4% vs 24.7%, respectively). PABV + PCI group had similar LOS but higher hospitalization cost (median [interquartile range] $30,089 [$21,925 to $48,267] versus$18,421 [$11,482 to$32,215], p <0.001) in comparison with the PABV group. Unstable condition, occurrence of any complication, and weekend admission were the main predictors of increased LOS and cost of hospital admission. Concomitant PCI and PABV during the same hospitalization are not associated with change in in-hospital mortality, complications rate, or LOS compared with PABV alone; however, it increases the cost of hospitalization

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Randomized Comparison of Transcatheter Edge-to-Edge Repair for Degenerative Mitral Regurgitation in Prohibitive Surgical Risk Patients.

BACKGROUND: Severe symptomatic degenerative mitral regurgitation (DMR) has a poor prognosis in the absence of treatment, and new transcatheter options are emerging. OBJECTIVES: The CLASP IID randomized trial (NCT03706833) is the first to evaluate the safety and effectiveness of the PASCAL system compared to the MitraClip system in patients with significant symptomatic DMR. In this report, we present the primary safety and effectiveness endpoints for the trial. METHODS: Patients with 3+ or 4+ DMR at prohibitive surgical risk were assessed by a central screening committee and randomized 2:1 (PASCAL:MitraClip). Study oversight also included an echocardiographic core laboratory and a clinical events committee. The primary safety endpoint was a composite major adverse event (MAE) rate at 30 days. The primary effectiveness endpoint was the proportion of patients with MR ≤2+ at 6 months. RESULTS: A pre-specified interim analysis in 180 patients demonstrated non-inferiority of the PASCAL system vs. MitraClip system for the primary safety and effectiveness endpoints, MAE: 3.4% vs. 4.8%, MR ≤2+: 96.5% vs. 96.8%, respectively. Functional and quality-of-life outcomes significantly improved in both groups (p CONCLUSIONS: The CLASP IID trial demonstrated safety and effectiveness of the PASCAL system and met non-inferiority endpoints, expanding transcatheter treatment options for prohibitive surgical risk patients with significant symptomatic DMR