Relative Survival After Transcatheter Aortic Valve Implantation: How Do Patients Undergoing Transcatheter Aortic Valve Implantation Fare Relative to the General Population?

Background: Transcatheter aortic valve implantation (TAVI) is indicated for patients with aortic stenosis who are intermediate‐high surgical risk. Although all‐cause mortality rates after TAVI are established, survival attributable to the procedure is unclear because of competing causes of mortality. The aim was to report relative survival (RS) after TAVI, which accounts for background mortality risks in a matched general population. Methods and Results: National cohort data (n=6420) from the 2007 to 2014 UK TAVI registry were matched by age, sex, and year to mortality rates for England and Wales (population, 57.9 million). The Ederer II method related observed patient survival to that expected from the matched general population. We modelled RS using a flexible parametric approach that modelled the log cumulative hazard using restricted cubic splines. RS of the TAVI cohort was 95.4%, 90.2%, and 83.8% at 30 days, 1 year, and 3 years, respectively. By 1‐year follow‐up, mortality hazards in the >85 years age group were not significantly different from those of the matched general population; by 3 years, survival rates were comparable. The flexible parametric RS model indicated that increasing age was associated with significantly lower excess hazards after the procedure; for example, by 2 years, a 5‐year increase in age was associated with 20% lower excess mortality over the general population. Conclusions: RS after TAVI was high, and survival rates in those aged >85 years approximated those of a matched general population within 3 years. High rates of RS indicate that patients selected for TAVI tolerate the risks of the procedure well

Assessment of aortic stiffness by cardiovascular magnetic resonance following the treatment of severe aortic stenosis by TAVI and surgical AVR

Aortic stiffness is increasingly used as an independent predictor of adverse cardiovascular outcomes. We sought to compare the impact of transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) upon aortic vascular function using cardiovascular magnetic resonance (CMR) measurements of aortic distensibility and pulse wave velocity (PWV).A 1.5 T CMR scan was performed pre-operatively and at 6 m post-intervention in 72 patients (32 TAVI, 40 SAVR; age 76 ± 8 years) with high-risk symptomatic severe aortic stenosis. Distensibility of the ascending and descending thoracic aorta and aortic pulse wave velocity were determined at both time points. TAVI and SAVR patients were comparable for gender, blood pressure and left ventricular ejection fraction. The TAVI group were older (81 ± 6.3 vs. 72.8 ± 7.0 years, p < 0.05) with a higher EuroSCORE II (5.7 ± 5.6 vs. 1.5 ± 1.0 %, p < 0.05). At 6 m, SAVR was associated with a significant decrease in distensibility of the ascending aorta (1.95 ± 1.15 vs. 1.57 ± 0.68 × 10(-3)mmHg(-1), p = 0.044) and of the descending thoracic aorta (3.05 ± 1.12 vs. 2.66 ± 1.00 × 10(-3)mmHg(-1), p = 0.018), with a significant increase in PWV (6.38 ± 4.47 vs. 11.01 ± 5.75 ms(-1), p = 0.001). Following TAVI, there was no change in distensibility of the ascending aorta (1.96 ± 1.51 vs. 1.72 ± 0.78 × 10(-3)mmHg(-1), p = 0.380), descending thoracic aorta (2.69 ± 1.79 vs. 2.21 ± 0.79 × 10(-3)mmHg(-1), p = 0.181) nor in PWV (8.69 ± 6.76 vs. 10.23 ± 7.88 ms(-1), p = 0.301) at 6 m.Treatment of symptomatic severe aortic stenosis by SAVR but not TAVI was associated with an increase in aortic stiffness at 6 months. Future work should focus on the prognostic implication of these findings to determine whether improved patient selection and outcomes can be achieved

Percutaneous treatment of patients with heart diseases: selection, guidance and follow-up. A review

Aortic stenosis and mitral regurgitation, patent foramen ovale, interatrial septal defect, atrial fibrillation and perivalvular leak, are now amenable to percutaneous treatment. These percutaneous procedures require the use of Transthoracic (TTE), Transesophageal (TEE) and/or Intracardiac echocardiography (ICE). This paper provides an overview of the different percutaneous interventions, trying to provide a systematic and comprehensive approach for selection, guidance and follow-up of patients undergoing these procedures, illustrating the key role of 2D echocardiography

Quantification of regurgitant fraction in mitral regurgitation by cardiovascular magnetic resonance: comparison of techniques.

BACKGROUND AND AIM OF THE STUDY: Cardiovascular magnetic resonance (CMR) assessment of mitral regurgitant volume from the subtraction of the right ventricular stroke volume (RVSV) from left ventricular stroke volume (LVSV) has commonly been performed using volumetric techniques. This is sensitive to errors in RVSV visualization and regurgitation of other heart valves, and therefore subtracting aortic flow volume from LVSV may be preferable. The study aim was to compare both techniques in a single CMR examination. METHODS: Twenty-eight patients with isolated mitral regurgitation underwent left ventricular (LV) and right ventricular (RV) volumetry and aortic flow volume measurements. Mitral regurgitant fraction (RF) was calculated as either RF(VOL) = [LVSV - RVSV] or RF(FLOW) = [LVSV - aortic flow volume], both expressed as a fraction of LVSV. The agreement of the measurements was assessed as a measure of robustness in clinical practice. RESULTS: There was good agreement between aortic and pulmonary flow (mean +/- SD difference -0.8 +/- 8.1 ml), and aortic flow volume and RVSV by volumetry (mean difference -2.6 +/- 11.8 ml). Intra- and interobserver variability (SD) of aortic flow volume (+/-6.6 ml and +/-5.3 ml) was superior to that of the RVSV (+/-8.5 ml and +/-12 ml). The intra- and inter-observer variability (SD) of RF(FLOW) was lower (+/-4.8% and +/-7.7%) than by RF(VOL) (+/-6.7% and +/-8.8%). CONCLUSION: The RF(FLOW) technique maximized intra- and inter-observer agreement, and is the optimal CMR technique to quantify mitral regurgitation. RF(FLOW) also has the advantage of allowing correction for aortic regurgitation when it is present, and is potentially independent of the effects of tricuspid and pulmonary regurgitation

Direct aortic transcatheter aortic valve implantation: A feasible approach for patients with severe peripheral vascular disease

Aortic stenosis is a prevalent disease with poor prognosis if left untreated. Transcatheter aortic valve implantation (TAVI) is an emerging treatment for patients at high risk for surgery. We describe a patient withno suitable peripheral access due to peripheral vascular disease (PVD) for TAVI. Direct aortic approachvia an 18-Fr sheath inserted into the ascending aorta was successfully performed with a 29-mm CoreValve implanted. Direct aortic approach is feasible for TAVI in patients with severe PVD without good peripheral access. © 2012 Elsevier Inc.link_to_subscribed_fulltex