The role of advanced imaging in transcatheter aortic valve implantation

Aortic stenosis, currently the most prevalent valvular heart disease in Europe, is an important public health problem, affecting thousands of patients every year. While surgical aortic valve replacement is still considered the “gold standard” treatment, recent innovations in transcatheter valve therapies have offered an attractive alternative: transcatheter aortic valve implantation (TAVI). In 2002, Cribier et al. announced the first human case description of a percutaneously implanted heart valve in a patient suffering from severe aortic stenosis. Since then, the number of patients that undergo TAVI has increased exponentially. Preliminary early and midterm results following TAVI have been promising. However, despite satisfactory hemodynamic results, TAVI procedures still face important safety issues such as paravalvular leaks, vascular complications, stroke, conduction disorders and the need for pacemaker implantation. Currently, TAVI is offered only to patients who are considered high risk candidates for surgical aortic valve replacement. A fundamental characteristic of percutaneous interventions is the lack of direct visualization of the target organ/tissue. Consequently, interventional cardiology is greatly related to and depending on imaging. Especially in TAVI, which is entering the field of traditional valve surgery, the role of multimodality cardiac imaging is mandatory. Contrast aortography, multi slice computed tomography (MSCT), magnetic resonance imaging and echocardiography can provide a detailed characterisation of vascular anatomy, aortic root dimensions, aortic valve calcifications and left ventricular (LV) function. The use of these imaging techniques is invaluable for patient selection and planning of the procedure. In addition, some techniques can be used during the operation to guide the implantation, as well as after the procedure to evaluate the positioning and function of the prosthesis. TAVI is a fascinating technology but it is still in its infancy. Further studies are needed in order to understand and modulate TAVI. The aim of the present thesis is to investigate the role of advanced cardiac imaging for TAVI

Next Generation Transcatheter Aortic Valve Systems: the PorticoTM Valve

Transcatheter aortic valve replacement (TAVR) is currently considered a valuable alternative for the treatment of severe symptomatic aortic stenosis patients who are inoperable or at excessively high surgical risk

Transcatheter Aortic Valve Implantation: What Lies Ahead?

  Ttranscatheter aortic valve implantation (TAVI) is currently reserved for high surgical risk or inoperable patients. In 2007, TAVI actually represented approximately 1.2% of all aortic valve procedures in Europe; this percentage increased to 6.5% in 2008. With an expectation of ~9000 TAVI procedures to be performed in 2009, TAVI may represent nearly13% of all aortic valve procedures. It is forecasted that by 2012 transcatheter valve therapies will account for approximately 40% of the total heart valve procedures performed in Europe. One major limiting factor relates to procedural complications of TAVI. Conduction abnormalities and the need for permanent pacemaker, paravalvular aortic regurgitation, stroke and vascular complications have received particular attention. The future and widespread adoption of TAVI will rely on a number of inter-related factors, including long-term durability and safety data, randomized controlled trials comparing TAVI with surgical aortic valve replacement and reimbursement for the technology

Transcatheter Mitral Valve Repair: Is there a Future?

Mitral regurgitation (MR) is a common disease in developed countries, affecting an estimated 9.3% of the population aged ≥75 years. Although surgical valve repair or replacement is currently the “gold standard” treatment for severe symptomatic MR, almost one-half of the patients are denied surgery. These are usually older patients with moderate left ventricular dysfunction and several non-cardiac co-morbidities. The aim of transcatheter mitral valve repair is to provide a treatment that is at least as effective as conventional valve surgery, and is associated with less morbidity and mortality. Currently an important number of devices are under evaluation, and can be categorized according to the treatment strategy.... (excerpt

Contemporary European practice in transcatheter aortic valve implantation: results from the 2022 European TAVI Pathway Registry

BackgroundA steep rise in the use of transcatheter aortic valve implantation (TAVI) for the management of symptomatic severe aortic stenosis occurred. Minimalist TAVI procedures and streamlined patient pathways within experienced Heart Valve Centres are designed to overcome the challenges of ever-increasing procedural volume.AimsThe 2022 European TAVI Pathway Survey aims to describe contemporary TAVI practice across Europe.Materials and methodsBetween October and December 2022, TAVI operators from 32 European countries were invited to complete an online questionnaire regarding their current practice.ResultsResponses were available from 147 TAVI centres in 26 countries. In 2021, the participating centres performed a total number of 27,223 TAVI procedures, with a mean of 185 TAVI cases per centre (median 138; IQR 77–194). Treatment strategies are usually (87%) discussed at a dedicated Heart Team meeting. Transfemoral TAVI is performed with local anaesthesia only (33%), with associated conscious sedation (60%), or under general anaesthesia (7%). Primary vascular access is percutaneous transfemoral (99%) with secondary radial access (52%). After uncomplicated TAVI, patients are transferred to a high-, medium-, or low-care unit in 28%, 52%, and 20% of cases, respectively. Time to discharge is day 1 (12%), day 2 (31%), day 3 (29%), or day 4 or more (28%).ConclusionReported adoption of minimalist TAVI techniques is common among European TAVI centres, but rates of next-day discharge remain low. This survey highlights the significant progress made in refining TAVI treatment and pathways in recent years and identifies possible areas for further improvement

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

History of Percutaneous Left Atrial Appendage Occlusion with AMPLATZER Devices.

AMPLATZER devices preceded WATCHMAN occluder in 2002 for catheter-based left atrial appendage occlusion. The AMPLATZER technique facilitates simultaneous closure of atrial shunts using two devices through one gear. Randomized WATCHMAN follow-up data showed a mortality benefit over warfarin. AMPLATZER data make this likely valid for the strategy. Particularly young people with atrial fibrillation should be offered left atrial appendage occlusion because the risk is confined to the intervention and early postintervention period. Guidelines should be adapted to make this progress in prevention of stroke and bleeding in patients with atrial fibrillation accessible for all, in the sense of a mechanical vaccination

Patients with intracranial bleeding and atrial fibrillation treated with left atrial appendage occlusion: Results from the Amplatzer Cardiac Plug registry

BACKGROUND In patients with non-valvular atrial fibrillation (NVAF), intracranial bleeding (ICB) constitutes a very challenging situation in which the rate of both ischemic and hemorrhagic events is increased. In these patients, left atrial appendage occlusion (LAAO) might represent a very valid alternative. OBJECTIVES To investigate the procedural safety and long-term outcome of patients undergoing LAAO therapy due to previous ICB. METHODS Data from the Amplatzer Cardiac Plug multicenter registry on 1047 consecutive patients were analyzed. Patients with previous ICB as indication for LAAO were compared to patients with other indications. RESULTS A total of 198 patients (18.9%) with previous ICB were identified. The CHADS-VASc score was similar (4.5±1.5 vs. 4.4±1.6, p=0.687) and the HAS-BLED score was higher in patients with previous ICB compared to those without (3.5±1.1 vs. 3.1±1.2, p<0.001). No significant differences in peri-procedural major adverse events were observed (2.5 vs 5.4%, p=0.1). Patients with previous ICB were more frequently on single acetylsalicylic acid therapy after LAAO (42.4% vs. 28.3%; p<0.001). With an average follow-up of 1.3years, the observed annual stroke/TIA rate (procedure and follow-up) for patients with previous ICB was 1.4% (75% relative risk reduction). The observed annual major bleeding rate (procedure and follow-up) for patients with previous ICB was 0.7% (89% relative risk reduction). CONCLUSIONS In patients with NVAF and previous ICB, LAAO seemed to be a safe procedure and was associated with a significant reduction in stroke/TIA and a remarkably low frequency of major bleeding during follow-up