Pacemaker Following TAVR Associated With Increased Tricuspid Reguritation

Background: Transcatheter Aortic Valve Replacement (TAVR) therapies have increased in the treatment of aortic disease. As TAVR procedures increase, more data is available on complications, such as the development of conduction abnormalities, often requiring pacemaker placement (PMP). A common complication of pacemaker lead placement is the development of tricuspid regurgitation which develops due to pacemaker wire impingement of leaflet function and coaptation. Methods: Retrospective data was obtained from a major urban Midwestern health center. 796 patients were isolated who underwent TAVR from January 2014 through June 2018. From that sample, 89 patients (11%) underwent PMP following TAVR procedure. From those 89 patients, a sample of 34 patients was isolated that received their pacemaker at 2 years or more prior from the date of data collection. In addition to data from both procedures and patient demographics, echographic data was obtained [1] prior to TAVR procedure [2] between TAVR procedure and PMP and [3] the most recent echocardiogram. Data obtained from the echocardiogram included ejection fraction, degree of tricuspid regurgitation, pulmonary artery pressure, Tricuspid Annular Plane Systolic Excursion (TAPSE), degree of inferior vena cava (IVC) dilation, right ventricular diameter (RVD), right ventricle systolic pressure, right atrium (RA) area and degree of hepatic flow reversal. Results: Overall there was an increase in the incidence of significant tricuspid regurgitation (defined as above mild) from 29% to 38% following TAVR and PMP. The various changes between echographic parameters were analyzed using the paired t-test and the Wilcoxon signed rank test. The results indicate that a statistically significant change for the RVD from prior to TAVR to after PMP, where the mean RVD increased from 2.9 cm to 3.5 cm (p-value = 0.039). While not statistically significant, it should also be noted that there was an increase in the degree of tricuspid regurgitation and RA area. Conclusion: There is increasing awareness of the prevalence of tricuspid valve disease. This project serves as a basis to understand the risk of developing tricuspid regurgitation after TAVR procedure. This research can help guide clinicians in future in TAVR patients who have preexisting tricuspid regurgitation and may be evaluated for pacemaker placement. Given recent advances in transcatheter tricuspid valve therapies, more research is required to understand the risk of TAVR procedure and to push therapy and development that may help correct such complications.https://scholarlycommons.henryford.com/merf2019clinres/1045/thumbnail.jp

Current and emerging strategies for the treatment of acute pericarditis: a systematic review

Pericarditis is a common disorder that has multiple causes and presents in various primary-care and secondary-care settings. It is diagnosed in 0.1% of all hospital admissions and in 5% of emergency room visits for chest pain. Despite the advance of new diagnostic techniques, pericarditis is most commonly idiopathic, and radiation therapy, cardiac surgery, and percutaneous procedures have become important causes. Pericarditis is frequently benign and self-limiting. Nonsteroidal anti-inflammatory agents remain the first-line treatment for uncomplicated cases. Integrated use of new imaging methods facilitates accurate detection and management of complications such as pericardial effusion or constriction. In this article, we perform a systematic review on the etiology, clinical presentation, diagnostic evaluation, and management of acute pericarditis. We summarize current evidence on contemporary and emerging treatment strategies

Inflammatory Markers in Bicuspid Transcatheter Aortic Valve Replacement

Background Aortic stenosis (AS) has a prevalence of 2%. Valve replacement is the definitive treatment for AS, with transcatheter aortic valve replacement (TAVR) offering a minimally invasive alternative to surgery. Bicuspid aortic valve (BAV) is the most common congenital cardiac abnormality. BAV patients are predisposed to AS, and comprise a distinct, younger TAVR patient population. Given limited prior work on inflammatory markers for TAVR risk assessment, this study sought to investigate if white blood cell count (WBC) correlates with BAV TAVR patient severity and post-TAVR outcomes. Methods A single-center retrospective analysis was performed on patients with BAV who underwent TAVR from 2014 to 2018 (N=37). Patient demographics, symptomatic severity (NYHA class) and anatomic severity: aortic valve area (AVA) and indexed aortic valve area (AVAI) were collected. WBC prior to TAVR and post-TAVR complications/readmissions were also collected. Correlations between WBC, patient severity, and adverse outcomes were assessed using the Pearson and Spearman correlation tests, two-sample t-tests, and the Wilcoxon rank sum test. Results A statistically significant correlation (p = .041) was found between elevated pre-procedure WBC and patient NYHA class. No association was found between pre-procedure WBC and AVA (p = .723), AVAI (p = .961), or adverse outcomes/readmission post-procedure (p = .116). Conclusions A statistically significant correlation between pre-procedure WBC and NYHA class demonstrates that WBC is an accurate predictor of BAV patient’s functional symptom severity and could thus serve as a readily-accessible metric to stratify BAV TAVR patients in pre-procedure planning. No correlation existed between WBC and anatomic valve severity

Real world outcomes using 20 mm balloon expandable SAPIEN 3/ultra valves compared to larger valves (23, 26, and 29 mm)-a propensity matched analysis

OBJECTIVE/BACKGROUND: Small balloon expandable valves have higher echocardiographic transvalvular gradients and rates of prosthesis-patient mismatch (PPM) compared to larger valves. However, the impact of these echocardiographic findings on clinical outcomes is unknown. We sought to determine the clinical outcomes of 20 mm SAPIEN 3 (S3 BEV) compared to larger S3 BEV in relation to echocardiographic hemodynamics. METHODS: Using the STS/ACC transcatheter valve registry, we performed a propensity-matched comparison of patients undergoing treatment of native aortic valve stenosis using transfemoral, balloon-expandable implantation of 20 mm and ≥ 23 mm S3 BEVs. Baseline and procedure characteristics, echocardiographic variables and survival were analyzed. Multivariable logistic regression was used to identify predictors of 1-year mortality. RESULTS: After propensity matching of the 20 mm and ≥ 23 mm SAPIEN 3 valves, 3,931 pairs with comparable baseline characteristics were identified. Small valves were associated with significantly higher echocardiographic gradients at discharge (15.7 ± 7.1 mmHg vs. 11.7 ± 5.5 mmHg, p \u3c 0.0001) and severe PPM rates (21.5% vs. 9.7%, p \u3c 0.0001). There was no significant difference in 1-year all-cause mortality (20 mm: 13.0% vs. ≥23 mm: 12.7%, p = 0.72) or other major adverse event rates and outcomes between the two cohorts. Based on a multivariable analysis, elevated discharge mean gradient (\u3e20 mmHg), severe PPM and the use of 20 mm versus ≥23 mm were not independent predictors of 1-year mortality. CONCLUSION: SAPIEN 3 20 mm valves were associated with higher echocardiographic gradients, and severe PPM rates compared to larger valves but these factors were not associated with significant differences in 1-year all-cause mortality or rehospitalization

Patent foramen ovale closure with vena cava thrombus: You need an arm and a neck!

In patients with challenging femoral vein anatomy, transcatheter patent foramen ovale (PFO) closure can be safely and effectively be done through the jugular veins guided by ICE from the arm. This novel technique can potentially save resources (anesthesia and TEE) and provide an option for patients without a femoral option

Emergency Alcohol Septal Ablation for Shock After TAVR: One More Option in the Toolbox

We hereby report a case of severe shock from left ventricular outflow tract obstruction following transcatheter aortic valve replacement that did not respond to medical therapy and had to be treated with emergent alcohol septal ablation (ASA). Emergent ASA should be considered for bail-out treatment for these refractory cases. (Level of Difficulty: Advanced.

Left Atrial Venoarterial Extracorporeal Membrane Oxygenation for Acute Aortic Regurgitation and Cardiogenic Shock

A 51-year-old man with past medical history of bioprosthetic aortic valve replacement presented in cardiogenic shock secondary to acute bioprosthesis degeneration with severe aortic regurgitation. Venoarterial extracorporeal membrane oxygenation is contraindicated in patients with severe AI. Use of left atrial venoarterial extracorporeal membrane oxygenation resulted in hemodynamic improvement, allowing patient stabilization for emergency valve-in-valve transcatheter aortic valve replacement