Concomitant Left Atrial Appendage Occlusion and Transcatheter Aortic Valve Replacement Among Patients With Atrial Fibrillation.

Background/Objectives: Atrial fibrillation is a frequent comorbidity amongst patients undergoing mitral valve transcatheter edge-to-edge repair (M-TEER) for mitral regurgitation. Left atrial appendage occlusion (LAAO) can be performed to reduce the risk of stroke in patients with atrial fibrillation. Both procedures require large-bore venous access, transseptal puncture, and real-time imaging of the left atrium. However, limited data exist evaluating the safety and feasibility of concomitant M-TEER and LAAO. Methods: We performed a retrospective review of all concomitant M-TEER and LAAO procedures at our institution between May 2019 and September 2024 to evaluate the safety and feasibility of this approach. Results: Concomitant left atrial appendage occlusion was successful in all 15 patients, requiring an additional 15 min (IQR 11-29) of procedural time. No patients died or had a major vascular complication. Routine transesophageal echocardiography performed within 90 days showed no device related thrombus, and no significant peri-device leak in any patients. Conclusions: Concomitant M-TEER and LAAO are feasible but additional prospective studies or randomized trials are needed to evaluate the potential clinical benefit.

Simultaneous Transcatheter Aortic Valve Implantation and Left Atrial Appendage Occlusion versus both Interventions as Stand-Alone Procedures

Aortic Stenosis and Atrial Fibrillation Left Atrial Appendage Occlusion—Could We? If So, How and When?

Sociodemographic disparities in atrial fibrillation (AF) management and thromboembolic prophylaxis have previously been reported, which may involve inequitable access to left atrial appendage occlusion (LAAO) during cardiac surgery. The present study aimed to evaluate the association of LAAO utilization with sex, race, and hospital region among patients with AF undergoing heart valve operations. Adults with AF undergoing valve replacement/repair in the 2012-2019 National Inpatient Sample were identified and stratified based on concurrent LAAO. Multivariable linear and logistic regressions were developed to identify factors associated with LAAO utilization. Mortality, complications including stroke and thromboembolism, hospitalization costs and length of stay (LOS) were secondarily assessed. Of 382,580 patients undergoing valve operations, 18.7% underwent concomitant LAAO. Over the study period, the proportion of female patients receiving LAAO significantly decreased from 44.8% to 38.9% (p<0.001). Upon risk adjustment, female (AOR 0.93 [95% CI 0.89-0.97]) and Black patients (0.91 [0.83-0.99]) had significantly reduced odds of undergoing LAAO compared to males and Whites, respectively. Additionally, hospitals in the Midwest (1.38 [1.24-1.51]) and West (1.26 [1.15-1.36]) had increased likelihood of LAAO whereas Northeast hospitals (0.85 [0.77-0.94)] had decreased odds relative to the South. Furthermore, LAAO was associated with decreased stroke (0.71 [0.60-0.84]) and thromboembolism (0.68 [0.54-0.86]), $4,200 reduction in costs and 1-day decrement in LOS. Female and Black patients had significantly lower odds while Midwest and Western hospitals had greater odds of LAAO utilization. Enhancing access to LAAO during valvular surgery is warranted to improve clinical and financial outcomes for patients with AF.

Coronary artery disease (CAD) is commonly observed in patients undergoing transcatheter aortic valve replacement (TAVR). Significant variability exists across institutions for strategies used for CAD diagnosis and its management. The heart team often relies upon traditional practice patterns and the decision for revascularization by percutaneous coronary intervention (PCI) is influenced by patient, angiographic, operator, and system-related factors. Contemporary coronary tomography angiography (CTA) shows significant promise for detection of clinically important CAD and preliminary data support CTA use for TAVR patients. The prognostic implications of CAD in a TAVR population remain unclear with studies showing conflicting data for the benefits of PCI. Recent trials show that medical management is an effective initial treatment strategy for stable CAD, a finding likely also applicable for asymptomatic and stable TAVR patients. In addition, PCI performed pre-TAVR, concomitant with TAVR or after TAVR has been shown to produce similar outcomes. Dual antiplatelet therapy (DAPT) is mandated after PCI but associated with increased risk of bleeding in TAVR population with accumulating evidence for single antiplatelet therapy (SAPT) post-TAVR unless DAPT or anticoagulation is indicated for another reason. Although coronary angiography remains the predominant modality for CAD assessment, CTA is increasingly being used in TAVR patients. There is limited evidence to guide CAD management in TAVR patients with significant variability in practice patterns. Medical therapy is recommended for asymptomatic and stable CAD patients with applicability for TAVR population. Despite prior concerns, recent studies suggest successful coronary access post-TAVR and similar outcomes for PCI offered pre-TAVR, concomitant with TAVR and post-TAVR settings. Safety of DAPT should be an important consideration for PCI in TAVR patients. Ongoing studies will determine the preferred testing for CAD diagnosis, benefit of revascularization, timing of PCI, and optimum antithrombotic therapy for TAVR populations.

Requiem for Routine Self-Expanding TAVR Valves? A Commentary on the Comparative Analysis of Evolut PRO Versus Sapien Ultra Valves for Transfemoral Transcatheter Aortic Valve Implantation Registry (OPERA-TAVI)

Doppler Mean Gradient Is Discordant to Aortic Valve Calcium Scores in Patients with Atrial Fibrillation Undergoing Transcatheter Aortic Valve Replacement

Failed bioprosthetic valve approaches: Transcatheter aortic valve replacement approach

Background: Pre-existing atrial fibrillation (AF) is common among patients undergoing transcatheter aortic valve replacement (TAVR). However, evidence regarding its impact on the risk of permanent pacemaker (PPM) implantation and other conduction disturbances (CDs) after TAVR remains inconsistent. The aim of this study was to assess the effect of baseline heart rhythm on the risk of conduction abnormalities following TAVR. Methods: This study included patients with severe AS who underwent TAVR using either balloon-expandable (BEVs) or self-expanding valves (SEVs). The primary endpoint was the incidence of PPM implantation and new or worsening left bundle branch block (LBBB) after TAVR according to baseline rhythm (sinus rhythm vs. AF). Secondary endpoints were predictors of PPM implantation, LBBB, the occurrence of periprocedural stroke, and in-hospital mortality. Results: A total of 5195 TAVR patients were included: 3560 with baseline sinus rhythm and 1635 with baseline AF. PPM implantation was more frequent in patients with AF than in those with sinus rhythm (17% vs. 15%, p = 0.033), whereas new or worsening LBBB was less common (11% vs. 14%, p = 0.026). After adjustment with multivariable logistic regression, these associations were no longer statistically significant (PPM implantation: OR 1.156, 95% CI 0.969–1.379, p = 0.108; new or worsening LBBB: OR 0.826, 95% CI 0.676–1.010, p = 0.062). Independent peri-procedural predictors of PPM implantation included baseline first-degree AV block, pre-procedural RBBB, the use of self-expandable valves, implantation of larger valve sizes (≥23 mm), and the need for valve repositioning. Conclusions: In this large cohort, baseline AF was not associated with an increased risk of PPM implantation or new onset LBBB compared with sinus rhythm. These findings suggest that baseline rhythm alone should not be considered an independent predictor of PPM implantation or CDs following TAVR.

Background There are conflicting results over the improvement rate and predictors of mitral regurgitation in patients undergoing transcatheter aortic valve replacement (TAVR). Purpose To define the cause, degree of improvement, and improvement predictors of moderate to severe mitral regurgitation in patients undergoing TAVR by using a simplified D-shaped mitral annulus model derived from multisection CT (MSCT). Materials and Methods This retrospective cohort study included 528 consecutive patients who underwent TAVR between April 2012 and October 2019. Patients with previous surgical aortic valve replacement and those with moderate or severe mitral stenosis were excluded. A total of 104 patients with moderate to severe mitral regurgitation met the inclusion criteria and were included in the final analysis. At least one grade reduction in the severity of mitral regurgitation was considered indicative of mitral regurgitation improvement after TAVR. Up to 5-year post-TAVR follow-up of mitral regurgitation improvement was evaluated. Mitral annular dimensions (annular area, circumference, and trigone-to-trigone, intercommissural, and anteroposterior distances) and annular calcification were assessed at MSCT with use of dedicated postprocessing software. Associations with mitral regurgitation improvement after TAVR were explored. Results A total of 104 patients with concomitant mitral regurgitation who underwent TAVR (mean age, 74 years ± 7; 61 men) were included in the study. Mitral regurgitation improved in 79 patients after TAVR and remained unchanged in the remaining 25 patients. Maximum improvement was observed in the 1st year after TAVR. D-shaped mitral annular parameters, including annular circumference (odds ratio [OR], 1.05; 95% CI: 1.01, 1.1; P = .02) and trigone-to-trigone (OR, 1.2; 95% CI: 1.03, 1.39; P = .02) and intercommissural (OR, 1.15; 95% CI: 1.02, 1.31; P = .02) distances, were related to mitral regurgitation improvement. In addition, patients with coronary artery disease had greater improvement in mitral regurgitation after TAVR (OR, 0.17; 95% CI: 0.04, 0.76; P = .02). Primary mitral regurgitation (OR, 5.1; 95% CI: 1.1, 24; P = .04) and D-shaped annular circumference (OR, 1.06; 95% CI: 1, 1.11; P = .04) were independent predictors of less mitral regurgitation improvement after TAVR. Conclusion Concomitant mitral regurgitation in patients undergoing transcatheter aortic valve replacement (TAVR) tends to improve after the procedure, with maximum improvement in the 1st year after TAVR. D-shaped annular circumference and primary mitral regurgitation were independent predictors of less mitral regurgitation improvement after TAVR. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Collins in this issue.

Transcatheter aortic valve replacement (TAVR) has been established as a standard of care worldwide in patients with degenerative severe aortic stenosis deemed at high or prohibitive risk for surgical aortic valve replacement. Since its early inception, stroke has been the most feared potential complication. In the early experience, rates of clinical stroke at 30 days after TAVR ranged between 4% and 6%. The substantial improvements in case selection, procedural technique, device technology development, and operator experience overtime dropped this rate substantially.1 Of note, in a large high-risk TAVR trial with a self-expandable device, the risk of stroke over 3 years was higher in the control group of patients undergoing surgical aortic valve replacement.2 Despite the availability of surgical aortic valve replacement for long time, the issues discussed hereafter have not yet been investigated in prospective, randomized fashion. Although we focus on TAVR, owing to the 2 papers we are commenting upon, we should acknowledge upfront that cerebrovascular event (CVE) prevention remains a common theme for all kinds of bioprosthetic aortic valves, via surgical or transcatheter implantation. See Articles by Kapadia et al and Kleiman et al CVE during or after TAVR is a multifactorial phenomenon with clinical, anatomic, procedural, and pharmacological factor contributions.1,3 During TAVR, the predominant pathological mechanisms may be cerebral embolism of calcific or atherothrombotic debris during positioning and implantation of the valve prosthesis.3 After TAVR, thromboembolic mechanisms may include endovascular thrombosis (including upon small size emboli), late embolization of calcific or atheromatous debris from the native aortic valve, ongoing thrombotic pannus (or mural thrombus layer) formation on the surface of the implanted prosthesis, and other mechanisms, including new-onset atrial fibrillation or the progression of atherothrombotic vascular disease.3 However, definitive scientific evidence characterizing the CVE risk peri-TAVR is still lacking. In …

Background Referral rates and outcomes of cardiac rehabilitation have not been evaluated in patients with transcatheter aortic valve replacement or compared with surgical aortic valve replacement. Method A retrospective cohort study was conducted in 488 patients who underwent transcatheter aortic valve replacement ( n = 199) and surgical aortic valve replacement ( n = 289) from a university-based statewide transcatheter aortic valve replacement/surgical aortic valve replacement program during 2015-2017. Cardiac rehabilitation consisted of supervised exercise, diet education, and stress and depression management. We compared changes from baseline in exercise duration and intensity during cardiac rehabilitation sessions, quality-of-life (36-Item Short-Form Health Survey), and psychosocial measures (anxiety, depression, mood, social support, and diet) between transcatheter aortic valve replacement and surgical aortic valve replacement patients using t-test and chi-square analyses. Results Of 488 patients, cardiac rehabilitation referral rates were similar at 41% (transcatheter aortic valve replacement 81/199 versus surgical aortic valve replacement 117/289), but enrollment rates were lower in transcatheter aortic valve replacement (27/199, 14%) versus surgical aortic valve replacement (102/289, 35%, p < 0.01). Among eligible patients, cardiac rehabilitation completion rates were lower in transcatheter aortic valve replacement (12%) than surgical aortic valve replacement (32%). Exercise intensity during cardiac rehabilitation improved in both groups in a similar fashion (transcatheter aortic valve replacement 1.03 ± 1.09 versus surgical aortic valve replacement 1.34 ± 1.15 metabolic equivalents), but increase in exercise duration was higher in transcatheter aortic valve replacement patients versus surgical aortic valve replacement patients (14.52 ± 6.42 versus 10.67 ± 8.38 min, p = 0.02). Improvement in physical composite score was higher in surgical aortic valve replacement versus transcatheter aortic valve replacement (8.72 ± 7.87 versus 2.36 ± 7.6, p = 0.02) while improvement in mental composite score was higher in transcatheter aortic valve replacement (8.19 ± 8.50) versus surgical aortic valve replacement (1.18 ± 7.23, p = 0.02). There was no significant difference between the two groups in improvement in psychosocial measures. Conclusion Cardiac rehabilitation enrollment was low in transcatheter aortic valve replacement patients versus surgical aortic valve replacement patients despite similar referral rates. Improvement in functional and quality-of-life performance was achieved in both transcatheter aortic valve replacement and surgical aortic valve replacement. Future studies should address obstacles for enrollment of transcatheter aortic valve replacement patients.

Robotic aortic valve replacement

Background Cardiac magnetic resonance (CMR) provides the gold standard for the assessment of ventricular volumes and mass. However, data on right ventricular systolic dysfunction (RVSD) and its prognostic significance on outcome in patients undergoing transcatheter aortic valve replacement (TAVR) are lacking. Methods We consecutively enrolled patients with severe aortic stenosis scheduled for TAVR who underwent preprocedural CMR. Kaplan-Meier estimates and multivariate Cox-regression analysis were used to identify factors associated with outcome, including RVSD. A composite of heart failure hospitalization and/or cardiovascular death was selected as primary study endpoint. Results 145 consecutive patients (80.5±7.6 years; 51.7% female) were prospectively included, 25 (17.2%) of which had RVSD defined as RV ejection fraction (RVEF) &lt;40%. RVSD was significantly associated with male sex, atrial fibrillation, reduced left ventricular (LV) EF (&lt;50%) and RV endsystolic volume on CMR (all p&lt;0.05). Serum NT-proBNP (14065±12042 vs. 3203±4615 ng/ml; p&lt;0.001) and creatinine levels (1.59±0.96 vs. 1.29±1.03 mg/dl; p=0.201) were elevated in patients with RVSD. A total of 27 events occurred during follow-up (29±13 weeks). While LVSD was not significantly associated with outcome (p=0.654), RVSD showed a strong and independent association with event-free survival in the multivariate Cox-regression analysis [hazard ratio 3.836 (95% confidence interval 1.670–8.810); p=0.002], which included all relevant CMR parameters, cardiovascular risk factors and routine biomarkers. Conclusions RVSD rather than LVSD, as determined by CMR, is an important predictor of outcome in patients undergoing TAVR. RV function might thus add useful prognostic information on top of established risk factors.

Surgical aortic valve replacement (SAVR) is the commonly used approach for aortic valve replacement (AVR) in patients with aortic stenosis at low or intermediate surgical risk. However, transcatheter aortic valve replacement (TAVR) has emerged as an alternative to SAVR for AVR. This meta-analysis aims to assess the comparative efficacy and safety of TAVR versus SAVR in low-to-intermediate surgical risk patients by analyzing temporal trends in the outcomes of TAVR and SAVR at various follow-up intervals, providing a more detailed understanding. A thorough literature search was performed across PubMed/MEDLINE, Embase, and the Cochrane Library from their inception up to May 2024 to identify eligible randomized controlled trials (RCTs). Clinical outcomes were evaluated using a random-effects model to pool risk ratios (RRs) with 95% CIs. A total of 17 studies reporting data at different follow-ups for nine trials were included (n=9092). No statistically significant difference was observed between TAVR and SAVR for reducing all-cause death at 30 days, 1 year, and 2 years but significantly increased risk with TAVR at 5 years or longer follow-up (RR=1.13, 95% CI: 1.03-1.23). However, TAVR was associated with a significantly decreased risk for cardiac death at 1-year follow-up (RR=0.79, 95% CI: 0.64-0.96) and comparable risk for cardiac death at 30 days, 2 years, and 5 years or longer follow-up when compared with SAVR. No statistically significant difference was observed between TAVR and SAVR for reducing the risk of myocardial infarction (MI) at 30 days, 1 year, 2 years, and 5 years or longer follow-up.TAVR was associated with a significantly lower risk of major bleeding events at 30 days (RR=0.38, 95% CI: 0.21-0.67); lower risk of acute kidney injury (AKI) at 30 days (RR=0.38, 95% CI: 0.26-0.54) and 1 year (RR=0.58, 95% CI: 0.41-0.82) and lower risk of new onset or worsening atrial fibrillation (AF) at 30 days (RR=0.25, 95% CI: 0.18-0.34), 1 year (RR=0.26, 95% CI: 0.16-0.41) and 2 years (RR=0.32, 95% CI: 0.20-0.49) when compared with SAVR. However, TAVR was associated with a significantly increased risk of permanent pacemaker implantation (PPI) at 30 days (RR: 2.62, 95% CI: 1.40-4.91), at 1 year (RR: 2.19, 95% CI: 1.24-3.87), at 2 years (RR: 2.74, 95% CI: 1.31-5.71), and beyond 5 years (RR: 1.95, 95% CI: 1.20-3.15). TAVR was also associated with a significantly increased risk of prosthetic valve thrombosis at 2 years (RR=2.70, 95% CI: 1.08-6.71), though no significant association was observed at 30 days, 1 year, or 5 years. Similarly, no significant differences were observed in aortic-valve reintervention rates at 30 days, 2 years, or 5 years, but TAVR showed a significantly increased risk at 1 year (RR=1.98, 95% CI: 1.21-3.24). TAVR was associated with a significantly increased risk of major vascular complications at 30 days (RR=2.37, 95% CI: 1.38-4.04) and a significantly increased risk of TIA at 2 years (RR: 1.43, 95% CI: 1.02-2.00, I2=0%). The risk of hospitalizations was comparable between the groups. TAVR and SAVR demonstrated comparable rates of all-cause death up to 2 years of follow-up. However, at 5 years or longer follow-up, TAVR was associated with a higher risk of all-cause death. While TAVR showed certain procedural advantages, such as a lower risk of major bleeding, AKI, and new-onset or worsening AF, the choice between TAVR and SAVR in patients with low or intermediate surgical risk should consider long-term outcomes, with SAVR potentially being more favorable due to better survival observed on longer follow-up durations.