Acute kidney injury after transcatheter aortic valve implantation: Impact of contrast agents, predictive factors, and prognostic importance in 203 patients with long-term follow-up.

BACKGROUND: Acute kidney injury (AKI) frequently occurs following transcatheter aortic valve implantation (TAVI) and has been related to a worse outcome. We investigated the importance of contrast medium composition, either iso-osmolar (IOCM) or low-osmolar (LOCM) and assessed predictors for AKI after TAVI. METHODS AND RESULTS: We assessed AKI in 203 TAVI patients treated mainly with trans-femoral implantation and analgosedation. A total of 100 patients received IOCM and 103 LOCM. AKI was defined according to the Valve Academic Research Consortium. Following TAVI, 39 patients (19.2%) developed AKI; 17.0% of the IOCM and 21.4% of the LOCM group (p=0.43). The only independent predictor for AKI was baseline serum creatinine [odds ratio (OR) 0.26, 95% confidence interval (CI) 0.01-0.64, p=0.002]. Patients with advanced AKI (stages 2 and 3) post-TAVI had significantly higher mortality at 2 years (log rank p<0.001), whereas patients with AKI stage 1 had a similar long-term outcome to non-AKI patients. CONCLUSIONS: Following TAVI, we observed no difference in the occurrence of AKI between IOCM and LOCM. Baseline creatinine was the only independent predictor of AKI, and patients who developed advanced AKI had significantly higher mortality at 2 years.

Transcatheter aortic valve implantation in patients with severely reduced left ventricular systolic function: a single-center experience.

AIMS: Current guidelines consider severe systolic left ventricular dysfunction [ejection fraction (EF) ≤20 %; left ventricular dysfunction (LVD)] a contraindication for transcatheter aortic valve implantation (TAVI). The purpose of this study was to evaluate the efficacy and safety of TAVI in this extreme risk subset of patients. METHODS AND RESULTS: The study population (253 patients) was divided into two groups; the LVD group [21 patients with left ventricular ejection fraction (LVEF) ≤20 %] and the control group (232 patients with LVEF >20 %). TAVI was generally performed transfemorally under analgosedation without mechanical circulatory support. Clinical and hemodynamic variables, as well as procedural and follow-up outcomes, were compared, and all events were defined according to the Valve Academic Research Consortium criteria for event definition. Mean EF in the LVD group was 18.3 ± 2.9 % compared to 50.9 ± 11.3 % in the control group. Patients in the LVD group were younger, more commonly males, had higher logistic EuroSCORE and lower mean aortic pressure gradients. Immediate procedural mortality was low and similar in both groups (0 vs. 2.2 % in the LVD and control group, respectively, p = 0.49). At 30 days, post-procedural vascular and bleeding complications as well as strokes were similar, but all-cause mortality was higher in the LVD group (14.3 vs. 3.4 %, p = 0.05). In the survivors of the LVD group, New York Heart Association functional class and LVEF significantly improved at 30 days and 6 months. Survival at 1 and 2 years was 70.2 vs. 86.0 % and 56.1 vs. 78.3 % in the LVD and control group, respectively (log-rank p = 0.03). CONCLUSIONS: TAVI without mechanical circulatory support appears feasible, safe and effective in patients with severe aortic stenosis and severe LVD, but short- and long-term mortality remain high. TAVI should be considered a viable treatment option in this subset of extremely compromised patients.

Comparison of outcomes in patients having isolated transcatheter aortic valve implantation versus combined with preprocedural percutaneous coronary intervention.

Coronary artery disease negatively affects the outcome of patients undergoing surgical aortic valve replacement and practice guidelines recommend revascularization at time of surgery. In patients undergoing transcatheter aortic valve implantation (TAVI), the impact of preprocedural percutaneous coronary intervention (PCI) on TAVI outcome has not been examined. We aimed in the present study to assess the feasibility and safety of performing PCI before TAVI and to evaluate procedural, 30-day, and 6-month clinical outcomes. We retrospectively analyzed 125 patients who underwent successful TAVI at a single institution and divided them into an isolated TAVI and a PCI + TAVI group. During the study period, a strategy of preprocedural PCI of all significant (>50%) lesions in major epicardial vessels was adopted. Study end points were adjudicated in accordance with the Valve Academic Research Consortium consensus on event definition. All patients were treated with the Medtronic CoreValve prosthesis (n = 55 with PCI + TAVI and n = 70 with isolated TAVI). Thirty-day mortality was 2% versus 6% for patients treated with PCI + TAVI versus isolated TAVI, respectively (p = 0.27). Neither periprocedural nor spontaneous myocardial infarction occurred in either group. Rates of 30-day stroke, major bleeding, major vascular complications, and the Valve Academic Research Consortium-defined combined safety end point (11% vs 13%, p = 0.74) did not differ between the 2 groups. Patients' symptoms significantly improved in the first month after TAVI, and extent of improvement did not differ between groups. Adverse events at 6 months were comparable. In conclusion, PCI before TAVI appears feasible and safe. Based on these early results revascularization should become an important consideration in patients with coronary artery disease undergoing TAVI.