Impact of osteoporotic risk in men undergoing transcatheter aortic valve replacement: a report from the LAPLACE-TAVI registry.

Low body weight and advanced age are among the best predictors of osteoporosis. Osteoporosis Self-Assessment Tool (OST) values are calculated by a simple formula [(body weight in kilograms - age in years) × 0.2] to identify patients at increased risk of osteoporosis. In our recent single-center study, we demonstrated an association between OST and poor outcomes in postmenopausal women after transcatheter aortic valve replacement (TAVR). We aimed to investigate the impact of osteoporotic risk in men with aortic stenosis who underwent TAVR in a large cohort. In this multi-center study, 1,339 men who underwent TAVR between April 2010 and July 2023 were retrospectively analyzed. Women were excluded from the present study. All patients were deemed appropriate for TAVR after a review by a multidisciplinary team. Baseline characteristics of patients were compared by dividing patients into three tertiles, based on the OST value: ≤ - 6.16, - 6.16 to - 4.14, and - 4.14 < for tertiles 1, 2, and 3, respectively. Primary endpoint was all-cause mortality after TAVR. Tertile 1 (patients with the lowest OST values) included older patients with smaller body mass index, lower hemoglobin and albumin levels. In addition, they had greater clinical frailty scale, slower 5-meter walk test, weaker hand grip strength, and more cognitive impairment, indicating increased frailty. They were more severely symptomatic, with lower ejection fractions, smaller aortic valve areas, and more tricuspid regurgitation than were patients in the other two groups. Multivariate analysis revealed that OST tertiles 3 was associated with decreased risk of all-cause mortality (hazard ratio, 0.66; 95% confidence interval, 0.48-0.90), compared with OST tertile 1 as a reference. For OST tertiles 1, 2, and 3, the estimated 1-year survival rates of all-cause mortality post-TAVR were 83.6% ± 1.9%, 91.1% ± 1.4%, and 93.1% ± 1.3%, respectively, (log-rank, p < 0.001).　In conclusions, in men as same as women, osteoporotic risk assessed by OST values was overlapped with increased frailty. The simple OST formula was useful for predicting all-cause mortality in patients undergoing TAVR in large registry datasets.

Pneumococcal infectious aortic aneurysm: A caution for a life-threatening vascular complication caused by non-vaccine-covered serotypes.

The 23-valent pneumococcal polysaccharide vaccine (PPSV23) has contributed to reducing pneumonia caused by Streptococcus pneumoniae. However, in Japan, invasive pneumococcal diseases caused by non-vaccine-covered serotypes have increased over the years. A 73-year-old man with a history of PPSV23 was referred to our hospital due to persistent fever and back pain following pneumococcal pneumonia. Contrast-enhanced computed tomography revealed an infectious aneurysm (IAA) at the distal part of the aortic arch. The patient was surgically treated with in situ aortic reconstruction and administered antibiotics. On pathogenic examination of the resected IAA, atherosclerotic changed aortic wall, neutrophil infiltration, and abscesses were observed. Although multiple blood culture tests were negative, tissue culture tests and 16S ribosomal RNA gene-based polymerase chain reaction identified S. pneumoniae. According to capsular polysaccharide synthesis B gene-based serotyping, the serotype was identified as 23A, which is not covered with PPSV23. Serotype 23 is among the most frequently identified serotypes in recent years and associated with in-hospital mortality. Although several pneumococcal serotypes are responsible for lethal infections, the association between these serotypes and disease is uncertain. Further studies on the association between pneumococcal serotypes and IAA, and the development of a broader-covered vaccine are required. Learning objective: •To be able to make a differential diagnosis of invasive pneumococcal pneumonia in patients with persistent fever and newly emerging back pain following pneumococcal infection.•To understand the importance of combining culture tests and molecular analysis to diagnose invasive pneumococcal diseases accurately.•To understand the threat of non-vaccine-covered serotypes even in patients with vaccination histories because the vaccine is limited to only one-fourth of all pneumococcal serotypes.

Frailty assessment using photographs in patients undergoing transcatheter aortic valve replacement.

BACKGROUND: When frailty is considered in patient selection, better outcomes are achieved in transcatheter aortic valve replacement (TAVR) procedures. This study investigated whether patient photographs could be utilized to qualitatively assess patient frailty and independently predict poor outcomes following TAVR. METHODS: This study included 1345 patients with severe aortic stenosis who underwent TAVR at the Sakakibara Heart Institute, Japan, between 2013 and 2022. Patient photographs were taken prior to the initial outpatient clinic examination or at discharge in case the patient's first visit was unplanned admission. Frailty was assessed from patient photographs using a four-point photographic frailty scale; 1 (non-frail), 2 (vulnerable), 3 (mild frail), and 4 (frail). Photographic frailty scale of 3 and 4 were defined as high. The primary endpoint was all-cause mortality following TAVR. RESULTS: Seven hundred ninety-six patients who had their facial photographs taken within six months before the TAVR procedure were analyzed. Patients with a higher photographic frailty scale belonged to New York Heart Association classes III/IV, and had higher Society of Thoracic Surgeons scores, higher incidence of wheelchair usage, lower hemoglobin, and smaller aortic valve areas. According to the frailty assessment, patients with a higher photographic frailty scale exhibited slower performance in the 5-m walk test, reduced hand grip strength, more severe dementia, had a higher clinical frailty scale, and lower serum albumin level. Multivariable Cox regression analysis revealed that the high photographic frailty scale was independently associated with all-cause mortality (adjusted hazard ratio 1.62, 95 % confidence interval 1.12-2.33, p = 0.010). Kaplan-Meier analysis indicated that patients with high photographic frailty scale had higher all-cause mortality rates compared to those with low scale (log-rank p = 0.011). CONCLUSIONS: Patient registration photographs can be used to obtain qualitative assessments of frailty in severe aortic stenosis cases, and such assessments can independently predict poor outcomes following TAVR.

Impact of osteoporotic risk in women undergoing transcatheter aortic valve replacement.

Low body weight and advanced age are reported to be among the best predictors of osteoporosis, and osteoporosis self-assessment tool (OST) values are calculated using a simple formula to identify postmenopausal women at increased risk of osteoporosis. In our recent study, we demonstrated an association between fractures and poor outcomes in postmenopausal women following transcatheter aortic valve replacement (TAVR). In this study, we aimed to investigate the osteoporotic risk in women with severe aortic stenosis and determined whether an OST could predict all-cause mortality following TAVR. The study population comprised 619 women who underwent TAVR. Compared to a quarter of patients with diagnosis of osteoporosis, 92.4% of participants were at high risk of osteoporosis based on OST criteria. When divided into tertiles based on OST values, patients in tertile 1 (lowest OST) displayed increased frailty, a higher incidence of multiple fractures, and greater Society of Thoracic Surgeons scores. Estimated all-cause mortality survival rates 3 years post-TAVR were 84.2 ± 3.0%, 89.5 ± 2.6%, and 96.9 ± 1.7% for OST tertiles 1, 2, and 3, respectively (p = 0.001). Multivariate analysis showed that the OST tertile 3 was associated with decreased risk of all-cause mortality compared with OST tertile 1 as the referent. Notably, a history of osteoporosis was not associated with all-cause mortality. Patients with high osteoporotic risk are highly prevalent among those with aortic stenosis according to the OST criteria. OST value is a useful marker for predicting all-cause mortality in patients undergoing TAVR.

Risk of Sinus Sequestration During Redo Transcatheter Aortic Valve Implantation: The Prevalence, Predictors, and Risk Stratification.

The number of patients who underwent transcatheter aortic valve implantation (TAVI) with the potential for reintervention is steadily increasing; however, there is a risk of sinus sequestration (SS) during a redo TAVI. The prevalence, predictors, and risk stratification of the risk for SS remain uncertain. We analyzed computed tomography acquired from 263 patients who underwent TAVI between 2021 and 2022: balloon-expandable valve (BEV) (71%) and self-expandable valve (SEV) (29%). Patients were considered at risk for SS if they met the following: (1) BEV frame > sinotubular junction (STJ) or SEV neocommissure greater than the STJ and (2) valve-to-STJ <2 mm. The risk of left, right, and any SS in 51%, 50%, and 65%, respectively, did not differ between BEV and SEV. The predictors of any SS were the height of the left and right coronary cusp (odds ratio [OR] 0.81 and 0.71, cutoff 18.6 and 19.2 mm, respectively) and STJ minus the annulus diameter (OR 0.65, cutoff 3.7 mm) in BEV, and STJ diameter (OR 0.47, cutoff 27.6 mm) in SEV. The number of predictors stratified the risk of any SS: low risk with BEV at 0 predictors (14% at risk of SS), intermediate risk at 1 predictor (65%), high risk at 2 or 3 predictors (81% and 95%), and low risk with SEV at 0 predictors (33%) versus high risk at 1 predictor (91%). In conclusion, 2/3 of patients who underwent TAVI were at risk of SS. The height of the coronary cusp and the STJ diameter were associated with and adequately stratified the risk of SS.

Outcomes of Octogenarians and Nonagenarians in a Contemporary Cardiac Care Unit　- Insights From 2,242 Patients Admitted Between 2019 and 2021.

Background: The number of octo- and nonagenarians admitted to cardiac care units (CCUs) has been increasing in the context of an aging society; however, clinical details and outcomes for these patients are scarce. Methods and Results: Data from 2,242 consecutive patients admitted to the CCU between 2019 and 2021 (age <80 years, 1,390 [62%]; octogenarians, 655 [29%]; nonagenarians, 197 [8.7%]) were reviewed using the in-hospital database for the Tokyo CCU Network. The primary cause of admission was acute coronary syndrome in younger patients and octogenarians (58% and 49%, respectively) and acute heart failure (AHF) in nonagenarians (42%). The proportions of females, underweight, hypertension, atrial fibrillation, myocardial infarction, stroke, previous heart failure, anemia, and malnutrition were higher among octo- and nonagenarians than among younger patients. In-hospital and 1-year mortality rates were greater in octo- and nonagenarians (younger vs. octogenarian vs. nonagenarian, 2.0% vs. 3.8% vs. 5.6% and 4.1% vs. 11.9% vs. 19.0%, respectively). Multivariate analysis revealed that 1-year mortality was associated with octo-/nonagenarian status (odds ratio [OR] 2.24 and 2.64), AHF (OR 2.88), body mass index (OR per 1-kg/m2 0.91), and albumin concentration (OR per 1-g/dL 0.27). Conclusions: Approximately 40% of patients admitted to the CCU were octo- or nonagenarians, and being an octo- or nonagenarian, having AHF, a lower body mass index, and lower albumin concentrations were associated with 1-year mortality after CCU admission.

Predictors for all-cause mortality in men after transcatheter aortic valve replacement: A report from the LAPLACE-TAVI registry.

Background: Information regarding the outcomes of transcatheter aortic valve replacement (TAVR) in men is limited. This study aimed to investigate short- to mid-term outcomes and prognostic predictors in this population. Method and Results: The data of 519 men were analyzed from 1,693 consecutive patients with symptomatic severe aortic stenosis who underwent TAVR at six hospitals between April 2010 and July 2020. The primary endpoint was all-cause mortality at 30 days after TAVR. The mean age and Society of Thoracic Surgeons (STS) score were 83.7 ± 5.9 years and 6.3 ± 4.7%, respectively. Overall, 23.5% of patients consumed alcohol with a frequency of > 1 drinks/week, and 12.1% consumed alcohol with a frequency of > 8 drinks/week, while 66.1% were former smokers and 4.2% were current smokers. Mortality at 30 days was 0.8%. During the median follow-up period of 448 days, the estimated survival rates at 1 year post-TAVR was 90.7 ± 1.4%. In multivariate analysis, the serum albumin level [hazard ratio (HR): 2.20, 95% confidence interval (CI):1.36-3.62, p = 0.001], atrial fibrillation (HR: 1.79, 95% CI: 1.13-2.82, p = 0.012), and STS score (HR: 1.33, 95% CI: 1.06-1.67, p = 0.015) were independently associated with all-cause mortality following TAVR. Adjusted hazard ratios of current smoking, heavy drinking, and presence of cancer were 1.05 (95% CI: 0.36-2.98),1.37 (95% CI: 0.75-2.48), and 1.13 (95% CI: 0.75-2.48), respectively. Conclusion: Our study demonstrated that serum albumin levels, atrial fibrillation, and STS score were independently associated with all-cause mortality following TAVR in men.

Discrepancy between invasive and echocardiographic transvalvular gradient after TAVI: Insights from the LAPLACE-TAVI registry.

BACKGROUND: Echocardiography-based transvalvular mean pressure gradient (ECHO-mPG) used to assess the forward valve function and structural valve deterioration could overestimate the true pressure gradient. This study evaluated the discrepancy between invasive and ECHO-mPG after transcatheter aortic valve implantation (TAVI) with respective valve type and size, its impact on a device success criterion, and predictors of a pressure discrepancy. METHODS: We analyzed 645 patients registered in a multicenter TAVI registry (balloon-expandable valve [BEV]: 500; self-expandable valve [SEV]: 145). The invasive transvalvular mPG was measured after valve implantation using two Pigtail catheters (CATH-mPG), while the ECHO-mPG was measured within 48 h after TAVI. Pressure recovery (PR) was calculated using the following formula: ECHO-mPG × effective orifice area (EOA)/ascending aortic area (AoA) × (1 - EOA/AoA). RESULTS: ECHO-mPG was weakly correlated with (r = 0.29, p < 0.0001), and consistently overestimated CATH-mPG in both BEV and SEV, and respective valve sizes. The magnitude of the discrepancy was larger for BEV than SEV (p < 0.001) and smaller valves (p < 0.001). After the correction of PR using the above formula, the pressure discrepancy remained for BEV (p < 0.001) but not SEV (p = 0.10). The proportion of patients with an ECHO-mPG > 20 mmHg decreased from 7.0% to 1.6% after correction (p < 0.0001). Among the baseline and procedural variables, post-procedural ejection fraction, BEV versus SEV, and smaller valves were associated with a larger discrepancy in mPG. CONCLUSIONS: ECHO-mPG could be overestimated after TAVI, especially in patients with a smaller BEV. A higher ejection fraction, BEV, and smaller valves were predictors of a pressure discrepancy between CATH- and ECHO-mPG.

Transcatheter edge-to-edge mitral valve repair with extended clip arms for ventricular functional mitral regurgitation.

BACKGROUND: The new sizing options of the MitraClip system (Abbott Vascular, Abbott Park, IL, USA) with extended clip arms were recently developed. Its applicability and effectiveness for ventricular functional mitral regurgitation (VFMR) are yet to be investigated. METHODS: We retrospectively reviewed consecutive patients with symptomatic VFMR who underwent transcatheter edge-to-edge repair between 2018 and 2022 at the Sakakibara Heart Institute. Pre- and post-procedural mitral valve morphologies were assessed using three-dimensional transesophageal echocardiography. RESULTS: In a total of 104 VFMR patients, the posterior mitral leaflet length was 12.8 ±â€¯2.8 mm and 92 % was indicative of the extended arm (≥9 mm). Although baseline VFMR was more severe in the patients treated with the extended arms (n = 35, XT group) than the patients treated with the standard arms (n = 69, NT group), the decrease in VFMR was greater in the XT group (delta three-dimensional vena contracta area - 43 ±â€¯33 mm2 vs. -31 ±â€¯22 mm2, p = 0.030) and residual VFMR was similar between the groups, with a significantly greater reduction in the mitral annulus anterior-posterior diameter (-4.9 ±â€¯2.2 mm vs -3.1 ±â€¯2.1 mm, p < 0.001) and mitral annulus area in the XT group. The use of extended arms was independently associated with shorter procedure time (81 ±â€¯26 min vs 108 ±â€¯41 min) after adjustment for device generation and the number of clips (p = 0.017). CONCLUSIONS: Most VFMR patients had enough leaflet lengths for transcatheter edge-to-edge repair using the MitraClip with the extended arms, which was associated with shorter procedure time and a greater decrease in the mitral annular size.

Long-Sheath Assisted Transcatheter Aortic Valve Replacement: The Best and Worst Cases.

Transfemoral transcatheter aortic valve replacement (TAVR) is quite challenging in patients with tortuous aorta. Recently, the combined method of buddy wire and long-sheath use was reported. We describe 2 cases having tortuous aorta undergoing transfemoral TAVR following opposite clinical courses. A long-sheath supported transfemoral approach is an effective method in patients with tortuous aorta; however, the tip of a large-bore sheath could cause an aortic injury during the procedure. The advantage of the transfemoral approach and risk of aortic injury should be counterbalanced, especially in patients with fragile tortuous aorta.

Impact of periprocedural bleeding on mid-term outcome in nonagenarians who underwent transcatheter aortic valve implantation: insights from LAPLACE registry.

Data from several recent studies have demonstrated the safety and efficacy of transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS) even in nonagenarians. However, the impact of periprocedural bleeding following TAVI on their outcome remains unclear. In the aLliAnce for exPloring cLinical prospects of AortiC valvE disease (LAPLACE) registry, we compared outcomes between the bleeding and no-bleeding groups among 1953 patients < 90 years old (mean age, 83.0 ± 4.6 years old) and 316 nonagenarians (mean age, 91.7 ± 1.9 years old) who underwent TAVI with a median follow-up period of 628 days. The group with any periprocedural bleeding showed a higher 30-day mortality than the no-bleeding group in patients < 90 years old (3.3% vs. 0.5%, p = 0.001) and nonagenarians (7.9% vs. 0.7%, p = 0.001). In patients < 90 years old, severe periprocedural bleeding (n = 85) was associated with a higher mid-term all-cause mortality rate than no severe bleeding (n = 1,868), even after adjusting for covariates (hazard ratio [HR], 1.994; 95% confidence interval [CI] 1.287-2.937; p = 0.002). On the other hand, in nonagenarians, any periprocedural bleeding (n = 38) was associated with a higher mid-term cardiovascular (CV) mortality rate (21.1% vs. 4.3%, log-rank p = 0.014) than no bleeding (n = 278), even after adjusting for covariates (HR, 3.104; 95% CI 1.140-8.449; p = 0.027). In conclusion, any periprocedural bleeding after TAVI was associated with mid-term CV mortality in nonagenarians, whereas severe bleeding was associated with mid-term all-cause mortality in patients < 90 years old.

Midterm Outcomes of Underweight Patients Undergoing Transcatheter Aortic Valve Implantation: Insight From the LAPLACE-TAVR Registry.

Background: Obesity is a major risk factor for cardiovascular disease; however, a paradoxical effect of obesity has been reported in patients with heart failure or myocardial infarction. Although several studies have suggested the same obesity paradox in patients undergoing transcatheter aortic valve replacement (TAVR), they included a limited number of underweight patients. Objectives: This study aimed to clarify the effect of being underweight on TAVR outcomes. Methods: We retrospectively analyzed 1,693 consecutive patients undergoing TAVR between 2010 and 2020. The patients were categorized according to body mass index: underweight (<18.5 kg/m2; n = 242), normal weight (18.5 to 25 kg/m2; n = 1,055), and overweight (>25 kg/m2; n = 396). We compared midterm outcomes after TAVR among the 3 groups; all clinical events were in accordance with the Valve Academic Research Consortium-2 criteria. Results: Underweight patients were more likely to be women and have severe heart failure symptoms, peripheral artery disease, anemia, hypoalbuminemia, and pulmonary dysfunction. They also had lower ejection fractions, smaller aortic valve areas, and higher surgical risk scores. Device failure, life-threatening bleeding, major vascular complications, and 30-day mortality occurred more frequently in underweight patients. The midterm survival rate of the underweight group was inferior to those of the other 2 groups (P < 0.0001; average follow-up, 717 days). In the multivariate analysis, underweight was associated with noncardiovascular mortality (HR: 1.78; 95% CI: 1.16-2.75) but not cardiovascular mortality (HR: 1.28; 95% CI: 0.58-1.88) after TAVR. Conclusions: Underweight patients had a worse midterm prognosis, demonstrating the obesity paradox in this TAVR population. (Outcomes of transcatheter aortic valve implantation in Japanese patients with aortic stenosis: multi-center registry; UMIN000031133).

Favorable Prognosis in Patients with Recovered Pulmonary Hypertension after TAVI: An Analysis of the LAPLACE-TAVI Registry.

Pulmonary hypertension (PH) is a common complication of aortic stenosis (AS). Despite the established association between PH and poor outcomes in patients with AS, the prognostic implication of a change in PH after transcatheter aortic valve implantation (TAVI) has been rarely evaluated. This study analyzed a prospective multi-center TAVI registry database involving six Japanese centers and used the transtricuspid pressure gradient (TRPG) obtained by echocardiography to estimate pulmonary artery systolic pressure. The participants (n = 2056) were first divided into two groups by TRPG before TAVI, a PH (−) group (TRPG < 30 mmHg) (n = 1407, 61.9%) and a PH (+) group (TRPG ≥ 30 mmHg) (n = 649, 28.6%). Next, by TRPG after (4.1 ± 5.3 days) TAVI, the PH (+) group was further subdivided into two groups, Recovered PH (TRPG < 30 mmHg, n = 253) and Persistent PH (TRPG after TAVI ≥ 30 mmHg, n = 396). The median follow-up duration was 1.8 years. The primary and secondary endpoints were the composite and each of cardiovascular (CV) death and heart failure hospitalization, respectively. Unadjusted Kaplan-Meier estimates with log-rank comparisons showed significantly higher cumulative incidences of primary and secondary endpoints in the Persistent PH group compared to other groups. Moreover, adjusted multivariate Cox-proportional hazard analyses showed that a decreased (−10 mmHg) TRPG after TAVI was linearly associated with a reduced risk of the primary endpoint (hazard ratio (HR): 0.76, 95% confidence interval (CI): 0.64−0.90, p = 0.0020). The findings in the present study indicate that the recovery of PH may partly contributes to the prognostic benefit of TAVI procedure in patients with AS and elevated pulmonary artery systolic pressure.

Transcatheter aortic valve replacement-related aortic dissection: A clinical case series.

OBJECTIVES: We review our experience with 13 periprocedural aortic dissection (AD) cases caused by transcatheter aortic valve replacement (TAVR). BACKGROUND: AD is a potentially lethal complication of TAVR; however, only sporadic case reports have been published to date. METHODS: Among 1335 consecutive patients who underwent TAVR in 2013-2021, we retrospectively extracted 13 patients (1.0%) with TAVR-related AD (Stanford type A in 6 [46%], type B in 7 [54%]). AD was defined as a new-onset dissected layer of the aortic wall and diagnosed by aortography, computed tomography, or transesophageal echocardiography. RESULTS: Five of the six type A AD cases (83%) were detected during TAVR versus only one of the seven type B AD cases (14%). Four of the seven type B AD cases (57%) were asymptomatic and incidentally detected on computed tomography. The presumed causes of AD were injury by the delivery sheath (39%), delivery catheter (23%), valve implantation (15%), stent edge (15%), and pre-dilation balloon (8%). Complicated AD occurred in only one patient (8%). Considering the patient's age and prohibitive surgical risk, all patients were treated conservatively and free of any aortic-related deaths or interventions during a follow-up of 1087 days. CONCLUSIONS: TAVR-related AD is a rare but life-threatening condition that may be underdiagnosed. Its optimal therapy remains unclear, and conservative management might be an option for selected patients. Further studies are needed to elucidate the incidence, risk factors, effective screening, optimal therapy, and outcomes of TAVR-related AD.