TAVI for patients with normal-flow low-gradient compared to high-gradient aortic stenosis.

BACKGROUND: Normal-flow (stroke volume index, SVi >35 ml/m2) low-gradient (dPmean <40 mmHg) aortic stenosis (NFLG-AS) is subject of scientific debate. Guidelines fail to give conclusive treatment recommendations. We hypothesized that NFLG patients are heterogenous, containing a subgroup similar to high-gradient aortic stenosis patients (dPmean ≥40 mmHg, HG-AS) concerning characteristics and outcomes. METHODS: 2326 patients undergoing transcatheter aortic valve replacement (TAVI) at our centre between 2013 and 2019 were analysed. 386 patients fulfilled criteria of NFLG-AS. Their median dPmean was 33 mmHg, which was used for grouping (204 patients with higher gradient NFLG-AS, 186 patients with lower gradient NFLG-AS). They were compared to 956 HG-AS patients. RESULTS: Characteristics of lower gradient NFLG-AS patients differed from HG-AS patients in many aspects while higher gradient NFLG-AS and HG-AS patients were mostly similar, underscored by higher Society of Thoracic Surgeons scores in lower gradient NFLG-AS (lower gradient NFLG-AS, 3.9, HG-AS, 3.0, p = 0.03, higher gradient NFLG-AS, 3.0, p = 0.04). Procedural complications were comparable. Estimated 3-year all-cause mortality was higher in lower gradient NFLG-AS compared to HG-AS patients (hazard ratio 1.7, p < 0.01), whereas mortality of higher gradient NFLG-AS was similar to HG-AS patients (hazard ratio 1.2, p = 0.31). Cardiovascular mortality was highest among lower gradient NFLG-AS patients (21.6% vs. higher gradient NFLG-AS, 15.4%, vs. HG-AS, 11.1%, p < 0.01). CONCLUSIONS: NFLG-AS patients are indeed heterogenous. NFLG-AS patients with higher gradients resemble HG-AS patients in clinical characteristics and outcomes and should not be treated differently. Lower gradient NFLG-AS patients have increased long-term mortality and the use of TAVI requires careful consideration.

Systolic or diastolic CT image acquisition for transcatheter aortic valve replacement - An outcome analysis.

BACKGROUND: Computed tomography (CT) imaging is the standard of care before transcatheter aortic valve replacement (TAVR). The aortic annulus undergoes conformational changes during the heart cycle. Therefore, the image acquisition time point can impact prosthesis sizing and fit. Clinical outcome data are lacking. The aim of this study was to compare systolic and diastolic cardiac CT data acquisition with regard to procedural and clinical outcomes in patients undergoing TAVR for severe aortic stenosis (AS). METHODS: Preprocedural high-pitch helical CT datasets were analyzed in 1954 patients undergoing TAVR between 2013 and 2018 â€‹at our center. Patients were stratified into two groups according to the acquisition heart phase (979 systolic and 975 diastolic). The study was approved by the local ethics committee. RESULTS: Median age was 81.6 [interquartile range 77.5-85.8] years and 964 (49.3%) patients were male. No significant difference was found for the Valve Academic Research Consortium-3 (VARC-3) endpoints of technical failure (systolic, 5.1% vs. diastolic, 5.2%, p â€‹= â€‹0.94) or device failure (systolic, 13.7% vs. diastolic, 13.5%, p â€‹= â€‹0.92). There was no difference in paravalvular regurgitation. All-cause 30-day mortality was comparable (systolic, 3.6% [95% confidence interval, 2.4-4.7%] vs. diastolic, 3.6% [2.4-4.8%], p â€‹= â€‹1.00), while 3-year mortality rates were higher in the diastolic group (Society of Thoracic Surgeons score adjusted hazard ratio, 1.25 [1.07-1.46], p â€‹< â€‹0.01). CONCLUSIONS: While the 30-day technical and clinical outcomes after TAVR are comparable between systolic and diastolic CT imaging, diastolic imaging was associated with higher long-term mortality. Therefore, the data support the guideline recommendation of systolic imaging.

TAVI in patients with low-flow low-gradient aortic stenosis-short-term and long-term outcomes.

OBJECTIVES: The study objective was to characterize different groups of low-flow low-gradient (LFLG) aortic stenosis (AS) and determine short-term outcomes and long-term mortality according to Valve Academic Research Consortium-3 (VARC-3) endpoint definitions. BACKGROUND: Characteristics and outcomes of patients with LFLG AS undergoing transcatheter aortic valve implantation (TAVI) are poorly understood. METHODS: All patients undergoing TAVI at our center between 2013 and 2019 were screened. Patients were divided into three groups according to mean pressure gradient (dPmean), ejection fraction (LVEF), and stroke volume index (SVi): high gradient (HG) AS (dPmean ≥ 40 mmHg), classical LFLG (cLFLG) AS (dPmean < 40 mmHg, LVEF < 50%), and paradoxical LFLG (pLFLG) AS (dPmean < 40 mmHg, LVEF ≥ 50%, SVi ≤ 35 ml/m2). RESULTS: We included 1776 patients (956 HG, 447 cLFLG, and 373 pLFLG patients). Most baseline characteristics differed significantly. Median Society of Thoracic Surgeons (STS) score was highest in cLFLG, followed by pLFLG and HG patients (5.0, 3.9 and 3.0, respectively, p < 0.01). Compared to HG patients, odds ratios for the short-term VARC-3 composite endpoints, technical failure (cLFLG, 0.76 [95% confidence interval, 0.40-1.36], pLFLG, 1.37 [0.79-2.31]) and device failure (cLFLG, 1.06 [0.74-1.49], pLFLG, 0.97 [0.66-1.41]) were similar, without relevant differences within LFLG patients. NYHA classes improved equally in all groups. Compared to HG, LFLG patients had a higher 3-year all-cause mortality (STS score-adjusted hazard ratios, cLFLG 2.16 [1.77-2.64], pLFLG 1.53 [1.22-193]), as well as cardiovascular mortality (cLFLG, 2.88 [2.15-3.84], pLFLG, 2.08 [1.50-2.87]). CONCLUSIONS: While 3-year mortality remains high after TAVI in LFLG compared to HG patients, symptoms improve in all subsets after TAVI.