Valve-in-valve transcatheter aortic valve implantation: The issues behind crossing a bioprosthesis.

Valve-in-valve transcatheter aortic valve implantation (ViV TAVI) is rapidly arising as a safe and effective alternative to redo-surgery in the treatment of bioprostheses deterioration. While scientific community is currently focusing its attention on the most common limitations related to this procedure, such as the risk of coronary obstruction and patient-prosthesis mismatch, data regarding the first step of a ViV TAVI, the crossing of a degenerated bioprosthesis, are still lacking. The aim of this review is to analyze the available information about bioprosthesis crossing, to show the inherent challenges encountered by interventional cardiologists during valve crossing and to describe the current strategies to perform a correct crossing.

A European Society of Oncologic Imaging (ESOI) survey on the radiological assessment of response to oncologic treatments in clinical practice.

OBJECTIVES: To present the results of a survey on the assessment of treatment response with imaging in oncologic patient, in routine clinical practice. The survey was promoted by the European Society of Oncologic Imaging to gather information for the development of reporting models and recommendations. METHODS: The survey was launched on the European Society of Oncologic Imaging website and was available for 3 weeks. It consisted of 5 sections, including 24 questions related to the following topics: demographic and professional information, methods for lesion measurement, how to deal with diminutive lesions, how to report baseline and follow-up examinations, which previous studies should be used for comparison, and role of RECIST 1.1 criteria in the daily clinical practice. RESULTS: A total of 286 responses were received. Most responders followed the RECIST 1.1 recommendations for the measurement of target lesions and lymph nodes and for the assessment of tumor response. To assess response, 48.6% used previous and/or best response study in addition to baseline, 25.2% included the evaluation of all main time points, and 35% used as the reference only the previous study. A considerable number of responders used RECIST 1.1 criteria in daily clinical practice (41.6%) or thought that they should be always applied (60.8%). CONCLUSION: Since standardized criteria are mainly a prerogative of clinical trials, in daily routine, reporting strategies are left to radiologists and oncologists, which may issue local and diversified recommendations. The survey emphasizes the need for more generally applicable rules for response assessment in clinical practice. CRITICAL RELEVANCE STATEMENT: Compared to clinical trials which use specific criteria to evaluate response to oncological treatments, the free narrative report usually adopted in daily clinical practice may lack clarity and useful information, and therefore, more structured approaches are needed. KEY POINTS: · Most radiologists consider standardized reporting strategies essential for an objective assessment of tumor response in clinical practice. · Radiologists increasingly rely on RECIST 1.1 in their daily clinical practice. · Treatment response evaluation should require a complete analysis of all imaging time points and not only of the last.

Patients younger than 70 undergoing transcatheter aortic valve implantation: Procedural outcomes and mid-term survival.

INTRODUCTION: Based on recent data, the indication for transcatheter aortic valve implantation (TAVI) is expanding to individuals at lower surgical risk, who are generally younger than subjects historically treated for severe aortic stenosis. Indeed, younger patients have traditionally been under-represented in current TAVI literature. The aim of the present study is to report about clinical features, procedural outcomes and mid-term outcomes of patients younger than 70 who underwent TAVI in a single high-volume center. MATERIALS AND METHODS: Consecutive patients younger than 70 years of age who underwent TAVI for severe, symptomatic aortic stenosis between 2007 and 2019 at a single, tertiary referral center have been included in this retrospective study. Procedural and mid-term outcomes were analyzed, comparing 1st generation with 2nd generation devices. RESULTS: Between 2007 and 2019, 1740 TAVI procedures were performed in our center. Among these, one hundred twenty-nine (7.4%) patients were younger than 70 years at the time of the intervention and were included in the present analysis. Fifty-eight patients (45%) were implanted with a 1st generation prosthesis while seventy-one patients (55%) were implanted with a 2nd generation device. Reasons which lead to a transcatheter approach in this population were: previous CABG (27.9%); porcelain aorta (24%); severe left ventricular systolic dysfunction (21.7%); prior chest radiation (19.4%); severe lung disease (8.5%); hemodynamic instability (7.0%); advanced liver disease (4.6%) and active cancer (3.9%). Overall device success rate was 89%, with no differences among 1st and 2nd generation devices. Threeyears all-cause mortality was 34%, with no difference among the two groups. Low incidence of aortic-valve re-intervention was observed at mid-term follow-up (late valve re-intervention = 2.3%). CONCLUSIONS: TAVI in young patient with appropriate indication for intervention is a safe procedure, associated with low rate of in hospital mortality and low rate of severe complications both with 1st and with 2nd generation devices. When considering long term durability, more data are needed; in our case series long-term follow up shows a good survival and also an extremely low rate of valve re-intervention.

First-in-man Valve-in-Valve with the new balloon-expandable Myval transcatheter heart valve in a failed sutureless Perceval bioprosthesis.

Sutureless aortic bioprostheses were introduced more than ten years ago, with the aim of decreasing cross-clamp time and thus becoming the first choice in older patients for many surgeons. However, published data are limited to a 5-year follow-up, and some cases of deterioration have already been described. High-risk patients who once have benefitted from a fast sutureless aortic replacement and now are experiencing a prosthesis dysfunction, could take advantage of a percutaneous Valve-in-Sutureless technique. Furthermore, thanks to technological improvement, new transcatheter prostheses have been designed, allowing a more precise positioning. In this report, we described the first Myval-in-Perceval case, which resulted in a safe and effective procedure.

Surgical feasibility of ascending aorta manipulation after transcatheter aortic valve implantation: a computed tomography theoretical analysis.

AIMS: The expansion of TAVI will involve an increase in the frequency of emergent or late cardiac surgery after THV implantation. This study was designed to investigate the anatomical feasibility of surgical cross-clamp and aortotomy after TAVI through a post-TAVI CT-scan assessment. METHODS AND RESULTS: We retrospectively analysed 117 CTs acquired after TAVI procedures with high stent prostheses in three high-volume centres between October 2008 and May 2017. The mean distance observed between the innominate artery and the top of the transcatheter heart valve was 45±11 mm, being <30 mm in 8/117 (6.8%) patients and <20 mm in none. The mean distance between the sinotubular junction and the first free site for aortotomy was 22±7 mm (>20 mm in 78/117 [66.7%] cases). A total of 56/117 (47.9%) patients showed a complete continuous contact between the anterior aortic wall and the anterior part of the valve stent. CONCLUSIONS: Aortic cross-clamp appears not to be an issue when cardiac surgery is needed after TAVI; however, a careful and possibly higher aortotomy may be required. CT should be performed prior to planned cardiac surgery after TAVI to determine a safe positioning for aortic cross-clamp and aortotomy.

[Aortic annulus rupture during transcatheter aortic valve implantation: complication prevention and management]. / Rottura dell'anello aortico durante impianto transcatetere di valvola aortica: prevenzione e gestione della complicanza.

Aortic annulus rupture is a dangerous complication of transcatheter aortic valve implantation, with an overall incidence of around 1%. Ruptures can be distinguished into supra-annular, involving injuries of the sinus of Valsalva and the sinotubular junction, annular, involving the fibrous portion of the aortic annulus, and sub-annular, located in the left ventricular outflow tract below the aortic valve cusp insertion. Annular rupture can be "contained", which usually evolves in aortic hematoma or pseudoaneurysm and rarely requires emergent cardiac surgery; or "non-contained", acutely evolving in hemopericardium with cardiac tamponade, often requiring emergent cardiac surgery and with an in-hospital mortality of 75%. Balloon-expandable oversizing and severe left ventricular outflow tract calcifications, especially under the left coronary cusp, are the most important risk factors for annular rupture. A careful computed tomography scan-based procedural planning is of paramount importance to reduce the risk of this complication. The presence and extension of left ventricular outflow tract calcifications, together with precise measurement of the virtual basal ring, should drive the operator to the right choice of prosthesis type and size in order to prevent this terrible complication.

Self-expandable valve-in-valve treatment for failing sutureless aortic bioprosthesis.

Aortic valve replacement still represents the gold standard treatment for severe symptomatic aortic stenosis. Sutureless bioprostheses have been so far developed to enhance the minimally invasive approach, resulting in a reduction of cross-clamp time. Even if the first implantation was carried out more than 10 years ago, some cases of valve degeneration treated with balloon-expandable valve-in-valve procedures have been previously described in the literature. Here, we present a case of early sutureless valve degeneration resulting in severe aortic regurgitation. After careful evaluation of the patient's comorbidities, a successful valve-in-valve was finally performed using a self-expandable transcatheter prosthesis. A wide discussion of the Heart Team decision-making process and of the technical aspects has been addressed.

Sex and Transcatheter Aortic Valve Implantation: Impact of Female Sex on Clinical Outcomes.

Transcatheter aortic valve implantation (TAVI) has emerged as an alternative treatment for severe symptomatic aortic stenosis in patients who are not suitable for surgery or are at high surgical risk. Approximately 50% of patients undergoing TAVI are female and this is reflected by a higher inclusion rate of women in TAVI trials. However, women undergoing TAVI have different baseline clinical characteristics in comparison to men, with fewer comorbidities and a more preserved left ventricular ejection fraction. This translates into favourable outcomes after TAVI, despite a higher rate of peri-procedural complications. This article discusses gender differences in terms of presentation, procedural characteristics and post-procedural results in patients with aortic stenosis undergoing TAVI, with particular focus on possible sex-specific factors affecting outcome.

Impact of Ascending Aorta Dilation on Mid-Term Outcome After Transcatheter Aortic Valve Implantation.

BACKGROUND: Severe aortic stenosis (AS) is often associated with ascending aorta dilation (AAD). AAD is amenable to surgical correction combined with aortic valve replacement. Transcatheter aortic valve implantation (TAVI) might represent a valid therapeutic option in these patients when AAD correction Is not indicated. The aim of the present study is to evaluate the impact of concomitant AAD on early and mid-term outcomes after TAVI for symptomatic severe AS. METHODS: This is a single-center observational study including patients undergoing transfemoral TAVI. All patients with previous surgery on the left ventricular outflow tract, aortic valve, or ascending aorta (except coronary artery bypass graft surgery) were excluded from the analysis. Patients undergoing TAVI for congenital aortic valve defects or subjects in whom a computed tomography (CT) scan was not available were excluded from the analysis. Ascending aortas were measured on CT scans using appropriate multiplanar reconstructions. Ascending aortas were qualified as dilated if the measurement was >40 mm. Study outcomes were death from any cause, significant paravalvular leaks (PVLs), and new permanent pacemaker (PPM) implant. RESULTS: The final population consisted of 680 subjects, 61% females, mean age 82 ± 7 years. One hundred subjects (15%) had AAD. No differences in terms of significant PVL or PPM implantation were found between subjects with or without AAD (P>.99 and P=.13, respectively). At a median follow-up of 498 ± 216 days, no significant difference in terms of mortality was found between subjects with or without AAD (P=.78). CONCLUSIONS: AAD does not appear to impact the mid-term outcomes in a cohort of subjects undergoing TAVI.

Impact of Mitral Annular Calcium on Outcomes after Transcatheter Aortic Valve Implantation.

A high prevalence of mitral annular calcium (MAC) is expected in patients undergoing transcatheter aortic valve implantation (TAVI); however, data regarding the prevalence of MAC and impact on risk of cardiovascular events are lacking. To determine the prevalence of MAC and its association with clinical outcomes in patients undergoing TAVI, we retrospectively analyzed 424 patients who underwent transfemoral TAVI from 2007 to 2015 and whose preoperative computed tomography images were available for assessment of MAC. Severe circumferential MAC (SC-MAC) was defined as calcification involving at least the whole posterior annulus alone or with the attachment of the anterior leaflet. Clinical outcomes were examined according to Valve Academic Research Consortium-2 criteria up to 2 years. SC-MAC was found in 17.7% of patients. Patients with SC-MAC were more likely to be female, with a higher prevalence of atrial fibrillation and peripheral artery disease. There were no differences between the groups regarding age, functional class, prevalence of diabetes, kidney disease, and operative risk. Female gender and peripheral artery disease were independent predictors of SC-MAC. SC-MAC did not appear to be associated with periprocedural and 30-day outcomes. At 2 years' follow-up, patients with SC-MAC had significantly higher cardiovascular and all-cause mortality rates. SC-MAC was an independent predictor of cardiovascular mortality during follow-up. In conclusion, SC-MAC is a frequent finding in the TAVI population and appears to be an independent predictor of cardiovascular mortality at 2 years' follow-up.

A Novel Technique for Prosthetic Valve Retrieval After Transcatheter Aortic Valve Embolization.

Although the rate of procedural complications during transcatheter aortic valve implantation has decreased because of technological advancement and increased operator experience, device embolization remains a rare but potentially fatal complication, even with new generation devices. We report, to our knowledge, the first case of Portico valve (St Jude Medical, Minneapolis, MN) migration despite apparent optimal initial implantation depth, which was retrieved using a novel strategy after failure of a traditional retrieval technique. We also describe a mechanism of left coronary artery systolic perfusion with diastolic backflow, which led to myocardial ischemia.

Use of a parallel stiff wire to facilitate percutaneous Impella RP ventricular assist device positioning.

Despite optimal medical management, some patients with severe right ventricular failure fail to respond and may benefit from additional support with the implantation of a RV assist device. Experience to date with Impella RP is limited. We report a case of percutaneous Impella RP implantation, using a parallel stiff wire to reduce anatomical tortuosity by acting as a buddy-wire to facilitate device implantation and reduce the risk of tricuspid ring damage in a patient recently treated with tricuspid ring annuloplasty.