The Impact of Percutaneous Coronary Intervention on Mortality in Patients With Coronary Lesions Who Underwent Transcatheter Aortic Valve Replacement.

OBJECTIVES: To analyze the effect of percutaneous coronary intervention (PCI) before transcatheter aortic valve replacement (TAVR) on all-cause and cardiovascular mortality after TAVR, differentiating between significant proximal lesions and the non-proximal (residual) lesions. METHODS: An institutional TAVR database was complemented with data on the extent of coronary artery disease (CAD), lesion location, lesion severity, and the location of PCI. Survival analysis was performed to investigate the impact on 6-month and 3-year mortality after TAVR in all patients and in subgroups of patients with significant proximal lesions (>70% diameter stenosis [DS], >50% DS in left main), the non-proximal residual lesions, and in a propensity score matched cohort. RESULTS: Among the 577 included patients, mean age was 83 years, 50% were female, and 31% had diabetes mellitus. Preprocedural PCI of unselected lesions was independently associated with increased 6-month mortality (hazard ratio, 2.2; 95% confidence interval, 1.0-4.6; P=.04), but selective PCI of significant proximal lesions did not have an association with higher mortality, nor did we find a significant effect of PCI on mortality in the propensity-matched cohort. CONCLUSION: Routine pre-TAVR PCI is not associated with mortality reduction in TAVR patients with coronary lesions in any segment or in patients with proximal coronary lesions. Despite the lack of a beneficial effect of routine pre-TAVR PCI, we cannot exclude a beneficial effect in a selection of patients with proximal lesions. Therefore, we strongly support the current clinical guidelines to only consider pre-TAVR PCI in proximal coronary lesions, while advocating a restrictive pre-TAVR PCI strategy.

Minimal invasive aortic valve replacement: associations of radiological assessments with procedure complexity.

OBJECTIVES: Limited aortic annulus exposure during minimal invasive aortic valve replacement (mini-AVR) proves to be challenging and contributes to procedure complexity, resulting in longer procedure times. New innovations like sutureless valves have been introduced to reduce procedure complexity. Additionally, preoperative imaging could also contribute to reducing procedure times. Therefore, we hypothesize that Computed Tomography (CT)-image based measurements are associated with mini-AVR complexity. METHODS: One hundred patients who underwent a mini-sternotomy and had a preoperative CT scan were included. With a CT-based mini-AVR planning tool, we measured access distance, access angle, annulus dimensions, and calcium volume. The associations of these measurements with cardiopulmonary bypass (CPB) time and aortic cross-clamp (AoX) time were assessed using univariable and multivariable regression models. In the multivariable models, these measurements were adjusted for age and suture technique. RESULTS: In the univariable regression models, calcium volume and annulus dimensions were associated with longer CPB and AoX time. After adjusting for age and suture technique, increasing calcium volume was still associated with longer CPB (adjusted ß-coefficient 0.002, 95%-CI (0.005, 0.019), p-value = 0.002) and AoX time (adjusted ß-coefficient 0.010, 95%-CI (0.004, 0.016), p-value = 0.002). However, after adjusting for these confounders, the association between annulus dimensions and procedure times lost statistical significance. CONCLUSION: Increase in calcium volume are associated with longer CPB and AoX times, with age and sutureless valve implantation as independent confounders. In contrast to previous studies, access angle was not associated with procedure complexity.

A computed tomography-based planning tool for predicting difficulty of minimally invasive aortic valve replacement.

OBJECTIVES: Minimally invasive aortic valve replacement has proven its value over the last decade by its significant advancement and reduction in mortality, morbidity and admission time. However, minimally invasive aortic valve replacement is associated with some on-site difficulties such as limited aortic annulus exposure. Currently, computed tomography scans are used to evaluate the anatomical relationship among the intercostal spaces, ascending aorta and aortic valve prior to surgery. We hypothesized that quantitative measurements of access distance and access angle are associated with outcome and access difficulty. METHODS: We introduce a novel minimally invasive aortic valve replacement planning prototype that allows automatic measurements of access angle, access distance and aortic annulus dimensions. The prototype visualizes these measurements on the chest cage as ISO contours. The association of these measures with outcome parameters such as extracorporeal circulation time, aortic cross-clamping time and access difficulty score was assessed. We included 14 patients who received a new valve by ministernotomy. RESULTS: The mean access angle was 40.3 ± 5.1°. It was strongly associated with aortic cross-clamping time (Pearson correlation coefficient = 0.60, P = 0.02) and access difficulty score (Spearman's rank correlation coefficient = 0.57, P = 0.03). Access angles were significantly different between easy and difficult access groups (P = 0.03). There was no significant association between access distance and outcome parameters. CONCLUSIONS: Access angle is strongly associated with procedure complexity. The automated presentation of this measure suggests added value of the prototype in clinical practice.

Automated CTA based measurements for planning support of minimally invasive aortic valve replacement surgery.

Minimally invasive aortic valve replacement (mini-AVR) procedures are a valuable alternative to conventional open heart surgery. Currently, planning of mini-AVR consists of selection of the intercostal space closest to the sinotubular junction on preoperative computer tomography images. We developed an automated algorithm detecting the sinotubular junction (STJ) and intercostal spaces for finding the optimal incision location. The accuracy of the STJ detection was assessed by comparison with manual delineation by measuring the Euclidean distance between the manually and automatically detected points. In all 20 patients, the intercostal spaces were accurately detected. The median distance between automated and manually detected STJ locations was 1.4 [IQR= 0.91-4.7] mm compared to the interobserver variation of 1.0 [IQR= 0.54-1.3] mm. For 60% of patients, the fourth intercostal space was the closest to the STJ. The proposed algorithm is the first automated approach for detecting optimal incision location and has the potential to be implemented in clinical practice for planning of various mini-AVR procedures.

Increased aortic tortuosity indicates a more severe aortic phenotype in adults with Marfan syndrome.

BACKGROUND: Patients with Marfan syndrome (MFS) have a highly variable occurrence of aortic complications. Aortic tortuosity is often present in MFS and may help to identify patients at risk for aortic complications. METHODS: 3D-visualization of the total aorta by MR imaging was performed in 211 adult MFS patients (28% with prior aortic root replacement) and 20 controls. A method to assess aortic tortuosity (aortic tortuosity index: ATI) was developed and reproducibility was tested. The relation between ATI and age, and body size and aortic dimensions at baseline was investigated. Relations between ATI at baseline and the occurrence of a clinical endpoint (aortic dissection, and/or aortic surgery) and aortic dilatation rate during 3 years of follow-up were investigated. RESULTS: ATI intra- and interobserver agreements were excellent (ICC: 0.968 and 0.955, respectively). Mean ATI was higher in 28 age-matched MFS patients than in the controls (1.92 ± 0.2 vs. 1.82 ± 0.1, p=0.048). In the total MFS cohort, mean ATI was 1.87 ± 0.20, and correlated with age (r=0.281, p<0.001), aortic root diameter (r=0.223, p=0.006), and aortic volume expansion rate (r=0.177, p=0.026). After 49.3 ± 8.8 months follow-up, 33 patients met the combined clinical endpoint (7 dissections) with a significantly higher ATI at baseline than patients without endpoint (1.98 ± 0.2 vs. 1.86 ± 0.2, p=0.002). Patients with an ATI>1.95 had a 12.8 times higher probability of meeting the combined endpoint (log rank-test, p<0.001) and a 12.1 times higher probability of developing an aortic dissection (log rank-test, p=0.003) compared to patients with an ATI<1.95. CONCLUSIONS: Increased ATI is associated with a more severe aortic phenotype in MFS patients.

Magnetic resonance angiographic assessment of upper extremity vessels prior to vascular access surgery: feasibility and accuracy.

A contrast-enhanced magnetic resonance angiography (CE-MRA) protocol for selective imaging of the entire upper extremity arterial and venous tree in a single exam has been developed. Twenty-five end-stage renal disease (ESRD) patients underwent CE-MRA and duplex ultrasonography (DUS) of the upper extremity prior to hemodialysis vascular access creation. Accuracy of CE-MRA arterial and venous diameter measurements were compared with DUS and intraoperative (IO) diameter measurements, the standard of reference. Upper extremity vasculature depiction was feasible with CE-MRA. CE-MRA forearm and upper arm arterial diameters were 2.94 +/- 0.67 mm and 4.05 +/- 0.84 mm, respectively. DUS arterial diameters were 2.80 +/- 0.48 mm and 4.38 +/- 1.24 mm; IO diameters were 3.00 +/- 0.35 mm and 3.55 +/- 0.51 mm. Forearm arterial diameters were accurately determined with both techniques. Both techniques overestimated upper arm arterial diameters significantly. Venous diameters were accurately determined with CE-MRA but not with DUS (forearm: CE-MRA: 2.64 +/- 0.61 mm; DUS: 2.50 +/- 0.44 mm, and IO: 3.40 +/- 0.22 mm; upper arm: CE-MRA: 4.09 +/- 0.71 mm; DUS: 3.02 +/- 1.65 mm, and IO: 4.30 +/- 0.78 mm). CE-MRA enables selective imaging of upper extremity vasculature in patients requiring hemodialysis access. Forearm arterial diameters can be assessed accurately by CE-MRA. Both CE-MRA and DUS slightly overestimate upper arm arterial diameters. In comparison to DUS, CE-MRA enables a more accurate determination of upper extremity venous diameters.

The relation between vascular access flow and different types of vascular access with systemic hemodynamics in hemodialysis patients.

Access flow (Qa) has an important effect on systemic hemodynamics in dialysis patients. A Qa : cardiac output (CO) ratio higher than 0.3 is considered a risk factor for high-output cardiac failure. However, the effect of different types of vascular access in hemodialysis patients has not yet been studied. The aim of the present study was to assess the relationship between Qa and systemic hemodynamics and to compare systemic hemodynamics between patients with elbow/upperarm access with forearm access types. Qa, CO, cardiac index (CI), central blood volume (CBV), and peripheral vascular resistance (PVR) were studied by the saline dilution technique in 58 hemodialysis patients (18 with elbow/upperarm access; 40 with forearm access types). This article found that Qa was significantly and positively related to CO and CI, and inversely related to PVR. CBV, Qa, and presence of cardiac failure were independent determinants of CI. Qa and the Qa : CO ratio were significantly higher, and PVR significantly lower, in patients with elbow/upperarm access compared to patients with forearm access types. When patients with cardiac failure were excluded, CO and CI were also significantly higher in patients with elbow/upperarm access types. Eleven percent of patients with elbow/upperarm fistula had a Qa : CO ratio above 0.3. In conclusion, Qa is strongly related to systemic hemodynamics in dialysis patients. In patients without cardiac failure, CO and CI are significantly higher in patients with elbow/upperarm access compared to patients with forearm access types. However, only a small percentage of patients with elbow/upperarm fistulae appeared to be in the risk zone for development of high-output cardiac failure.