Incidence and predictors of cardiogenic shock following surgical or transcatheter tricuspid valve intervention.

OBJECTIVE: The objective of this study was to evaluate the incidence of and risk factors associated with cardiogenic shock (CS) following surgery versus transcatheter tricuspid valve intervention (TTVI) for tricuspid regurgitation (TR). BACKGROUND: Surgical therapy for TR is associated with high rates of CS. Postprocedural shock has not been studied following TTVI. METHODS: We performed a single-center retrospective analysis of isolated tricuspid valve (TV) surgery or TTVI for TR. The primary outcome was postprocedural class D or E CS according to Society for Cardiovascular Angiography and Interventions (SCAI) CS classification scheme, and secondary outcome was in-hospital mortality. Multivariable logistic regression modeling was performed for primary and secondary outcomes. Support vector machine analysis was performed for sensitivity analysis. RESULTS: From 2008 to 2020, a total of 122 patients underwent isolated TV surgery (n = 58, 14 TV repair, and 44 TV replacement) or TTVI (n = 64, 36 TV repair, and 28 TV replacement). Surgical patients were significantly younger than TTVI patients (67.5 vs. 80 years, p < 0.0001). Multivariable modeling revealed an association between the primary outcome and surgery (odds ratio [OR]: 8.75, 95% confidence interval [CI]: 2.83, 27.03, p = 0.0002), as well as baseline central venous pressure (CVP, OR: 1.12, 95% CI: 1.02, 1.22, p = 0.016). Additionally, class DE CS was independently associated with in-hospital mortality (OR: 5.21, 1.35, 20.09, p = 0.016). CVP and surgery were found to have highest importance indices in support vector machine analysis. CONCLUSION: In patients undergoing TV intervention for TR, surgery versus TTVI and elevated CVP are associated with advanced postprocedural CS. Patients developing advanced CS are at increased risk of in-hospital mortality.

Right Heart Morphology of Candidate Patients for Transcatheter Tricuspid Valve Interventions.

PURPOSE: This study quantitatively evaluated the phasic right heart morphology of candidate patients for a transcatheter tricuspid valve intervention (N=32) and of subjects with trace to no tricuspid regurgitation (N = 14). METHODS: Cardiac computed tomography angiography (CCTA) and transthoracic/transesophageal echocardiography (TTE/TEE) images were analyzed using dedicated research and clinical software. Using CCTA, the phasic right atrial and ventricular volumes, annulus dimensions, annulus-to-right coronary artery (RCA) distances, circumferential topography of the annular tissue shelf, vena cava dimensions (inferior and superior), vena cava positions, axis angles, and annular excursions were quantified. Using TTE/TEE, leaflet geometry, regurgitation, hemodynamics, and heart function were quantified. Measurements within and between groups were quantitatively compared with regression analyses to explore relationships between right heart features. RESULTS: The phasic position and orientation of the vena cava and the circumferential topography of the annular tissue shelf were quantitatively presented for the first time. The candidate patient group exhibited greater chamber dimensions, enlarged vena cava, distended vena cava positions, positional shallowing of the annular tissue shelf, geometric annular distortion, leaflet distention, moderate or greater regurgitation, and impaired ventricular function. Atrial volume correlated strongly with directional vena cava positions as well as with annular dimensions. Annulus-to-RCA distances and annular excursions were comparable between groups. CONCLUSIONS: This study provides new and further insight to the right heart morphology and functional characteristics of candidate patients for a transcatheter tricuspid valve intervention. These data provide a platform from which these patients can continue to be better understood for further improving transcatheter system design and use.

Anatomic classification of mitral annular calcification for surgical and transcatheter mitral valve replacement.

BACKGROUND AND AIM OF THE STUDY: A systematic approach to quantify mitral annular calcification (MAC) in all-comers by multidetector computed tomography (MDCT) is essential to guide treatment, but lacking. METHODS: From September 2015 to July 2019, 82 patients with MAC underwent MDCT at two institutions to evaluate for surgical mitral valve replacement (SMVR), transcatheter mitral valve replacement (TMVR), or medical management. Type 1 MAC was defined as <270° annular calcium and Type 2 as ≥270°. Absence/presence of predicted left ventricular outflow tract (LVOT) obstruction with virtual valve placement was used to further define Type 2 MAC into 2A/B for our treatment algorithm. RESULTS: Type 1 MAC was present in 51.2%, Type 2A in 18.3%, and Type 2B in 30.5%. Operable Type 1 patients (50.0%) underwent hybrid transatrial TMVR or SMVR. Type 2A underwent a variety of treatments, and Type 2B surgical candidates (40.0%) underwent hybrid transatrial TMVR secondary to difficult suture anchoring with significant MAC and predicted LVOT obstruction. At a follow-up of 29.6 ± 12.0 months, mortality was 42.7% with 46.3% in the intervention group and 39.0% in the medical group (p = 0.47). All percutaneous TMVR patients expired. This translated to a disproportionate number of Type 2A deaths (80.0% with intervention), but all were high/extreme surgical risk. The hybrid TMVR group consisted of 95.0% Type 1/2B patients and had a lower Society of Thoracic Surgeons predicted risk of operative mortality (7.4% vs. 9.2%, p = 0.43)/mortality. CONCLUSIONS: The highest mortality was seen in percutaneous TMVR Type 2A MAC patients, but they were at the greatest risk. Here we provide an objective MAC treatment algorithm for all-comers based on operability/anatomy.

Urologic Complications in Patients Receiving Indwelling Urinary Catheters During Transcatheter Aortic Valve Replacement.

OBJECTIVES: The minimalist approach to transcatheter aortic valve replacement (TAVR) focuses on avoiding extraneous invasive measures. Data describing the clinical impact of routine indwelling urinary catheter (IUC) in TAVR patients is limited. We sought to examine outcomes after IUC placement in patients undergoing TAVR. METHODS: We performed a retrospective analysis of 773 consecutive patients undergoing TAVR between 2011 and 2015. Patients were excluded who did not receive an IUC, had a pre-existing IUC, had renal replacement therapy, or underwent non-transfemoral TAVR. Patients were classified by presence of the composite of in-hospital urologic adverse events (UAEs), defined as urinary retention, IUC reinsertion, discharge with IUC, new hematuria, or urinary tract infection (UTI). The primary study endpoint was all-cause mortality at 1 year. RESULTS: A total of 520 patients met study criteria and were analyzed. The incidence of UAE was 28.6%. Urinary retention after IUC removal occurred in 14.6% of patients. UTIs occurred in 6.5% and acute kidney injury occurred in 13.6% of IUC patients. UAE was associated with an increased rate of 30-day and 1-year all-cause mortality (hazard ratio [HR], 2.84; 95% confidence interval [CI], 1.09-7.35; P=.02 and HR, 1.96; 95% CI, 1.22-3.16; P<.01, respectively). After multivariable adjustment for important baseline differences, UAEs were associated with significantly greater hazard of 1-year mortality (adjusted HR, 1.79; 95% CI, 1.07-2.99; P=.03) but not 30-day mortality (adjusted HR, 1.96; 95% CI, 0.67-5.49; P=.22). CONCLUSION: UAEs were frequent in patients receiving an IUC during TAVR and were associated with substantial morbidity, as well as longer hospital stay. Further research is required to establish whether avoidance of IUC as a component of the minimalist approach will reduce UAEs.

Imaging in patients with severe mitral annular calcification: insights from a multicentre experience using transatrial balloon-expandable valve replacement.

AIMS: To investigate valve sizing and the haemodynamic relevance of the predicted left ventricular outflow tract (LVOT) in patients with mitral annular calcification (MAC) undergoing transatrial transcatheter valve implantation (THV). METHODS AND RESULTS: In total, 21 patients undergoing transatrial THV, multiplanar reconstruction (MPR), maximum intensity projection (MIP), and cubic spline interpolation (CSI) were compared for MA sizing during diastole. In addition, predicted neo-LVOT areas were measured in 18 patients and correlated with the post-procedural haemodynamic dimensions. The procedure was successful in all patients (100%). Concomitant aortic valve replacement was performed in eight patients (43%) (AVR group). Sizing using MPR and MIP yielded comparable results in terms of area, perimeter, and diameter, whereas the dimensions obtained with CSI were systematically smaller. The simulated mean systolic neo-LVOT area was 133.4 ± 64.2 mm2 with an anticipated relative LVOT area reduction (neo-LVOT area/LVOT area × 100) of 59.3 ± 14.7%. The systolic relative LVOT area reduction, but not the absolute neo-LVOT area, was found to predict the peak (r = 0.69; P = 0.002) and mean (r = 0.65; P = 0.004) post-operative aortic gradient in the overall population as well as separately in the AVR (peak: r = 0.91; P = 0.002/mean: r = 0.85; P = 0.002) and no-AVR (peak: r = 0.89; P = 0.003/mean: r = 0.72; P = 0.008) groups. CONCLUSION: In patients with severe MAC undergoing transatrial transcatheter valve implantation, MPR, and MIP yielded comparable annular dimensions, while values obtained with CSI tended to be systematically smaller. Mitral annular area and the average annular diameter appear to be reliable parameters for valve selection. Simulated relative LVOT reduction was found to predict the post-procedural aortic gradients.

Early Single-Site Experience With Transcatheter Tricuspid Valve Replacement.

OBJECTIVES: This study presents a single-site experience of 5 patients with severe tricuspid regurgitation (TR) who underwent implantation of a novel transcatheter tricuspid valve replacement device. BACKGROUND: Functional TR is the most common etiology of severe TR in the developed world and is associated with unfavorable clinical outcomes. Although numerous transcatheter repair devices are currently in early clinical trials, most result in incomplete degrees of TR reduction and functional improvement. METHODS: Transcatheter tricuspid valve replacement was performed in 5 patients with compassionate use of the novel GATE System. All patients had symptomatic, massive and/or torrential TR at baseline. All patients had computed tomography, transthoracic and transesophageal echocardiographic assessment of the tricuspid valve and right heart anatomy. All patients had a surgical transatrial approach performed with valve implantation guided by fluoroscopy and intraprocedural transesophageal echocardiography. RESULTS: Baseline characteristics of the patients showed a substantial burden of comorbidities. All patients had successful implantation of the transcatheter valve, with significant reduction of TR to ≤2+. Baseline poor right ventricular (RV) function measured by global longitudinal strain and RV change in pressure divided by change in time were associated with post-implantation RV failure and poor clinical outcomes in this small group. Four of the 5 patients were followed for 3 to 6 months following the initial implantation and showed evidence of RV remodeling, increased cardiac output, and reduction in New York Heart Association functional class. CONCLUSIONS: Implantation of a first-generation TTVR device was technically feasible in patients with more than severe TR. Transcatheter tricuspid valve replacement was associated with RV remodeling, increased cardiac output, and improvement in New York Heart Association functional class in most patients. Further studies are needed to refine patient population selection for this device and to determine long-term outcomes.

Bicuspid aortic valve increases risk of permanent pacemaker implant following aortic root replacement.

OBJECTIVES: We aimed to assess the incidence and possible differences in postoperative conduction delay after aortic root replacement (ARR) in bicuspid aortic valve (BAV) patients compared with a tricuspid aortic valve (TAV). METHODS: A total of 380 patients undergoing ARR at our institution between 2005 and 2013 were included in the analysis. Patients were stratified by aortic valve anatomy: BAV, n = 191 vs TAV, n = 189. Electrocardiographic and echocardiographic data were retrospectively analysed at different time points (pre-, postoperatively and at follow-up). Primary outcome of interest was permanent pacemaker (PPM) implantation within 30 days, the composite of new PPM or new left fascicular or bundle branch block (PPM or LBBB) was the secondary outcome of interest. Age range was 24-89.5 years and incidence of preoperative moderate to severe aortic stenosis was 9.7%. RESULTS: BAV patients had higher incidence of PPM implantation within 30 days (5.8 vs 1.6% in TAV, P = 0.053); moreover, the composite of PPM or LBBB was also more frequent in BAV (8.4 vs 2.1%, P = 0.010). BAV was independently associated with PPM insertion (OR 4.08, P = 0.047) and also an independent predictor of PPM or LBBB in multiple regression (OR 4.96, P = 0.006). CONCLUSIONS: Significantly higher incidence of PPM implantation or LBBB may exist after ARR in bicuspid patients and BAV was confirmed to be an independent predictor for postoperative conduction disturbances by multivariable regression.

Silent intralesional microhemorrhage as a risk factor for brain arteriovenous malformation rupture.

BACKGROUND AND PURPOSE: We investigated whether brain arteriovenous malformation silent intralesional microhemorrhage, that is, asymptomatic bleeding in the nidal compartment, might serve as a marker for increased risk of symptomatic intracranial hemorrhage (ICH). We evaluated 2 markers to assess the occurrence of silent intralesional microhemorrhage: neuroradiological assessment of evidence of old hemorrhage-imaging evidence of bleeding before the outcome events-and hemosiderin positivity in hematoxylin and eosin-stained paraffin block sections. METHODS: We identified cases from our brain arteriovenous malformation database with recorded neuroradiological data or available surgical paraffin blocks. Using 2 end points, index ICH or new ICH after diagnosis (censored at treatment, loss to follow-up, or death), we performed logistic or Cox regression to assess evidence of old hemorrhage and hemosiderin positivity adjusting for age, sex, deep-only venous drainage, maximal brain arteriovenous malformation size, deep location, and associated arterial aneurysms. RESULTS: Evidence of old hemorrhage was present in 6.5% (n=975) of patients and highly predictive of index ICH (P<0.001; OR, 3.97; 95% CI, 2.1-7.5) adjusting for other risk factors. In a multivariable model (n=643), evidence of old hemorrhage was an independent predictor of new ICH (hazard ratio, 3.53; 95% CI, 1.35-9.23; P=0.010). Hemosiderin positivity was found in 36.2% (29.6% in unruptured; 47.8% in ruptured; P=0.04) and associated with index ICH in univariate (OR, 2.18; 95% CI, 1.03-4.61; P=0.042; n=127) and multivariable models (OR, 3.64; 95% CI, 1.11-12.00; P=0.034; n=79). CONCLUSIONS: The prevalence of silent intralesional microhemorrhage is high and there is evidence for an association with both index and subsequent ICH. Further development of means to detect silent intralesional microhemorrhage during brain arteriovenous malformation evaluation may present an opportunity to improve risk stratification, especially for unruptured brain arteriovenous malformations.