Low Bone Mineral Density on Computed Tomography: Association with Poor Survival after Transcatheter Aortic Valve Replacement.

Background: Transcatheter aortic valve replacement (TAVR) has evolved as first-line therapy for severe aortic valve stenosis (AS), with pre-procedural computed tomography (CT) providing critical anatomical information. While primarily used for anatomical planning, TAVR-CT also offers an opportunity to assess low bone mineral density (BMD), a known indicator of frailty. Despite this, the prognostic role of BMD in TAVR patients remains unknown. This study aimed to evaluate BMD on routine TAVR-CT and its impact on long-term survival. Methods: In this retrospective study, 770 consecutive TAVR patients (mean age 80.7 ± 6.7 years, 54.0% males) between November 2015 and March 2022 were included. BMD was measured from a single axial image at the thoracic vertebral level on unenhanced CT scans. Cox regression models assessed the impact of BMD on mortality, and Restricted Cubic Spline models identified potential mortality thresholds. Results: The mean BMD value, as measured on non-contrast CT, was 147.5 ± 5.4 Hounsfield units, demonstrating a noteworthy association with mortality (adjusted hazard ratio per 100 HU decrease: 1.27 [95%CI: 1.01-1.59], p = 0.041). Restricted cubic spline analysis indicated that BMD below 200 HU was linked to a substantial increase in mortality risk. Upon crude Cox regression analysis, every 100 HU decrease was associated with a 32% increase in risk for death (HR 1.32 [95%CI: 1.068-1.65)], p = 0.010). Conclusions: In conclusion, low BMD on TAVR-CT is independently associated with reduced survival, suggesting its potential as a tool for comprehensive frailty assessment and improved risk prediction in TAVR patients.

Total Muscle Area and Visceral Adipose Tissue Measurements for Frailty Assessment in TAVR Patients.

Background: Transcatheter aortic valve replacement (TAVR) is a treatment option for severe aortic valve stenosis. Pre-TAVR assessments, extending beyond anatomy, include evaluating frailty. Potential frailty parameters in pre-TAVR computed tomography (CT) scans are not fully explored but could contribute to a comprehensive frailty assessment. The primary objective was to investigate the impact of total muscle area (TMA) and visceral adipose tissue (VAT) as frailty parameters on 5-year all-cause mortality in patients undergoing TAVR. Methods: Between 01/2017 and 12/2018, consecutive TAVR patients undergoing CT scans enabling TMA and VAT measurements were included. Results: A total of 500 patients qualified for combined TMA and VAT analysis. Age was not associated with a higher risk of 5-year mortality (HR 1.02, 95% CI: 0.998-1.049; p = 0.069). Body surface area normalized TMA (nTMA) was significantly associated with 5-year, all-cause mortality (HR 0.927, 95% CI: 0.927-0.997; p = 0.033), while VAT had no effect (HR 1.002, 95% CI: 0.99-1.015; p = 0.7). The effect of nTMA on 5-year, all-cause mortality was gender dependent: the protective effect of higher nTMA was found in male patients (pinteraction: sex × nTMA = 0.007). Conclusions: Normalized total muscle area derived from a routine CT scan before transcatheter aortic valve replacement complements frailty assessment in patients undergoing TAVR.

Mixed aortic valve disease: association with paravalvular leak and reduced survival after transcatheter aortic valve replacement.

AIMS: Transcatheter aortic valve replacement (TAVR) revolutionized the therapy of severe aortic stenosis (AS) with rising numbers. Mixed aortic valve disease (MAVD) treated by TAVR is gaining more interest, as those patients represent a more complex cohort as compared with isolated AS. However, concerning long-term outcome for this cohort only, limited data are available. The aim of the study is to assess the prevalence of MAVD in TAVR patients, investigate its association with paravalvular regurgitation (PVR), and analyse its impact on long-term mortality after TAVR. METHODS AND RESULTS: We conducted a registry-based cohort study using the Vienna TAVR registry, enrolling patients who underwent TAVR at Medical University of Vienna between January 2007 and May 2020 with available transthoracic echocardiography before and after TAVR (n = 880). Data analysis included PVR incidence and long-term survival outcomes. A total of 647 (73.52%) out of 880 patients had ≥ mild aortic regurgitation next to severe AS. MAVD was associated with PVR compared with isolated AS with an odds ratio of 2.06, 95% confidence interval (CI): 1.51-2.81 (P = <0.001). More than mild PVR after TAVR (n = 168 out of 880: 19.09%) was related to higher mortality compared with the absence of PVR with a hazard ratio (HR) of 1.33, 95% CI: 1.05- 1.67 (P = 0.016). MAVD patients developing ≥ mild PVR after TAVR were also associated with higher mortality compared with the absence of PVR with an HR of 1.30 and 95% CI: 1.04-1.62 (P = 0.022). CONCLUSION: MAVD is prevalent among TAVR patients and presents unique challenges, with increased PVR risk and worse outcomes compared with isolated AS. Long-term survival for MAVD patients, not limited to those developing PVR post-TAVR, is compromised. Earlier intervention before the occurrence of structural myocardial damage or surgical valve replacement might be a potential workaround to improve outcomes.

Impact of stroke history on procedural cerebrovascular insult probability and long-term outcome after TAVI.

BACKGROUND: In TAVI procedural stroke is one of the most feared complications and for this reason also extensively studied. But there is a lack of data concerning the impact of previous stroke on procedural stroke and on long-term survival. The aim of this registry-based cohort study is to evaluate the prevalence of previous stroke in TAVI patients and its impact on procedural stroke risk as well as long-term outcome. METHODS: We included all patients treated with TAVI between January 2007 and December 2020 and investigated concerning previous stroke in their medical history. Among 958 patients, 55 patients had previous stroke and were included in the present analysis. RESULTS: The salient finding of the present study is that previous stroke is significantly associated with higher all-cause mortality and has established itself as a predictor for poor outcome after TAVI. This is also observed after adjusting for confounders like EuroSCORE II (European system for cardiac operative risk evaluation) and AF (atrial fibrillation) as one of the main underlying diseases for cerebrovascular insult (CVI). However, previous stroke is not associated with higher rates of procedural CVI. CONCLUSION: A history of stroke is significantly associated with higher all-cause mortality and has established itself as a predictor for poor outcome after TAVI without higher rates of procedural stroke.

Routine 4D Cardiac CT to Identify Concomitant Transthyretin Amyloid Cardiomyopathy in Older Adults with Severe Aortic Stenosis.

Background Transthyretin amyloid cardiomyopathy (ATTR-CM) often coexists with severe aortic stenosis (AS). Although strain analysis from cardiac MRI and echocardiography was demonstrated to predict coexisting ATTR-CM, comparable data from four-dimensional (4D) cardiac CT are lacking despite wide availability. Purpose To evaluate the diagnostic performance of 4D cardiac CT-derived parameters in identifying ATTR-CM in older adults considered for transcatheter aortic valve implantation (TAVI). Materials and Methods This prospective single-center screening study for ATTR-CM included consecutive patients with severe AS considered for TAVI who underwent 4D cardiac CT between August 2019 and August 2021 approximately 1 day before technetium 99m (99mTc) 3,3-diphosphono-1,2-propanodicarboxylic-acid (DPD) scintigraphy. The diagnostic performance of CT-based left ventricular (LV), right ventricular, and left atrial dimensions, ejection fraction (EF), and myocardial strain were evaluated against 99mTc-DPD scintigraphy as the reference standard to identify ATTR-CM. Predictors and an unweighted cardiac CT score were validated with internal bootstrapping. The assignment of variables to the score was based on cutoff values achieving the highest Youden index J. Results Among 263 participants (mean age, 83 years ± 4.6 [SD]; 149 male and 114 female participants), 99mTc-DPD scintigraphy (Perugini grade 2 or 3) confirmed coexisting ATTR-CM in 27 (10.3%). CT-derived LV mass index, LV and LA global longitudinal strain (GLS), and relative apical longitudinal strain each predicted the presence of ATTR-CM with an area under the curve (AUC) of at least 0.70. Implementing these parameters with cutoff values of 81 g/m2 or higher, -14.9% or higher, less than 11.5%, and 1.7 or higher in the CT score, respectively, yielded high diagnostic performance (AUC = 0.89; 95% CI: 0.81, 0.94; P < .001) robust to internal bootstrapping validation (AUC = 0.88; 95% CI: 0.82, 0.94). If two criteria were fulfilled, the sensitivity and specificity in the detection of ATTR-CM were 96.3% (95% CI: 81.0, 99.9) and 58.9% (95% CI: 52.3, 65.2), respectively. Conclusion When compared against 99mTc-DPD scintigraphy as the reference standard, routine 4D cardiac CT in older adults considered for TAVI provided high diagnostic performance in the detection of concomitant ATTR-CM by assessing LV and left atrial GLS, relative apical longitudinal strain, and LV mass index. ClinicalTrials.gov registration no.: NCT04061213 © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Tavakoli and Onder in this issue.

Altered blood flow due to larger aortic diameters in patients with transcatheter heart valve thrombosis.

The etiology of transcatheter heart valve thrombosis (THVT) and the relevance of the aortic root geometry on the occurrence of THVT are largely unknown. The first aim of this pilot study is to identify differences in aortic root geometry between THVT patients and patients without THVT after transcatheter aortic valve implantation (TAVI). Second, we aim to investigate how the observed difference in aortic diameters affects the aortic flow using idealized computational geometric models. Aortic dimension was assessed using pre-TAVI multi-detector computed tomography scans of eight patients with clinical apparent THVT and 16 unaffected patients (two for each THVT patient with same valve type and size) from the Bern-TAVI registry. Among patients with THVT the right coronary artery height was lower (-40%), and sinotubular junction (STJ) and ascending aorta (AAo) diameters tended to be larger (9% and 14%, respectively) compared to the unaffected patients. Fluid-structure interaction (FSI) in two idealized aortic models with the observed differences in STJ and AAo diameter showed higher backflow rate at the STJ (+16%), lower velocity magnitudes in the sinus (-5%), and higher systolic turbulent dissipation rate in the AAo (+8%) in the model with larger STJ and AAo diameters. This pilot study suggests a direct effect of the aortic dimensions on clinically apparent THVT. The FSI study indicates that larger STJ and AAo diameters potentially favor thrombus formation by increased backflow rate and reduced wash-out efficiency of the sinus. The reported observations require clinical validation but could potentially help identifying patients at risk for THVT.

Impact of COVID-19 Surge Periods on Clinical Outcomes of Transcatheter Aortic Valve Implantation.

Healthcare systems adopted various strategies to minimize the impact of the COVID-19 pandemic on clinical outcomes of patients with symptomatic severe aortic stenosis referred for transcatheter aortic valve implantation (TAVI). We aimed to compare baseline characteristics and procedural and clinical outcomes of patients who underwent TAVI during COVID-19 surge periods with those of patients who underwent TAVI during the nonsurge and prepandemic periods. In the prospective Bern TAVI registry, the pandemic period was divided into surge and nonsurge periods on the basis of the mean number of occupied beds in the intensive care unit in each month and matched with 11 months immediately preceding the pandemic. A total of 1,069 patients underwent TAVI between April 1, 2019 and December 31, 2021. Patients who underwent TAVI during surge periods had a higher surgical risk (Society of Thoracic Surgeons predicted risk of mortality) than that of patients who underwent TAVI during nonsurge and prepandemic periods. Diagnosis-to-procedure time (in days) was longer for patients who underwent TAVI during the surge period than during the nonsurge and prepandemic periods (95.20 ± 121.07 vs 70.99 ± 72.25 and 60.46 ± 75.43, both p <0.001). At 30 days, all-cause mortality was higher in the surge than in the nonsurge group (4.9 vs 1.1%, hazard ratio 4.68, 95% confidence interval 1.55 to 14.10, p = 0.006), and in the surge than in the prepandemic group (4.9 vs 1.3%, hazard ratio 3.67, 95% confidence interval 1.34 to 10.11, p = 0.012). In conclusion, TAVI during COVID-19 surge periods was associated with higher Society of Thoracic Surgeons predicted risk of mortality score, delayed procedure scheduling, and increased 30-day mortality than that of TAVI during nonsurge and prepandemic periods.

Incidental detection of malignancy during preprocedural workup for transcatheter aortic valve implantation: A longitudinal cohort study.

The aim of this retrospective analysis was to investigate the prevalence and prognostic importance of incidental malignancy detected during pre-TAVI computed tomography. Among 579 patients, CT-work-up for TAVI exposed previously undetected malignancy in 4.5% of patients. TAVI patients with a new malignancy had a 2.9-fold increased risk of death at 1 year, and a 16 month shorter mean survival time compared to patients with no malignancy.

Long-term risk of unplanned percutaneous coronary intervention after transcatheter aortic valve replacement.

BACKGROUND: Coronary access after transcatheter aortic valve replacement (TAVR) can be challenging and complicate percutaneous coronary intervention (PCI). AIMS: We aimed to investigate the incidence, characteristics, and predictors of unplanned PCI after TAVR. METHODS: In a single-centre registry, TAVR candidates were systematically screened for concomitant coronary artery disease (CAD) through the use of coronary angiography prior to TAVR. Rates of unplanned PCI were prospectively collected and independently adjudicated. RESULTS: Among 3,015 patients undergoing TAVR between August 2007 and December 2020, 67 patients (2.2%) underwent unplanned PCI after TAVR. The indication for unplanned PCI was acute coronary syndrome in more than half of the cases. Patients with unplanned PCI were younger (80.2±6.5 years vs 81.9±6.4 years; p=0.028) and more likely to be male (75% vs 50%; p<0.001) than those without unplanned PCI. In a multivariable analysis, the number of diseased vessels, male sex, and younger age were independently associated with an increased risk of unplanned PCI. The cumulative incidence rates of unplanned PCI at 1, 5, and 10 years were 0.1%, 0.4%, and 0.6% in patients with no CAD at the time of TAVR, 0.7%, 2.5%, and 3.4% in patients with single-vessel disease, and 1.5%, 5.4%, and 7.4% in patients with multivessel disease, respectively. CONCLUSIONS: The lifetime risk of unplanned PCI after TAVR is low in patients with no CAD at the time of TAVR but accumulates over time in patients with known CAD, particularly multivessel disease. CLINICALTRIALS: gov: NCT01368250.

Risk and Timing of Noncardiac Surgery After Transcatheter Aortic Valve Implantation.

Importance: Noncardiac surgery after transcatheter aortic valve implantation (TAVI) is a clinical challenge with concerns about safety and optimal management. Objectives: To evaluate perioperative risk of adverse events associated with noncardiac surgery after TAVI by timing of surgery, type of surgery, and TAVI valve performance. Design, Setting, and Participants: This cohort study was conducted using data from a prospective TAVI registry of patients at the tertiary care University Hospital in Bern, Switzerland. All patients undergoing noncardiac surgery after TAVI were identified. Data were analyzed from November through December 2021. Exposures: Timing, clinical urgency, and risk category of noncardiac surgery were assessed among patients who had undergone TAVI and subsequent noncardiac surgery. Main Outcomes and Measures: A composite of death, stroke, myocardial infarction, and major or life-threatening bleeding within 30 days after noncardiac surgery. Results: Among 2238 patients undergoing TAVI between 2013 and 2020, 300 patients (mean [SD] age, 81.8 [6.6] years; 144 [48.0%] women) underwent elective (160 patients) or urgent (140 patients) noncardiac surgery after TAVI and were included in the analysis. Of these individuals, 63 patients (21.0%) had noncardiac surgery within 30 days of TAVI. Procedures were categorized into low-risk (21 patients), intermediate-risk (190 patients), and high-risk (89 patients) surgery. Composite end points occurred within 30 days of surgery among 58 patients (Kaplan-Meier estimate, 19.7%; 95% CI, 15.6%-24.7%). There were no significant differences in baseline demographics between patients with the 30-day composite end point and 242 patients without this end point, including mean (SD) age (81.3 [7.1] years vs 81.9 [6.5] years; P = .28) and sex (25 [43.1%] women vs 119 [49.2%] women; P = .37). Timing (ie, ≤30 days from TAVI to noncardiac surgery), urgency, and risk category of surgery were not associated with increased risk of the end point. Moderate or severe prosthesis-patient mismatch (adjusted hazard ratio [aHR], 2.33; 95% CI, 1.37-3.95; P = .002) and moderate or severe paravalvular regurgitation (aHR, 3.61; 95% CI 1.25-10.41; P = .02) were independently associated with increased risk of the end point. Conclusions and Relevance: These findings suggest that noncardiac surgery may be performed early after successful TAVI. Suboptimal device performance, such as prosthesis-patient mismatch and paravalvular regurgitation, was associated with increased risk of adverse outcomes after noncardiac surgery.

Impact of First-Phase Ejection Fraction on Clinical Outcomes in Patients Undergoing Transcatheter Aortic Valve Implantation.

BACKGROUND: First-phase left ventricular ejection fraction (LVEF1) is an early marker of left ventricular remodeling. Reduced LVEF1 has been associated with adverse prognosis in patients with aortic stenosis (AS) and preserved left ventricular ejection fraction (LVEF). It remains to be determined, whether reduced LVEF1 differentiates clinical outcomes after aortic valve replacement. OBJECTIVES: We investigated the impact of LVEF1 on clinical outcomes in patients undergoing transcatheter aortic valve implantation (TAVI) for symptomatic severe AS with preserved LVEF (≥ 50%). METHODS: In the prospective Bern TAVI registry, we retrospectively categorized patients according to LVEF1 as assessed by transthoracic echocardiography. Clinical outcomes of interest were all-cause mortality and residual heart failure symptoms (New York Heart Association (NYHA) functional class III or IV) at 1 year after TAVI. RESULTS: A total of 644 patients undergoing TAVI between January 2014 and December 2019 were included in the present analysis. Patients with low LVEF1 had a lower LVEF (62.0 ± 6.89% vs. 64.3 ± 7.82%, P < 0.001) and a higher left ventricular mass index (129.3 ± 39.1 g/m2 vs. 121.5 ± 38.0 g/m2; P = 0.027) compared to patients with high LVEF1. At 1 year, the incidence of all-cause/cardiovascular death, and NYHA III or IV were comparable between patients with low and high LVEF1 (8.3% vs. 9.2%; P = 0.773, 3.9% vs. 6.0%; P = 0.276, 12.9% vs. 12.2%; P = 0.892, respectively). CONCLUSIONS: Reduced LVEF1 was not associated with adverse clinical outcomes following TAVI in patients with symptomatic severe AS with preserved LVEF. CLINICAL TRIAL REGISTRATION: https://www. CLINICALTRIALS: gov. NCT01368250.

Transcatheter aortic valve implantation in patients with rheumatic aortic stenosis.

BACKGROUND: Rheumatic heart disease (RHD) accounts for the highest number of deaths from valvular heart disease globally. Yet, rheumatic aortic stenosis (AS) was excluded from landmark studies investigating the safety and efficacy of transcatheter aortic valve implantation (TAVI). We aimed to describe the clinical and anatomical characteristics of patients with rheumatic AS undergoing TAVI, and to compare procedural and clinical outcomes with patients undergoing TAVI for degenerative AS. METHODS: In a prospective TAVI registry, patients with rheumatic AS were identified based on International Classification of Diseases version 10 codes and/or a documented history of acute rheumatic fever and/or the World Heart Federation criteria for echocardiographic diagnosis of RHD, and were propensity score-matched in a 1:4 ratio to patients with degenerative AS. RESULTS: Among 2329 patients undergoing TAVI, 105 (4.5%) had rheumatic AS. Compared with patients with degenerative AS, patients with rheumatic AS were more commonly female, older, had higher surgical risk and more commonly suffered from multivalvular heart disease. In the unmatched cohort, both technical success (85.7% vs 85.9%, p=0.887) and 1-year cardiovascular mortality (10.0% vs 8.6%; HR 1.16, 95% CI 0.61 to 2.18, p=0.656) were comparable between patients with rheumatic and degenerative AS. In contrast, patients with rheumatic AS had lower rates of 30-day and 1-year cardiovascular mortality compared with matched patients with degenerative AS (1.9% vs 8.9%, adjusted HR (HRadj) 0.18, 95% CI 0.04 to 0.80, p=0.024; and 10.0% vs 20.3%, HRadj 0.44, 95% CI 0.24 to 0.84, p=0.012, respectively). CONCLUSION: TAVI may be a safe and effective treatment strategy for selected elderly patients with rheumatic AS. TRIAL REGISTRATION NUMBER: NCT01368250.

Reproducibility of 4D cardiac computed tomography feature tracking myocardial strain and comparison against speckle-tracking echocardiography in patients with severe aortic stenosis.

BACKGROUND: Myocardial strain is an established parameter for the assessment of cardiac function and routinely derived from speckle tracking echocardiography (STE). Novel post-processing tools allow deformation imaging also by 4D cardiac computed tomography angiography (CCT). This retrospective study aims to analyze the reproducibility of CCT strain and compare it to that of STE. METHODS: Left (LV) and right ventricular (RV), and left atrial (LA) ejection fraction (EF), dimensions, global longitudinal (GLS), circumferential (GCS) and radial strain (GRS) were determined by STE and CCT feature tracking in consecutive patients with severe aortic stenosis evaluated for transcatheter aortic valve implantation. RESULTS: 106 patients (mean age 79.9 â€‹± â€‹7.8, 44.3% females) underwent CCT at a median of 3 days (IQR 0-28 days) after STE. In CCT, strain measures showed good to excellent reproducibility (intra- and inter-reader intraclass correlation coefficient ≥0.75) consistently in the LV, RV and LA. In STE, only LV GLS and LA GLS yielded good reproducibility, whereas LV GCS and LV GRS showed moderate, and RV GLS and free wall longitudinal strain (FWLS) poor reproducibility. Agreement between CCT and STE was strong for LV GLS only, while other strain features displayed moderate (LV GCS, LA GLS) or weak (LV GRS, RV GLS and FWLS) inter-modality correlation. CONCLUSION: LV, RV and LA CCT strain assessments were highly reproducible. While a strong agreement to STE was found for LV GLS, inter-modality correlation was moderate or weak for LV GCS, LV GRS, and RV and LA longitudinal strain, possibly related to poor reproducibility of STE measurements.

Clinical outcomes following transcatheter aortic valve implantation in patients with porcelain aorta.

BACKGROUND: Current guidelines favor transcatheter aortic valve implantation (TAVI) over surgical aortic valve replacement in patients with porcelain aorta (PAo). The clinical relevance of PAo in patients undergoing TAVI is however incompletely understood. The purpose of this study is to evaluate clinical outcome of patients with PAo undergoing TAVI. METHODS: Consecutive patients undergoing TAVI were enrolled in a prospective single-center registry. Presence of PAo was evaluated by ECG-gated multi-slice computed tomography prior to the intervention. The primary endpoint was disabling stroke. RESULTS: Among 2199 patients (mean age, 82.0 â€‹± â€‹6.3 years; 1135 females [51.6%]) undergoing TAVI between August 2007 and December 2019, 114 patients (5.2%) met VARC-2 criteria for PAo. Compared to individuals without PAo, patients with PAo were younger (79.4 â€‹± â€‹7.4 years vs. 82.1 â€‹± â€‹6.2 years; p â€‹< â€‹0.001), had a lower left ventricular ejection fraction (51.8 â€‹± â€‹14.9% vs. 55.3 â€‹± â€‹14.2%; p â€‹= â€‹0.009) and higher STS-PROM Scores (6.5 â€‹± â€‹4.3% vs. 4.9 â€‹± â€‹3.4%; p â€‹< â€‹0.001). At 1 year, disabling stroke occurred more often in patients with PAo (7.2%) than in those without (3.0%) (HRadj, 2.49; 95% CI, 1.12-5.55). The risk difference emerged within 30 days after TAVI (HRadj, 3.70; 95% CI, 1.52-9.03), and was driven by a high PAo-associated risk of disabling stroke in patients with alternative access (HRadj, 5.79; 95% CI, 1.38-24.3), not in those with transfemoral (HRadj, 1.47; 95% CI 0.45-4.85). CONCLUSIONS: TAVI patients with PAo had a more than three-fold increased risk of periprocedural disabling stroke compared to patients with no PAo. The difference was driven by a higher risk of stroke in patients treated by alternative access.