Annular versus supra-annular sizing for TAVI in bicuspid aortic valve stenosis.

AIMS: We sought to compare annular versus supra-annular sizing for transcatheter aortic valve implantation (TAVI) in patients with a bicuspid aortic valve (BAV). METHODS AND RESULTS: In this retrospective single-centre analysis, we measured the aortic annulus (Ann) and intercommissural distance (ICD) on multidetector computed tomography scans in 217 BAV patients. With annular sizing being the default method for prosthesis size selection in all cases, we determined clinically relevant sizing errors and assessed the hypothetical impact of supra-annular sizing. Overall there was no significant difference between ICD and Ann (25.1 [23.5; 27.3] vs. 25.4 [23.6; 27.1] mm; p=0.24); intra-individually, ICD was similar to Ann in 26.7%, smaller in 40.1%, and larger in 33.2%. Annular sizing was appropriate in 96.3%, oversized in 0.5%, and undersized in 3.2% of cases. Supra-annular sizing would have resulted in a divergent size selection in 38.7% (smaller: 17.5%, larger: 19.8%, ICD out of range for TAVI prostheses: 1.4%) with potential improvement in a few cases with annular sizing errors, but potential worsening due to improper size selection in a much larger proportion of patients. CONCLUSIONS: Annular sizing for TAVI in BAV is feasible and safe. The added value of supra-annular sizing is questionable.

Predictors and outcome of conversion to cardiac surgery during transcatheter aortic valve implantation.

OBJECTIVES: Due to increasing clinical experience with transcatheter aortic valve implantation (TAVI) procedures, sophisticated imaging and advanced device technology, TAVI complication rates are low; however, patients requiring conversion to surgery are confronted with an increased mortality risk. In this retrospective study, we evaluated the predictors for conversion and the outcomes of these patients. METHODS: We analysed the records of all patients undergoing TAVI in our centre from 2011 to 2016 and focused on cases that required conversion to sternotomy. We investigated reasons and risk factors for conversion as well as 30-day and 1-year outcomes. RESULTS: During the study period, 32 (2.1%) of 1775 patients undergoing TAVI required immediate conversion to sternotomy. Annular rupture (5 of 32; 16%), device embolization (9 of 32; 28%) and pericardial tamponade (15 of 32; 47%) were the most common reasons for conversion. Usage of a self-expandable valve showed to be the only predictor for conversion (odds ratio 0.38, 95% confidence interval 0.16-0.90; P = 0.03). Survival at 30 days and 1 year was 56% and 41%, respectively. Patients who survived 30 days after conversion showed higher preoperative ejection fraction, shorter duration of surgery and shorter perfusion time. CONCLUSIONS: In this high-volume, single-centre experience, conversion to sternotomy during TAVI occurred in about 2%, with annular rupture, device embolization and pericardial tamponade being the most common causes. Complications requiring conversion showed to be unpredictable. However, in view of these life-threatening complications, the 30-day survival rate exceeding 50% emphasizes the importance of an experienced and well-attuned heart team providing immediate access to surgical bailout procedures.

TAVI risk scoring using established versus new scoring systems: role of the new STS/ACC model.

AIMS: The aim of this study was to validate the recently developed STS/ACC TAVR in-hospital mortality risk score for predicting in-hospital mortality after transcatheter aotic valve implantation (TAVI) and to compare its ability to predict 30-day mortality with that of four other established risk models (EuroSCORE I, EuroSCORE II, STS-PROM, and German AV Score). METHODS AND RESULTS: The study cohort included 946 consecutive patients who underwent TAVI between 2013 and 2015. Each of the five scores was fitted as a continuous linear variable into a logistic regression model estimating 30-day mortality. The STS/ACC TAVR score was additionally analysed for in-hospital mortality. C-statistics and likelihood ratio (LR) test p-values were estimated for each model to describe the model fit. The ability of the STS/ACC score to predict in-hospital mortality was similar to the reported STS/ACC TVT registry data (this study's C-statistic 0.65 vs. STS/ACC TVT registry 0.66). The STS-PROM score (C-statistic=0.68; LR p<0.0001) and the new STS/ACC TAVR score (C-statistic=0.68; LR p<0.0001) were superior to the other scores (EuroSCORE I [C-statistic=0.55; LR p=0.02], EuroSCORE II [C-statistic=0.58; LR p=0.02], German AV Score [C-statistic=0.62; LR p<0.01]) for prediction of 30-day mortality. CONCLUSIONS: These data show the superiority of the STS-PROM and STS/ACC TAVR scores compared with other existing risk calculation models in predicting 30-day mortality after TAVI in a German all-comers population. The STS/ACC TAVR score, however, is easier to calculate (12 vs. 28 variables), and may thus gain wider acceptance and be accompanied by improved inter-observer reliability.