scholarly journals Intravascular ultrasound for valve frame expansion and orifice area measurement as well as paravalvular leak assessment during transcatheter aortic valve replacement

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
L Kalinczuk ◽  
G S Mintz ◽  
Z Chmielak ◽  
M Dabrowski ◽  
P Stoklosa ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Valve Replacement ◽  
Intravascular Ultrasound ◽  
Valve Replacement ◽  
Transcatheter Aortic Valve Replacement ◽  
Paravalvular Leak ◽  
Orifice Area ◽  
Transcatheter Aortic Valve ◽  
Angio Ct ◽  
Frame Expansion

Abstract Introduction Valve frame expansion (measured outer valve frame area/nominal valve dimension), but not oversizing (nominal valve dimension/annulus area, %) determines pattern of restored blood flow after transcatheter aortic valve replacement (TAVR). There is no online measure of frame expansion, and error in current echocardiographic assessment of effective orifice area (EOA) and paravalvular leak (PVL) are common. Purpose To evaluate large imaging field intravascular ultrasound (IVUS) during TAVR for measuring valve geometry [frame expansion, minimal geometric orifice area (min GOA), and mechanism of PVL] with transthoracic echo and angio-CT serving for comparative measures, along with the nominal EOA as established by Hahn et al. Methods After successful TAVR either a 10MHz Vision PV 0.035" (60mm imaging field) or 20MHz Vision PV 0.018" (24mm imaging field plus Chr omaFlo) IVUS catheter (Philips) was slowly pulled from the left ventricle outflow (LVOT) to the aorta with continuous imaging of the aortic root. Results There were 16 pts (80.8±7.1 yrs, 8 female) treated for de novo aortic stenosis (n=15) or failed bioprosthesis (n=1), 7 of whom were treated with balloon-expandable TAVR. PV 0.35" catheters were used in 8 pts (including valve-in-valve) and allowed complete geometry assessment of 26.6±2.7mm nominal prosthesis Ø (Figure 1A) whereas PV 0.018" allowed complete geometry assessment in only 4 of 8 pts with nominal prosthesis Ø of 26.1±2.8mm (Figure 1B). Actual % valve inflow expansion (IVUS outer frame/valve nominal dimension) was significantly smaller than % valve oversizing (80%±19% vs 125±19%, p=0.005). Min GOA was substantially bigger than corresponding nominal EOA and EOA calculated using the post-procedural LVOT diameter (272±84mm2 vs 174±25mm2 vs 181±59mm2, p=0.001 correspondingly). However, min GOA was similar to EOA calculated using baseline LVOT area (272±84mm2 vs 230±90mm2; r=0.713, p=0.009). IVUS and angio-CT measurements of outer prosthesis frame area were similar for inflow, coaptation site, and outflow (460±143mm2 vs 454±134mm2 and 455±134mm2 vs 447±114mm2 and 722±174mm2 vs 725±180; p≤0.001 for all paired correlations). Inflow expansion (IVUS outer frame/baseline CT annulus area) tended to be smaller among valves with ≥mild vs no PVL (95±14% vs 107±11%, p=0.156), with clear ChromaFlo signal seen in the space between the aortic annulus wall and outer-valve frame surface (Figure 1C). Conclusions Large imaging field IVUS during TAVR allows for peri-procedural assessment of actual valve geometry that differs substantially from nominal. IVUS offers online tomographic perspective and highest accuracy in anatomy evaluation corresponding with valve function. FUNDunding Acknowledgement Type of funding sources: None. Figure 1

scholarly journals Outcome of transcatheter aortic valve replacement in bicuspid aortic valve stenosis with new-generation devices

2020 ◽  
Vol 32 (1) ◽  
pp. 20-28
Author(s):  
Riccardo Gorla ◽  
Matteo Casenghi ◽  
Alice Finotello ◽  
Federico De Marco ◽  
Simone Morganti ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Stress Distribution ◽  
Aortic Valve Replacement ◽  
Valve Replacement ◽  
Bicuspid Aortic Valve ◽  
Transcatheter Aortic Valve Replacement ◽  
Paravalvular Leak ◽  
Orifice Area ◽  
Transcatheter Aortic Valve ◽  
New Generation

Abstract OBJECTIVES To compare device success and paravalvular leak rates of 3 new-generation transcatheter aortic valve replacement devices in patients with bicuspid aortic valve stenosis and to test their biomechanical performance in a computer-based simulation model of aortic root with increasing ellipticity. METHODS This retrospective multicentre study included 56 bicuspid aortic valve patients undergoing transcatheter aortic valve replacement with new-generation devices: Lotus/Lotus Edge (N = 15; 27%), Evolut-R (N = 20; 36%) and ACURATE neo (N = 21; 37%). Three virtual simulation models of aortic root with increasing index of eccentricity (0–0.25–0.5) were implemented. Stress distribution, stent–root contact area and paravalvular orifice area were computed. RESULTS Device success was achieved in 43/56 patients (77%) with comparable rates among Lotus (87%), Evolut-R (60%) and ACURATE neo (86%; P = 0.085). Moderate paravalvular leak rate was significantly lower in the Lotus group as compared to Evolut-R group (0% vs 30%; P = 0.027) and comparable to the ACURATE neo group (0% vs 10%; P = 0.33). By index of eccentricity = 0.5, Lotus showed a uniform and symmetric pattern of stress distribution with absent paravalvular orifice area, ACURATE neo showed a mild asymmetry with small paravalvular orifice area (1.1 mm2), whereas a severely asymmetric pattern was evident with Evolut-R, resulting in a large paravalvular orifice area (12.0 mm2). CONCLUSIONS Transcatheter aortic valve replacement in bicuspid aortic valve patients with new-generation devices showed comparable device success rates. Lotus showed moderate paravalvular leak rate comparable to that of ACURATE neo and significantly lower than Evolut-R. On simulation, Lotus and ACURATE neo showed optimal adaptability to elliptic anatomies as compared to Evolut-R.

scholarly journals The role of far-field intravascular ultrasound in transcatheter aortic valve replacement

2021 ◽  
Vol 73 (1) ◽  
Author(s):  
Ahmed Hassanin ◽  
Hasan Ahmad ◽  
Massoud Leesar ◽  
Diaa Hakim
Keyword(s):  
Aortic Valve ◽  
Aortic Valve Replacement ◽  
Intravascular Ultrasound ◽  
Valve Replacement ◽  
Transcatheter Aortic Valve Replacement ◽  
Paravalvular Leak ◽  
Far Field ◽  
Transcatheter Aortic Valve ◽  
Novel Technology

AbstractPrecise and accurate characterization of the aortic valve complex is a vital step in the procedure planning for transcatheter aortic valve replacement (TAVR). Far-field intravascular ultrasound (IVUS) is a novel technology that can be utilized to assess aortic valve annulus and predict paravalvular leak, with comparable results to multi-detector computed tomography—the current gold standard in the preprocedural planning in TAVR. Far-field IVUS carries the advantage of minimal contrast use and lower radiation exposure. In this commentary, we describe two cases of far-field IVUS use during TAVR procedures and review its role as a complementary tool to current the imaging modalities used in TAVR.

scholarly journals Concurrent mechanical haemolytic anaemia and heparin-induced thrombocytopenia following transcatheter aortic valve replacement

2018 ◽  
pp. bcr-2017-224069
Author(s):  
Nathan W Furukawa ◽  
Fernando M Jumalon ◽  
Daniel B Friedman ◽  
Linda R Kelly
Keyword(s):  
Aortic Valve ◽  
Aortic Valve Replacement ◽  
Prothrombin Time ◽  
Valve Replacement ◽  
Haemolytic Anaemia ◽  
Transcatheter Aortic Valve Replacement ◽  
Severe Aortic Stenosis ◽  
Paravalvular Leak ◽  
Heparin Induced Thrombocytopenia ◽  
Transcatheter Aortic Valve

A 78-year-old man with a history of severe aortic stenosis presented with confusion, irregular behaviour and dyspnoea 8 days following transcatheter aortic valve replacement. His exam was consistent with a heart failure exacerbation and he had elevated aminotransferases, bilirubin and prothrombin time suggestive of shock liver. A CT head scan demonstrated a subacute large left temporoparietal infarction. His aminotransferase and prothrombin time levels normalised with diuresis, but his indirect bilirubin remained elevated and he developed anaemia and thrombocytopenia consistent with a haemolytic anaemia. A transthoracic echocardiogram demonstrated a paravalvular leak. His thrombocytopenia continued to worsen prompting testing for antibodies against heparin-PF4 complexes which was positive. A serotonin release assay later returned positive, confirming the diagnosis of heparin-induced thrombocytopenia. This case illustrates that the presence of haemolytic anaemia does not necessarily exclude other causes of thrombocytopenia that may occur concurrently.

scholarly journals Infective Endocarditis After Surgical and Transcatheter Aortic Valve Replacement: A State of the Art Review

2020 ◽  
Vol 9 (16) ◽  
Author(s):  
Sophia L. Alexis ◽  
Aaqib H. Malik ◽  
Isaac George ◽  
Rebecca T. Hahn ◽  
Omar K. Khalique ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Valve Replacement ◽  
Valve Replacement ◽  
Transcatheter Aortic Valve Replacement ◽  
Prosthetic Valve Endocarditis ◽  
Paravalvular Leak ◽  
Surgical Aortic Valve Replacement ◽  
Entry Site ◽  
Transcatheter Aortic Valve ◽  
Significant Difference

Abstract Prosthetic valve endocarditis (PVE) after surgical aortic valve replacement and transcatheter aortic valve replacement (TAVR) carries significant morbidity/mortality. Our review aims to compare incidence, predisposing factors, microbiology, diagnosis, management, and outcomes of PVE in surgical aortic valve replacement/TAVR patients. We searched PubMed and Embase to identify published studies from January 1, 2015 to March 13, 2020. Key words were indexed for original reports, clinical studies, and reviews. Reports were evaluated by 2 authors against a priori inclusion/exclusion criteria. Studies were included if they reported incidence and outcomes related to surgical aortic valve replacement/TAVR PVE and excluded if they were published pre‐2015 or included a small population. We followed the Cochrane methodology and Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines for all stages of the design and implementation. Study quality was based on the Newcastle‐Ottawa Scale. Thirty‐three studies with 311 to 41 025 patients contained relevant information. The majority found no significant difference in incidence of surgical aortic valve replacement/TAVR PVE (reported as 0.3%–1.2% per patient‐year versus 0.6%–3.4%), but there were key differences in pathogenesis. TAVR has a specific set of infection risks related to entry site, procedure, and device, including nonstandardized protocols for infection control, valve crimping injury, paravalvular leak, neo‐leaflet stress, intact/calcified native leaflets, and intracardiac hardware. With the expansion of TAVR to lower risk and younger patients, a better understanding of pathogenesis, patient presentation, and guideline‐directed treatment is paramount. When operative intervention is necessary, mortality remains high at 20% to 30%. Unique TAVR infection risks present opportunities for PVE prevention, therefore, further investigation is imperative.

Impact of annular and cusps calcification on occurrence of paravalvular leak after transcatheter aortic valve replacement with intra- versus supra-annular devices

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
I Michalowska ◽  
L Kalinczuk ◽  
M Dabrowski ◽  
Z Chmielak ◽  
K Zielinski ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Valve Replacement ◽  
Valve Replacement ◽  
Transcatheter Aortic Valve Replacement ◽  
Independent Effect ◽  
Paravalvular Leak ◽  
Transcatheter Aortic Valve ◽  
Device Deployment ◽  
The Impact ◽  
Annular Calcification

Abstract Introduction Severe annular and valve cusps calcification is frequent among patients treated with transcatheter aortic valve replacement (TAVR). Severe annular calcification increases the risk of paravalvular leak (PVL) and was associated with worse outcomes. Whether it is accompanied by an independent effect of calcifications localized on cusps and whether the impact of cusps/annular calcification depends on supra vs intra-annular valve design is unknown. Purpose To assess the impact of cusps/annular calcifications on occurrence of moderate PVL after successful TAVR with devices of either intra- or supra-annular design. Methods 282 consecutive patients (80.3±7.6 yrs, 63% female) with baseline 384-slice CT scan were successfully treated with TAVR between Jul 2012 and Oct 2017, either with intra-annular or supra-annular devices. Severe annular calcification (clear protrusion) and severe cusps calcification (Rosenhek 4 score) were identified using a Syngo Via. Results 138 (48.9%) patients were treated with intra-annular and 144 (51.15) with supra-annular devices. Whereas severe annular calcification was similar (23.9% vs 20.1%), there was more severe cusps calcification among intra-annular valves (52.9% vs 41.7%, p=0.073). Intra-annular devices were used less frequently among bicuspid aortic valves, were also of smaller diameter, less frequently deployed after pre-dilation, and less frequently post-dilated. Post-procedure mean aortic gradient tended to be higher among intra-annular devices. Moderate PVL was less frequent among intra- vs supra-annular valves (14.5% vs 34.0%, p<0.001). However, PVL occurrence was higher (30.3%) among those (33/138, 23.9%) treated with an intra-annular valve who had severe annular calcification vs 9.5% in pts treated with an intra-annular TAVR who did not have severe annular calcification (p=0.008) unlike in patients treated with a supra-annular valve who had a high frequency of PVL with or without severe annular calcium (37.9% vs 33.0%). After excluding patients with severe annular calcium (n=62, 22%), moderate PVL was similar between those with vs without severe cusp calcification whether treated with intra- or supra-annular valves (11.8% vs 7.4% and 29.3% vs 35.1%, respectively). Combined VARC-2 safety endpoints plus 2-yr mortality occurrence were lower for intra- vs supra-annular devices (30.4% vs 43.8%, p=0.026). Conclusions Moderate PVL after intra-annular TAVR device deployment occurs in 30% of patients with protruding annular calcification. Severe cusps calcification unaccompanied by annular calcium was not associated with PVL occurrence. Higher frequency of moderate PVL (34%) seen after supra-annular valve deployment appears to be related to other parameters rather than presence of severe annular or cusps calcification. Funding Acknowledgement Type of funding source: None

scholarly journals Third-Generation Balloon and Self-Expandable Valves for Aortic Stenosis in Large and Extra-Large Aortic Annuli From the TAVR-LARGE Registry

2020 ◽  
Vol 13 (8) ◽  
Author(s):  
Germán Armijo ◽  
Gilbert H.L. Tang ◽  
Nynke Kooistra ◽  
Alfredo Nunes Ferreira-Neto ◽  
Stefan Toggweiler ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Aortic Valve Replacement ◽  
Valve Replacement ◽  
Transcatheter Aortic Valve Replacement ◽  
Paravalvular Leak ◽  
Third Generation ◽  
Large Area ◽  
Transcatheter Aortic Valve ◽  
Sapien 3

Background: Currently, 2 third-generation transcatheter valves, 29-mm Sapien-3 and 34-mm Evolut-R (ER), are indicated for large sized aortic annuli. We analyzed short and 1-year performance of these valves in patients with large (area ≥575 mm 2 or perimeter ≥85 mm) and extra-large (≥683 mm 2 or ≥94.2 mm) aortic annuli undergoing transcatheter aortic valve replacement. Methods: A total of 833 patients across 12 centers with symptomatic aortic stenosis and large aortic annuli underwent transcatheter aortic valve replacement with 29-mm Sapien-3 (n=640) or 34-mm ER (n=193). Clinical, anatomic, and procedural characteristics were collected, and Valve Academic Research Consortium-2 outcomes were reported. Results: Median aortic annulus area and perimeter were 617 mm 2 (591–657) and 89.1 mm (87.0–92.1), respectively (704 mm 2 [689–743] and 96.0 mm [94.5–97.9] in the subgroup of 124 patients with extra-large annuli). Overall device success was 94.3% (Sapien-3, 95.8% and ER, 89.3%; P =0.001), with a higher rate of significant paravalvular leak ( P =0.004), second valve implantation ( P =0.013), and valve embolization ( P =0.009) in the ER group. Thirty-day and 1-year mortality was 2.4% and 9.2%, respectively, without differences between groups. Valve hemodynamics were excellent (mean gradient, 8.8±3.6 mm Hg; 3.3% rate of moderate-severe paravalvular leak) in the extra-large annulus, without differences compared with the large annulus group. Conclusions: In patients with large and extra-large aortic annuli, transcatheter aortic valve replacement using 29-mm Sapien-3 and 34-mm ER is safe and feasible. Observed differences in clinical outcomes and hemodynamic performance may guide valve choice in this cohort of patients undergoing transcatheter aortic valve replacement.

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