Philipp Kahlert

Objectives: To evaluate the impact of baseline left ventricular ejection fraction (LVEF) and its interaction with low‐gradient aortic stenosis (LGAS) on all‐cause mortality after transfemoral aortic valve implantation (TF‐TAVI).Methods: We reviewed mortality data of 624 consecutive single center TF‐TAVI patients and categorized LVEF according to current ASE/EACVI recommendations (normal, mildly‐, moderately‐, and severely abnormal).Results: Baseline LVEF was normal in 336 (53.8%), mildly abnormal in 160 (25.6%), moderately abnormal in 91 (14.6%), and severely abnormal in 37 (5.9%) patients, and 1‐year mortality was 19%, 17%, 23%, and 43% (P = 0.002), respectively. Patients with LGAS had a similar 1‐year mortality compared to those without LGAS in groups with normal (19% vs 19%, P = 0.899) and mildly abnormal LVEF (16% vs 17%, P = 0.898). One‐year mortality of patients with LGAS was significantly greater than in those without LGAS in presence of moderately abnormal LVEF (31% vs 11%, P = 0.022), and it was numerically greater than in those without LGAS in presence of severely abnormal LVEF (48% vs 25%, P = 0.219). In multivariate analysis, only the combination of moderately/severely abnormal LVEF and LGAS predicted increased 1‐year mortality (HR: 2.12, 95% CI: 1.4–3.2, P < 0.001). Other variables, including EuroSCORE I did not affect this result.Conclusions: Moderately/severely abnormal LVEF (≤40%) at baseline is associated with increased mortality after TF‐TAVI, especially when the mean transvalvular aortic gradient is <40 mm Hg (LGAS), while outcomes in patients with normal and mildly abnormal LVEF are comparable regardless of the pressure gradient across the native aortic valve. (DRKS00013729).

Transcatheter aortic valve implantation (TAVI) has proven to be the standard of care for patients with prohibitive and high operative risk; today, it is considered a reasonable alternative to surgical aortic valve replacement in intermediate-risk patients. As indications for TAVI move toward patients at lower risk, safety aspects are becoming even more important. Furthermore, adequate patient selection is key for predictable procedural success with minimal complications, translating into an optimal clinical outcome. Decisions on valve type and size as well as on the access route are based on multimodality imaging including echocardiography, multislice computed tomography, and cardiac catheterization with peripheral angiography. This combination of multiple imaging modalities provides the best picture of a patient’s anatomical and physiological suitability for the TAVI procedure. Yet, the reliability of preprocedural imaging is influenced by the quality of the images, which should be as high as possible, and both image acquisition and interpretation should be performed in a standardized manner. This article provides a concise overview of standardized multimodality imaging for the preprocedural planning and assessment of patients undergoing TAVI. Die kathetergeführte Aortenklappenimplantation („transcatheter aortic valve implantation“, TAVI) ist die Therapie der Wahl bei inoperablen Patienten oder Patienten mit hohem operativem Risiko sowie eine alternative Therapieoption zum chirurgischen Aortenklappenersatz bei Patienten mit intermediärem Risiko. Mit Ausdehnung der Indikationsstellung für eine TAVI auf Patienten mit einem niedrigeren Risiko gewinnen einzelne Sicherheitsaspekte zusätzlich an Bedeutung. Die adäquate Patientenauswahl ist der Schlüssel für einen vorhersehbaren Erfolg der Prozedur mit einer geringen Komplikationsrate, was sich wiederum in einem guten klinischen Ergebnis widerspiegelt. Die Entscheidung bezüglich Typ und Größe der Klappenprothese sowie des Zugangswegs bedarf einer multimodalen Bildgebung mittels Echokardiographie, Computertomographie („multislice computed tomography“, MSCT) sowie Herzkatheteruntersuchung mit Angiographie. Die Kombination dieser verschiedenen Bildgebungsmodalitäten stellt die Anatomie am besten dar und ermöglicht somit ein Abschätzen der Eignung des Patienten für eine TAVI. Die Zuverlässigkeit der präinterventionellen Bildgebung ist abhängig von der Bildqualität, die stets möglichst hoch sein sollte; sowohl die Bilderfassung als auch die Interpretation sollten in einer standardisierten Form erfolgen. Dieser Artikel gibt eine Übersicht zur Evaluation von Patienten für eine TAVI-Prozedur mittels multimodaler Bildgebung.

The Official Journal of EuroPCR and the European Association of Percutaneous Cardiovascular Interventions (EAPCI)

Acute kidney injury (AKI) is a common complication following transcatheter aortic valve implantation (TAVI) leading to increased mortality and morbidity. Urinary G1 cell cycle arrest proteins TIMP-2 and IGFBP7 have recently been suggested as sensitive biomarkers for early detection of AKI in critically ill patients. However, the precise role of urinary TIMP-2 and IGFBP7 in patients undergoing TAVI is unknown. In a prospective observational trial, 40 patients undergoing TAVI (either transaortic or transapical) were enrolled. Serial measurements of TIMP-2 and IGFBP7 were performed in the early post interventional course. The primary clinical endpoint was the occurrence of AKI stage 2/3 according to the KDIGO classification. Now we show, that ROC analyses of [TIMP-2]*[IGFBP7] on day one after TAVI reveals a sensitivity of 100 % and a specificity of 90 % for predicting AKI 2/3 (AUC 0.971, 95 % CI 0.914-1.0, SE 0.0299, p = 0.001, cut-off 1.03). In contrast, preoperative and postoperative serum creatinine levels as well as glomerular filtration rate (GFR) and perioperative change in GFR did not show any association with the development of AKI. Furthermore, [TIMP-2]*[IGFBP7] remained stable in patients with AKI ≤1, but its levels increased significantly as early as 24 h after TAVI in patients who developed AKI 2/3 in the further course (4.77 ± 3.21 vs. 0.48 ± 0.68, p = 0.022). Mean patients age was 81.2 ± 5.6 years, 16 patients were male (40.0 %). 35 patients underwent transapical and five patients transaortic TAVI. 15 patients (37.5 %) developed any kind of AKI; eight patients (20 %) met the primary endpoint and seven patients required renal replacement therapy (RRT) within 72 h after surgery. Early elevation of urinary cell cycle arrest biomarkers after TAVI is associated with the development of postoperative AKI. [TIMP-2]*[IGFBP7] provides an excellent diagnostic accuracy in the prediction of AKI that is superior to that of serum creatinine.

Background: Transcatheter aortic valve implantation (TAVI) has rapidly evolved to the standard‐of‐care for inoperable patients with severe, symptomatic aortic valve stenosis, and to an alternative treatment option for high‐risk patients. However, the randomized PARTNER trial excluded patients with conditions frequently encountered in daily clinical practice.Methods: From 2006 to 2011, 467 high‐risk patients, who underwent transfemoral TAVI (Edwards Sapien n = 166; Medtronic CoreValve n = 301) at two German centers were divided into a “PARTNER‐like” (n = 227) and a “Real‐World” cohort (n = 240), based on the original PARTNER trial in‐ and exclusion criteria. Differences in 30‐day and 2‐year mortality and morbidity were assessed.Results: Mean age of patients was 80 ± 8 years with a logistic EuroSCORE of 22 ± 16%. The most frequent exclusion criteria were previous PCI (15.4%), prior valve surgery (13.7%), chronic renal failure (12.0%), and severe mitral regurgitation (10.8%). Despite significant differences in baseline data, estimated perioperative mortality in terms of STS and logistic EuroScore was identical between both groups. However, patients in the “Real‐World” cohort had a non‐significant trend towards a higher 30‐day mortality (10.0% vs. 6.7%, P = 0.088) and a significantly higher 2‐year mortality (23.3% vs. 14.5%, P = 0.016) compared with patients of the “PARTNER‐like” cohort.Conclusion: Patients meeting PARTNER study exclusion criteria had an acceptable outcome at 30 days and 2 years, however, with significant differences to “PARTNER‐like” patients. Still, our results indicate that also real‐life patients with relevant comorbidities, who would have been excluded from the randomized PARTNER trials, benefit from TAVI with acceptable short‐ and long‐term outcome.