Anthony Camuglia

Background: Valve-in-valve transcatheter aortic valve implantation is a less invasive alternative to redo surgery for failed surgical bioprostheses, but optimal antithrombotic management is uncertain. Objectives: To compare outcomes across antithrombotic regimens after valve-in-valve procedures in real-world practice. Methods: In the Australasian Cardiac Outcomes Registry (2018–2025), 1,050 adults were grouped by discharge regimen: single antiplatelet therapy, dual antiplatelet therapy, oral anticoagulation, or oral anticoagulation plus antiplatelet therapy. Outcomes included 30-day and 12-month mortality, stroke/TIA, life-threatening or major bleeding, major adverse cardiac and cerebrovascular events, and echocardiographic valve performance. Results: Thirty-day mortality was higher with oral anticoagulation (1.7%) and combination therapy (3.6%) than with single or dual antiplatelet therapy (both 0%; p < 0.001). The 30-day MACCE rate was greater with oral anticoagulation (4.5%) and combination therapy (4.4%) than with single (1.5%) or dual antiplatelet therapy (0.4%) ( p = 0.003); stroke/TIA and bleeding were infrequent and similar across groups. At 12 months, MACCE remained highest with oral anticoagulation (11.8%) and combination therapy (10.7%) compared with single (5.0%) and dual antiplatelet therapy (3.2%) ( p = 0.001). Mortality at 12 months was numerically higher with oral anticoagulation or combination therapy (5.2% and 4.4%) than with single or dual antiplatelet therapy (1.8% and 2.4%) ( p = 0.116). At 30 days, transvalvular gradients were lower in patients receiving oral anticoagulation-containing regimens; however, no significant differences in gradients, valve area, ejection fraction, or regurgitation were observed at 12 months. In multivariable analysis, combination therapy was independently associated with higher odds of 12-month MACCE compared with SAPT (OR 2.76, 95% CI 1.03–7.37; p = 0.043). Higher STS score and greater frailty were also independently associated with 12-month MACCE. Conclusions: In this observational cohort of patients undergoing valve-in-valve TAVI, oral anticoagulation-containing regimens were associated with higher early mortality and higher 12-month MACCE rates than antiplatelet-only strategies. However, these associations should be interpreted cautiously, as they likely reflect in part the greater baseline comorbidity burden of patients prescribed anticoagulation rather than a direct treatment effect. No sustained haemodynamic benefit was observed at 12 months. Individualised antithrombotic therapy and prospective randomised studies are warranted.

Coronary obstruction (CO) is a potential pitfall for transcatheter aortic valve replacement (TAVR), especially in valve in valve procedures into degenerated surgical or transcatheter prostheses. Bioprosthetic leaflet modification techniques that incorporate electrosurgery are evolving as the preferred strategy to mitigate the risk of CO in high CO risk settings. The UNICORN method is proposed as a more predictable leaflet modification strategy than the earlier described BASILICA approach, but its proponents have hitherto mandated the use of a balloon‐expandable valve (BEV) prosthesis. Many patients have small prostheses and therein face a significant risk of patient prosthesis mismatch with BEV in this setting. This risk may be curtailed if a self‐expanding valve (SEV) prosthesis could be used. Herein described is a modified approach to allow for the utilization of SEV systems in this setting.

A total of 1001 subjects (82.0 years, 62.5% female, 63.7% NYHA III/IV at baseline) with severe aortic stenosis at high surgical risk were enrolled in the prospective CONFIDENCE registry and treated with a Portico™ transcatheter heart valve (THV) using either a first-generation delivery system (DS) or the FlexNav™ DS. The objective of this registry is to characterize the procedural safety and device performance of the Portico™ THV at 30 days. The study collected ‘standard-of-care’ clinical and device performance data, with adverse events adjudicated by an independent clinical event committee according to the Valve Academic Research Consortium-2 criteria. The implantation of a single Portico™ THV was successful in 97.5% of subjects. The 30-day all-cause mortality, cardiovascular mortality, and disabling stroke rates were 2.6%, 2.1%, and 1.8%, respectively. A new pacemaker was implanted in 19.0% of subjects at 30 days. At 30 days, the effective orifice area and mean gradient values were 1.82 cm² and 7.1 mmHg, respectively. The 30-day rate of moderate paravalvular leak (PVL) was 2.1%, with no occurrence of severe PVL. The Portico™ THV demonstrated improved hemodynamic performance and low rates of safety events at 30 days in a large cohort of subjects implanted with the Portico™ THV with either the first-generation DS or FlexNav™ DS.

Transcatheter aortic valve implantation (TAVI) is relatively contraindicated in the bicuspid aortic valve, and to our knowledge has not been tried where the true native annulus is of a size far in ...

Patients with a true porcelain aorta and a failed mechanical aortic valve prosthesis have limited treatment options. Using a hybrid of an open trans‐ventricular approach with peripheral cardiopulmonary bypass and integration of transcatheter techniques this challenge can be overcome. Trans‐ventricular mechanical valve extraction (with transcatheter endovascular occlusion and cardioplegia) followed by direct ante‐grade transcatheter heart valve implantation offers a potential solution to this conundrum. The procedure described is a novel technique that allows for the effective treatment of patients with failed mechanical surgical aortic valve prostheses in the setting of an inoperable porcelain aorta. In addition, a collaborative integrated multi‐disciplinary heart team environment is required for the management of these complex patients.