Anson Cheung

BACKGROUND: As transcatheter aortic valve replacement (TAVR) expands to patients with longer life expectancy, the impact of failure mechanisms on outcomes of TAVR-explant and redo-TAVR remains uncertain. We sought to evaluate outcomes of TAVR reintervention based on the failure mechanism of the index transcatheter aortic valve. METHODS: From 2009 to 2022, 553 patients from 29 centers in the EXPLANTORREDO-TAVR registry (Explant or Redo Transcatheter Aortic Valve Replacement) underwent TAVR-explant or redo-TAVR for transcatheter aortic valve failure. Patients with endocarditis were excluded. Patients with structural valve deterioration (SVD, N=224 [64.9%]) were compared with those with nonstructural valve dysfunction (NSVD, N=121 [35.1%]), comprising paravalvular leak (86.0%) and prosthesis-patient mismatch (14.0%). Outcomes were assessed at 30 days and 1 year. RESULTS: Mean age was 75.6±9.3 years, with 42% women. There were no differences in reintervention type between groups (redo-TAVR in 58.0% SVD versus 49.6% NSVD; TAVR-explant: 42.0% versus 50.4%; P =0.14). Compared with NSVD, SVD was the predominant mode of failure in balloon-expandable valves (50.7% versus 24.8%; P P P =0.003). Mortality at 30 days and 1 year did not differ significantly between SVD and NSVD for either redo-TAVR (30 days: 3.2% versus 1.7%, P =1.00; 1 year: 18.0% versus 12.0%; P =0.47) or TAVR-explant (30 days: 16.3% versus 12.1%, P =0.63; 1 year: 40.0% versus 29.5%; P =0.39). There were also no differences in risk-adjusted 3-year cumulative mortality between groups (redo-TAVR: hazard ratio, 1.30 [95% CI, 0.68–2.46], P =0.43 [ref=NSVD]; TAVR-explant: hazard ratio, 1.24 [95% CI, 0.64–2.41]; P =0.53). CONCLUSIONS: SVD and NSVD failures had distinct valve types and reintervention timing, with SVD having a longer time to TAVR reintervention, but the failure mechanism did not impact reintervention type or clinical outcomes.

Aims: Tricuspid regurgitation (TR) is associated with increased morbidity and mortality. The optimal timing for referral and intervention remains uncertain. To evaluate outcomes in patients with TR referred for tricuspid valve intervention. Methods and results: Fifty-eight consecutive patients were referred from May 2018 to April 2023. Patients were stratified into two groups: Group 1 who underwent either tricuspid valve transcatheter edge-to-edge repair (T-TEER) or transcatheter tricuspid valve replacement (TTVR); Group 2 who died without intervention due to: awaiting candidacy assessment; awaiting intervention; deemed unsuitable for intervention. Key endpoints: in-patient, 30-day, 12- and 18-month mortality; new pacemaker implantation; echocardiographic TR grading; improvement in NYHA functional class; and heart failure-related readmissions at 30 days and 12 months. Among 58 patients, 43 underwent intervention (TTVR, n = 29; T-TEER, n = 14), 15 died without intervention (awaiting assessment n = 11; awaiting procedure n = 1, unsuitable n = 3). At the time of referral, the mean age was 77.0 ± 9.8 years, and 52 patients (90%) were diagnosed with functional TR; 30-day mortality in Group 1 was 12%, and 12-month mortality reached 33%, with heart failure readmission (37%); 12-month mortality in Group 2 was 73%. At 18 months, mortality reached 37% in Group 1 and 100% in Group 2. Baseline characteristics differed significantly between the groups for body mass index, severity of TR (massive or torrential), NYHA III–IV symptoms, and validated mortality scores. Conclusion: Referrals for TR often occur after substantial comorbidities have developed resulting in high mortality but should be considered for a referral and intervention at an earlier stage.

Purpose of Review Mitral and tricuspid regurgitation represents a clinical challenge. They are associated with a poor prognosis, and many patients are not eligible for conventional surgery. Transcatheter therapies have been the focus of numerous studies and devices over the past decade. Here, we provide a summary of current options for transcatheter treatment of these 2 entities. Recent Findings Recent studies have demonstrated the benefits of edge-to-edge repair for increasing numbers of patients. Encouraging early results with transcatheter valve replacement are also becoming available. Summary To date, transcatheter edge-to-edge repair is currently the first-line transcatheter treatment for both mitral and tricuspid regurgitation for many patients who are not candidates for surgery. A number of transcatheter replacement devices are under development and clinical investigation but, for the most part, their current use is limited to compassionate cases or clinical trials.

Background: The 3M-TAVR trial (3M-Transcatheter Aortic Valve Replacement) demonstrated the feasibility and safety of next-day hospital discharge after transfemoral TAVR with implementation of a minimalist pathway. However, the economic impact of this approach is unknown. Therefore, we evaluated costs for patients undergoing minimalist TAVR compared with conventional TAVR. Methods: We used propensity matching to compare resource utilization and costs (from a US health care system perspective) for patients in the 3M-TAVR trial with those for transfemoral TAVR patients enrolled in the contemporaneous S3i trial (PARTNER SAPIEN-3 Intermediate Risk). Procedural costs were estimated using measured resource utilization for both groups. For the S3i group, all other costs through 30-day follow-up were assessed by linkage with Medicare claims; for 3M, these costs were assessed using regression models derived from S3i cost and resource utilization data. Results: After 1:1 propensity matching, 351 pairs were included in our study (mean age 82, mean Society of Thoracic Surgery risk score 5.3%). There were no differences in death, stroke, or rehospitalization between the 3M-TAVR and S3i groups through 30-day follow-up. Index hospitalization costs were $10 843/patient lower in the 3M-TAVR cohort, driven by reductions in procedure duration, anesthesia costs, and length of stay. Between discharge and 30 days, costs were similar for the 2 groups such that cumulative 30-day costs were $11 305/patient lower in the 3M-TAVR cohort compared with the S3i cohort ($49 425 versus $60 729, 95% CI for difference $9378 to $13 138; P <0.001). Conclusions: Compared with conventional transfemoral TAVR, use of a minimalist pathway in intermediate-risk patients was associated with similar clinical outcomes and substantial in-hospital cost savings, which were sustained through 30 days. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02287662.

Video 1 Transcatheter solutions for transcatheter aortic valve replacement dysfunction: is redo transcatheter aortic valve replacement a durable option? Authors: Andrew G. Chatfield, Anson Cheung, Mariama Akodad, Anthony Chuang, Laura Besola, Stephanie Sellers, David A. Wood, Janarthanan Sathananthan, John Webb

Video 1 Transapical transcatheter mitral valve-in-valve (TMVIV): (A) pre-implant intraoperative transesophageal echocardiography (TEE); (B) prosthesis position control; (C) prosthesis deployment; (D) post-implant intraoperative TEE. Video 2 Trans-septal transcatheter mitral valve-in-valve (TMVIV): (A) pre-implant intraoperative TEE; (B) balloon septostomy; (C) prosthesis advancement through the interatrial septum; (D) prosthesis deployment; (E) fully deployed prosthesis and Amplatzer device (Abbott Cardiovascular, Plymouth, MN, USA) to close the iatrogenic atrial septal defect; (F) post-implant intraoperative TEE. Authors: Laura Besola, Anson Cheung, Jian Ye, Myriam Akodad, Andrew Chatfield, Gnalini Sathananthan, Robert Moss, John Webb

Background: The LATERAL trial validated the safety and efficacy of the thoracotomy approach for implantation of the HeartWare HVAD System, leading to Food and Drug Administration approval. We sought to analyze 24-month adverse event (AE) rates, including a temporal analysis of the risk profile, associated with the thoracotomy approach for the HVAD system. Methods: AEs from the LATERAL trial were evaluated over 2 years postimplant. Data was obtained from the Interagency Registry for Mechanically Assisted Circulatory Support database for 144 enrolled United States and Canadian patients. Temporal AE profiles were expressed as events per patient year. Results: During 162.5 patient years of support, there were 25 driveline infections (0.15 events per patient year), 50 gastrointestinal bleeds (0.31 events per patient year), and 21 strokes (0.13 events per patient year). Longitudinal AE analysis at follow-up intervals of <30 and 30 to 180 days, and 6 to 12 and 12 to 24 months revealed the highest AE rate at <30 days, with a decrease in total AEs within the first 6 months. After 6 months, most AE rates either stabilized or decreased through 2 years, including a 95% overall freedom from disabling stroke. Conclusions: Two-year follow-up of the LATERAL trial revealed a favorable morbidity profile in patients supported with the HVAD system, as AE rates were more likely to occur in the first 30 days postimplant, and overall AE rates were significantly reduced after 6 months. Importantly, 2-year freedom from disabling stroke was 95%. These data further support the improving AE profile of patients on long-term HVAD support. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02268942.