Search Results (65)

Background/Objectives: Transcatheter aortic valve replacement (TAVR) has been introduced as an optimal treatment for patients with severe aortic stenosis, offering a minimally invasive alternative to surgical aortic valve replacement. Predicting these outcomes following TAVR is crucial. Artificial intelligence (AI) has emerged as a promising tool for improving post-TAVR outcome prediction. In this systematic review and meta-analysis, we aim to summarize the current evidence on utilizing AI in predicting post-TAVR outcomes. Methods: A comprehensive search was conducted to evaluate the studies focused on TAVR that applied AI methods for risk stratification. We assessed various ML algorithms, including random forests, neural networks, extreme gradient boosting, and support vector machines. Model performance metrics—recall, area under the curve (AUC), and accuracy—were collected with 95% confidence intervals (CIs). A random-effects meta-analysis was conducted to pool effect estimates. Results: We included 43 studies evaluating 366,269 patients (mean age 80 ± 8.25; 52.9% men) following TAVR. Meta-analyses for AI model performances demonstrated the following results: all-cause mortality (AUC = 0.78 (0.74–0.82), accuracy = 0.81 (0.69–0.89), and recall = 0.90 (0.70–0.97); permanent pacemaker implantation or new left bundle branch block (AUC = 0.75 (0.68–0.82), accuracy = 0.73 (0.59–0.84), and recall = 0.87 (0.50–0.98)); valve-related dysfunction (AUC = 0.73 (0.62–0.84), accuracy = 0.79 (0.57–0.91), and recall = 0.54 (0.26–0.80)); and major adverse cardiovascular events (AUC = 0.79 (0.67–0.92)). Subgroup analyses based on the model development approaches indicated that models incorporating baseline clinical data, imaging, and biomarker information enhanced predictive performance. Conclusions: AI-based risk prediction for TAVR complications has demonstrated promising performance. However, it is necessary to evaluate the efficiency of the aforementioned models in external validation datasets. Full article

The introduction of transcatheter aortic valve replacement (TAVR) has revolutionized the management of aortic stenosis (AS), leading to significant improvements in patient outcomes. Over time, advancements in device technology have further optimized safety and performance of TAVR. However, as the pool of low-risk patients undergoing TAVR expands, many of whom present with concomitant coronary artery disease (CAD), new challenges have emerged. A large proportion of TAVR candidates suffer from CAD, and the clinical implications of this comorbidity remain a subject of debate. Research on the relationship between AS and CAD has yielded conflicting results, but severe CAD is generally linked to worse outcomes in AS patients. The coexistence of AS and CAD complicates diagnosis and management, requiring a comprehensive understanding of both invasive and non-invasive diagnostic techniques, along with careful revascularization strategies. This review explores the prevalence, clinical impact, and diagnostic challenges of CAD in TAVR patients, highlighting emerging methods for its assessment. Key aspects of treatment, including the timing of coronary revascularization, coronary re-access after TAVR in different settings, as well as practical tips and tricks for coronary cannulation, are also discussed. The complexity of managing AS and CAD is further intensified by the need for individualized approaches, particularly in hybrid procedures and subsequent TAVR interventions. Ongoing research and technological innovations offer promising solutions for refining the management of CAD in AS patients undergoing TAVR, with an emphasis on improving prognostic accuracy, optimizing revascularization strategies, and enhancing post-procedural care. Full article

Transcatheter aortic valve replacement (TAVR) is now established as a safe and effective treatment for severe aortic stenosis across all surgical risk categories. Nevertheless, periprocedural conduction disturbances—including new-onset left bundle branch block (LBBB), right bundle branch block (RBBB), and other intraventricular blocks—remain among the most frequent complications, often resulting in permanent pacemaker (PPM) implantation and impacting left ventricular remodeling. A review was conducted using the PubMed/MEDLINE database. Relevant clinical trials, observational studies, and meta-analyses addressing post-TAVR LBBB were included and analysed with a focus on frequency, risk factors, and association with adverse outcomes. We describe the incidence of post-TAVR conduction disturbances and identify key predictors: pre-existing RBBB, membranous septum length, valve oversizing, implantation depth, infra-annular leaflet extension, compression ratio, and valve type/generation. New-onset LBBB is a frequent complication after TAVR and may negatively affect patient outcomes. Accurate risk stratification and standardised post-procedural monitoring protocols are essential. Further prospective studies are needed to better define management strategies for patients developing LBBB after TAVR. Full article

Background: Transcatheter aortic valve replacement (TAVR) is at the forefront of structural heart programs all over the world. With a growing number of TAVR procedures in lower-risk and younger patients, acute and chronic complications require decisive treatment. The aim of the present study is to retrospectively analyze the efficacy of surgical bailout strategies in case of complications from TAVR that had been performed in the highest-volume center in Italy over the past ten years. Methods: Acute complications were defined as events occurring in the first 24 h after surgery, while chronic complications were defined as events occurring within the first year post-implant. We retrospectively analyzed the 2731 patients who had undergone TAVR at our institution from January 2015 to August 2024. Results: A total of 21 patients were included, with a median age of 78 years (IQR 11y). The majority of patients underwent TAVR with a self-expanding prosthesis (76%). A total of 11 patients (52%) presented acute complications, of which the most common were aortic dissection (n = 4 [19%]) followed by left ventricular perforation (n = 3 [14%]). The most common chronic complication was early endocarditis (n = 5 [24%]). The most common bailout strategy was aortic valve replacement (AVR), which was sufficient in 10 patients (48%), followed by complete root replacement (n = 4 [19%]). In-hospital mortality was higher in acute compared with chronic complications albeit not statistically significant (n = 4 [36%] vs. n = 2 [20%], p = 0.64), highlighting the very high risk of all these surgeries. Conclusions: Bailout and post-TAVR surgery are critical issues, with overall acceptable yet significant mortality considering the very high risk of these procedures. In our experience, half of the overall complications cannot be resolved with a simple explant and subsequent valve replacement, thereby underlining the importance of skilled cardiothoracic surgery teams on site to address complex issues such as ventricular perforation and emergency aortic/root replacement. Full article

With recent guidelines expanding transcatheter aortic valve replacement (TAVR) to younger patients, indications for redo-TAVR will also likely increase. When compared with TAVR, redo-TAVR is a rare and novel procedure. Current clinical data derived from registries suggest excellent safety, with low rates of 30-day and 1-year mortality following redo-TAVR. Proper understanding of data from bench studies regarding optimal valve configurations, of patient anatomy and of the technical properties of transcatheter heart valves (THV) is essential for patient selection and procedural success. Lifetime management of redo-TAVR should start before the index procedure, as the choice of the index THV has a major impact on the feasibility of redo-TAVR. Procedural optimization by adequate valve sizing, commissural alignment and adequate implant depth of both index and redo-THV are critical determinants of optimal hemodynamics for maximized valve longevity, as well as lifelong coronary access. Full article

Background and Objectives: Transcatheter aortic valve implantation is associated with a higher risk for elevated trans-prosthetic gradients and prosthesis-patient mismatch in patients with a small aortic annulus. We aimed to assess the short-term hemodynamic performance of self-expanding transcatheter aortic valves with an intra-annular leaflet position in patients with small aortic anatomies. Materials and Methods: Consecutive patients with small aortic annuli (annular area < 430 mm²), who underwent transcatheter aortic valve implantation with a self-expanding Portico or Navitor (Abbott Medical, St. Paul, MN, USA) transcatheter aortic valve between October 2017 and August 2024 at the University Medical Centre Ljubljana, Slovenia, were analyzed. The main endpoints were the post-procedural mean trans-prosthetic gradient, the presence of moderate or severe prosthesis-patient mismatch or paravalvular regurgitation. Results: Overall, 37 patients were included in the study (29 patients with a native aortic valve and 8 patients undergoing valve-in-valve transcatheter aortic valve implantation). The mean age was 81.6 ± 4.3 years, 32 patients (86.5%) were female. The median annular perimeter was 70.8 mm (interquartile range 67.3–74.1 mm) and the median annular area was 379 mm² (interquartile range 355–412 mm²). The post-procedural mean trans-prosthetic gradient was 9.0 ± 3.5 mmHg, with no cases with a mean gradient > 20 mmHg. Moderate and severe prosthesis-patient mismatch was observed in 21.2% and 3.0% of patients, respectively. Mild paravalvular regurgitation was noted in 44.1% of patients, there were no cases of moderate or severe paravalvular regurgitation. One patient (3.0%) had moderate valvular regurgitation. Conclusions: Self-expanding transcatheter aortic valves with an intra-annular leaflet position are associated with favorable hemodynamic performance in patients with a small aortic annulus. Full article

Aims: The aim of this paper is to report 30-day and 1-year outcome data regarding the first 200 patients who underwent the TAVR procedure using the Myval THV system at our single centre. Methods: From November 2019 to October 2022, 200 consecutive patients underwent TAVR procedure. Outcomes were analysed according to the VARC-2 definitions, and device performance was assessed via transthoracic echocardiography. Data collection was approved by the local Ethical Committee. Results: The mean age of the cohort was 75.3 ± 6.9 years, and 122 (61%) participants were male. The mean EuroSCORE II and STS was 5.4 ± 5.4 and 5.8 ± 3.8, respectively. The proportion of patients with a bicuspid aortic valve was 18%. The transfemoral access approach was the most common (surgical vs. percutaneous: 1% vs. 98%), and in two patients, surgical subclavian access was used. VARC-2 outcomes were as follows: 99% device success, 2% STROKE, 5% and 4.5% major and minor vascular complications, respectively, and a 29.5% rate of new permanent pacemaker implantation. At discharge, the incidence of aortic regurgitation grade II or above was 5.5% without relevant PVL (grade II or above 0.5%). In-hospital mortality was only 1%. At 1 year, the all-cause mortality rate was 8.5% (cardiac origin in three cases), and two patients had valve-related dysfunction requiring surgical aortic replacement. Conclusions: Our results showed excellent 30-day and 1-year outcomes regarding patient survival, technical success, and valve-related adverse events using the Myval transcatheter heart valve system. The limitations of our study comprise a single-centre design with retrospective data collection. Full article

Transcatheter aortic valve replacement (TAVR) has revolutionized the treatment of aortic stenosis, particularly in patients at high risk of adverse events for traditional open-heart surgery. Since the early 2000s, TAVR has evolved rapidly with advancements in device technology, procedural techniques, and patient selection criteria. Over the past 20 years, this catheter-based procedure has significantly improved patient survival and quality of life, demonstrating both the safety and efficacy of TAVR, even in patients at low surgical risk. This paper reviews the latest advances in valve design and strategies for treating aortic stenosis. It explores the challenges with long-term outcomes given the younger age of patients undergoing TAVR and the prospects of emerging technologies to improve long-term outcomes. Full article

Background: Prosthesis-patient mismatch (PPM) has been demonstrated to affect the outcome of both surgical (SAVR) and transcatheter aortic valve replacement (TAVR) patients. Supra-annular transcatheter valves (SAV) appear to offer a superior solution to intra-annular valves (IAV) in this regard. However, data on the comparison of the intra-annular self-expanding (SE) NAVITOR and the intra-annular balloon-expandable (BE) Sapien 3 Ultra in small annuli are limited. Methods: A total of 179 patients with severe native aortic valve stenosis were treated with either the SE NAVITOR (SEV; n = 104) or the BE Sapien 3 Ultra (BEV; n = 75) between March 2019 and June 2024. We compared the clinical and hemodynamic outcomes of the cohort according to the implanted prostheses. BMI-adjusted PPM was defined in accordance with the VARC-3 recommendations. Results: The device success at 30 days was superior in patients treated with the NAVITOR prosthesis (94.2% vs. 80.0%, p < 0.001), mainly driven by a higher rate of elevated gradients in the BEV group. The post-procedural mean gradient (8.0 mmHg vs. 13.0 mmHg, p < 0.001) as well as the rate of moderate to severe prosthesis patient mismatch (12.2% vs. 33.3%, p = 0.002) was higher in BEV recipients while the rate of more than moderate paravalvular leakage (PVL) or Valve in Valve (VinV) due to PVL (1.0% vs. 1.3%, p = 1.000) was similar between both groups. Pacemaker implantations were numerically more common after SEV (18.4% vs. 8.5%, p = 0.110). There was a trend towards higher thirty-day all-cause mortality among patients treated with SAV (3.8% vs. 1.3%, p = 0.401). Conclusion: The NAVITOR system may offer a more favorable hemodynamic profile compared to the Sapien 3 Ultra device in patients with small aortic annuli. Full article

Transcatheter aortic valve replacement (TAVR) was introduced in 2002 and has become integral in the management of aortic stenosis. As an alternative to surgical aortic valve replacement, it relies heavily on safe access to the aortic annulus for implantation of a valve prosthesis. Throughout its development and in current practice, the transfemoral (TF) arterial route for retrograde valve delivery has been the primary approach. However, this route is not appropriate for all patients, which has led to the development of multiple alternate access options. This review discusses the development of access for TAVR, followed by a thorough discussion of TF access. The commercially available products, preprocedural planning, closure techniques, and procedural complications are all discussed. We also describe the various alternate access routes with particular emphasis on the most recently developed route, transcaval access (TCv), with focus on procedural indications, technical considerations, and comparative outcomes. As TAVR technology, indications, and availability all expand, the knowledge and implementation of safe access are of utmost importance. Full article

Background: Transcatheter aortic valve replacement (TAVR) has emerged as a well-established option for patients with severe aortic stenosis who present high or extreme surgical risk. Direct comparisons of outcomes between different valve prostheses are important to assist operators in making an informed device selection. We aimed to perform a comparative analysis of early clinical outcomes at 30 days and long-term outcomes up to 3 years after TAVR using self-expandable Portico or CoreValve Evolut R valve prostheses. Methods: Out of 396 patients treated with either Portico or CoreValve Evolut R valves from January 2018 to December 2021, 79 patients were assigned to each group after 1:1 propensity score matching based on baseline parameters. Peri- and postprocedural outcomes at 30 days and up to a 3-year follow-up period were retrospectively collected according to the Valve Academic Research Consortium (VARC-2) criteria. Results: The immediate survival rate was 100% in both groups. The 30-day mortality was 0.0% in the Portico group and 1.3% in the CoreValve Evolut group (p = 1). Minor postprocedural bleeding was more frequent in the Evolut group both at 30 days (8.9% vs. 0%, p = 0.02) and at 3 years (11.4% vs. 3.8%, p = 0.133). There were no statistically significant differences regarding the combined safety endpoint (p = 1), acute kidney injury (AKIN 2 or AKIN 3) (p = 1; p = 0.477), or new pacemaker implantation (p = 0.31), at either 30 days or 3 years. Postprocedural myocardial infarction and stroke showed comparable rates in both groups. Conclusions: In terms of early clinical outcomes, no statistically significant differences were observed between the two groups of self-expandable valve prostheses, except for a significantly higher rate of minor bleeding in the Evolut group at 30 days. Notably, this trend of increased minor bleeding in the Evolut group persisted over the 3-year follow-up period, although the difference did not reach statistical significance. Both groups demonstrated low rates of all-cause mortality and clinical complications at long-term follow-up. The choice of valve should be customized to the individual characteristics of each patient. Full article

Background: The detection of unexpected findings (UF) during CT scans of patients undergoing TAVR is frequent; however, it is unclear whether such findings have a clinical impact on the TAVR pathway. Methods: We conducted a retrospective, single-center observational study enrolling patients who were candidates for TAVR. All enrolled patients underwent a CT scan before valve implantation. The primary outcome of this study was all-cause mortality, while the secondary outcome was to determine whether the diagnosis of clinically relevant UF on CT scans results in a significant delay in the TAVR procedure. Results: A total of 284 patients were enrolled. Clinically relevant UF were identified in 15% of the patients, with the most common types being pulmonary masses or nodules. During the follow-up period, 83 patients (29.2%) died. The prognosis was worsened by chronic kidney disease (HR 1.76, p = 0.03) and left ventricular dilatation (HR 1.74, p = 0.04), while the diagnosis of clinically relevant UF did not impact all-cause mortality (p = 0.38). No statistically significant differences were found in the delay from the diagnosis of severe aortic stenosis to TAVR between patients with and without clinically relevant UF (p = 0.07), although patients with clinically relevant UF experienced a median delay of approximately 37 days in the TAVR procedure. Conclusions: The presence of clinically relevant UF on preoperative CT scans does not affect all-cause mortality but shows a trend toward increasing the time from diagnosis to the procedure in patients with severe aortic stenosis undergoing TAVR. Further studies are required to confirm these findings in larger patient cohorts. Full article

Transcatheter aortic valve replacement (TAVR) in patients with severe aortic stenosis and raphe-type bicuspid aortic valve (BAV) is still associated with poor outcomes in terms of increased risk of paravalvular regurgitation, stroke, and permanent pacemaker implantation. There is no definitive consensus on the optimal sizing method for prosthesis selection in this setting. The LIRA method is a supra-annular tailored sizing method specifically designed for bicuspid anatomy that might increase accuracy of prosthesis choice in BAV patients and improve TAVR outcomes. This is the first report of the combination of the novel LIRA method for prosthesis sizing together with the adoption of the technological improvements introduced by the Evolut FX prosthesis as a useful tool for improving outcomes in this high risk subgroup of patients. Full article

Prosthetic valve endocarditis (PVE) has undergone significant changes over the past five decades and is currently affecting an aging population, with an increasing prevalence in patients with transcatheter valve implants. The introduction of transcatheter aortic valve replacement (TAVR) represents a significant advance in the field of interventional cardiology and cardiac surgery. The incidence of IE after TAVR has remained stable, with rates similar to those reported after surgical aortic valve replacement. This is despite significant refinements in the TAVR procedure, with less invasive handling and its extension to younger and healthier patients. TAVR should be considered as a potential treatment option for patients with PVE, despite some differences. In terms of evolutionary advances, there have been notable and significant developments in the fields of microbiology and imaging diagnostics. The 2023 Duke-International Society for Cardiovascular Infectious Diseases diagnostic criteria for infective endocarditis now incorporate significant advances in molecular biology and fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography. This has led to a significant enhancement in diagnostic sensitivity for PVE while maintaining the same level of specificity in validation studies. PVE is a deadly disease. A multidisciplinary endocarditis treatment team in a cardiac center is essential to improve outcomes. The availability of novel surgical options allows clinicians to offer an increasing number of patients the opportunity to avoid surgical intervention. Some patients will complete antimicrobial treatment at home. Those with prosthetic valves are eligible for antibiotic prophylaxis before dental procedures. Post-TAVR infective endocarditis (IE) is a subcategory of prosthetic valve endocarditis. This condition presents a particularly complex scenario, characterized by a distinctive clinical and microbiological profile, a high prevalence of IE-related complications, an ambiguous role of cardiac surgery, and a poor prognosis for the majority of patients with TAVR IE. The number of TAVR procedures is set to skyrocket in the coming years, which will undoubtedly lead to a significant rise in the number of people at risk of this life-threatening complication. This review will provide an overview of this rare complication in light of the advent of IE following TAVR. It is crucial to gain a comprehensive understanding of the disease and its associated complications to enhance clinical outcomes. Full article