Faculty Bibliography

BACKGROUND:Previous studies from the Low Risk TAVR (LRT) trial demonstrated that transcatheter aortic valve replacement (TAVR) is safe and feasible in low-risk patients, with excellent 30-day and 1-year outcomes. The objective of this study was to report clinical outcomes and the impact of 30-day hypoattenuated leaflet thickening (HALT) on structural valve deterioration (SVD) 2 years after TAVR. METHODS:The LRT trial was the first Food and Drug Administration-approved Investigational Device Exemption trial in the United States to evaluate the safety and feasibility of TAVR in low-risk patients with symptomatic severe tricuspid aortic stenosis (AS). Valve hemodynamics and SVD by echo were recorded 30 days, 1 year, and 2 years post-TAVR. RESULTS:The LRT trial enrolled 200 low-risk patients to receive TAVR. Their mean age was 73.6 years and 61.5% were men. At 2-year follow-up, the mortality rate was 4.2%; the cardiovascular death rate was 1.6%. The disabling stroke rate was 1.1%, permanent pacemaker implantation rate was 8.6%, and 4 patients (2.2%) presented with endocarditis (2 between years 1 and 2). Of the 14% of TAVR subjects who had evidence of HALT at 30 days, there was no impact on valve hemodynamics, endocarditis or stroke at 2 years. CONCLUSIONS:TAVR for low-risk patients with symptomatic severe tricuspid AS is safe at 2 years. The presence of HALT at 30 days did not impact the early hemodynamic improvements nor the durability of the valve structure.

Background: B-type natriuretic peptide (BNP) has been established as a predictor of outcomes in patients who undergo surgical aortic valve replacement (SAVR). Studies on the prognostic value of BNP in high-risk patients undergoing transcatheter aortic valve replacement (TAVR) have yielded conflicting results. Additionally, BNP has not been well-studied in low- and intermediate-risk patients undergoing TAVR. The purpose of this study was to clarify the prognostic utility of baseline BNP in low-, intermediate-, and high-risk patients with severe aortic stenosis (AS) undergoing TAVR.
Method(s): This was a retrospective observational study of 1544 low-, intermediate-, and high-risk patients who underwent TAVR at our institution from 2012-2019. Included were patients who had a BNP <7 days prior to TAVR. Patients were then trichotomized into those with a pre-TAVR BNP <250 pg/mL (cohort 1), between 250-500 pg/mL (cohort 2), and >500 pg/mL (cohort 3). Outcomes of interest were inpatient and 30-day mortality. Statistical analyses of outcomes were performed using multivariate binary logistic regression.
Result(s): Of the 1544 patients screened, 1487 patients had a BNP level <7 days prior to TAVR and thus were included in the study. Patients in cohort 3 with a baseline BNP >500 pg/mL were 3.31 times more likely to have inpatient death (CI 0.142, 0.643; P=0.0019), 2.70 times more likely to have death within 30 days (CI 0.192, 0.711; P=0.0029) and 1.81 times more likely to have death within 1 year (CI 0.348, 0.880, p=0.0152).
Conclusion(s): Our study of 1487 low-, intermediate-, and high-risk patients demonstrates a baseline BNP greater than 500 pg/mL is an independent predictor of inpatient, 30-day and 1-year mortality. BNP has prognostic implications in TAVR patients across all risk groups and can help identify the subset of patients who may warrant closer follow up following TAVR.
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Background: The advent of transcatheter aortic valve replacement (TAVR) has ignited the search for a mitral equivalent. Ongoing trials will attempt to design a safe and effective transcatheter mitral valve replacement (TMVR) device. In the interim, the US Food and Drug Administration has approved the balloon-expandable transcatheter heart valve system for the treatment of degenerated mitral bioprostheses. The purpose of this study was to detail the short- and long-term outcomes of high-risk patients undergoing TMVR at our institution.
Method(s): In this retrospective observational study, we reviewed data on the first 26 patients with previous surgical mitral valve replacement (MVR, 76.9%) or repair with ring (23.1%) who underwent TMVR using the third-generation transcatheter balloon-expandable valve at NYU Langone Hospital - Long Island from 2015 through 2019. We reviewed pre-/post-TMVR echocardiographic data, inpatient, 30-day, and 1-year data. Statistical analysis was performed using Student's t-test and Wilcoxon signed rank test.
Result(s): Of the 26 patients, the primary indication for TMVR was bioprosthetic valve regurgitation in 9 patients, bioprosthetic transvalvular stenosis in 9 patients, and mixed mitral disease in 8 patients. The average Society of Thoracic Surgeons score for MVR was 13.0%. Of the 26 TMVRs, 19 were transseptal and 7 were transapical. There was a 100% device implantation success rate and a 96.2% inpatient survival rate. At 30 days, there was a 96% survival rate. Mitral valve mean gradient (13.3 mmHg to 6.8 mmHg, p < 0.0001) and mitral regurgitation (3+ to 1+, p < 0.0001) showed significant improvement after TMVR. There were significant 30-day and 1-year improvements in patients' Kansas City Cardiomyopathy Questionnaire score following TMVR (47.8 to 75.7 to 84.0, p <0.0001).
Conclusion(s): We found that treatment of degenerated mitral bioprostheses using TMVR with the third-generation balloon-expandable transcatheter heart valve in high-risk patients resulted in significant improvements in short-term and long-term heart failure symptoms, which translated to robust short- and long-term survival.
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Background: Following a period of stability, the coronavirus disease 2019 (COVID-19) pandemic appears to be re-intensifying globally. As the pandemic continues to evolve, so does our understanding of its implications on ST-segment elevation myocardial infarction (STEMI). We sought to describe a single center STEMI experience at one of the epicenters of the COVID-19 pandemic.
Method(s): This was a retrospective observational study which included consecutive suspected STEMI patients from March 1 through August 31, 2019, (Cohort 1) compared to the same time period in 2020 (Cohort 2), at a tertiary referral center in Nassau County, New York.
Result(s): Cohort 2 (n=93) saw a similar number of acute myocardial infarction (AMI) team activations compared to cohort 1 (n=90) (Figure 1). Infection control measures and additional investigation were required to clarify the diagnosis in cohort 2, resulting in longer door-to-balloon times (95.9 minutes vs. 74.4 minutes, p=0.0587). We observed similar inpatient length of stay (LOS) (3.6 days vs. 5.0 days, p=0.0901) and mortality (13.2% vs. 9.2%, p=0.5876).
Conclusion(s): Our single-center study, located at one of the epicenters of the pandemic, demonstrated a similar number of AMI team activations, mimicking the seasonal variability seen in 2019, but with longer door-to-balloon times. Despite this, inpatient LOS and mortality remained unchanged. [Formula presented]
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OBJECTIVES:The aim of this study was to investigate whether the degree of aortic angulation (AA) affects outcomes after transcatheter aortic valve replacement (TAVR) using newer-generation transcatheter heart valves (THVs). BACKGROUND:AA ≥48° has been reported to adversely influence accurate THV deployment, procedural success, fluoroscopy time, and paravalvular leak (PVL) in patients undergoing TAVR with early generation self-expanding (SE) THVs. METHODS:A retrospective observational study was conducted among 841 patients across all risk strata who underwent transfemoral TAVR using the balloon-expandable (BE) SAPIEN 3 or the SE CoreValve Evolut PRO from 2015 to 2020. The previously published cutoff of 48° was used to analyze procedural success and in-hospital outcomes according to THV type. Receiver-operating characteristic analysis was performed to investigate the impact of AA on an in-hospital composite outcome (need for >1 THV, more than mild PVL, new permanent pacemaker implantation, stroke, and death). RESULTS:AA ≥48° did not influence outcomes in patients with BE THVs. Additionally, AA ≥48° did not influence procedural success (99.1% vs. 99.1%; p = 0.980), number of THVs used (1.02 vs. 1.04; p = 0.484), rates of more than mild PVL (0.4% vs. 0%; p = 0.486), new permanent pacemaker implantation (11.8% vs. 17.1%; p = 0.178), in-hospital stroke (3.9% vs. 1.8%; p = 0.298), or in-hospital death (0.4% vs. 0.9%; p = 0.980) in patients with SE THVs. Receiver-operating characteristic analysis demonstrated similar outcomes irrespective of AA, with areas under the curve of 0.5525 for SE THVs and 0.5115 for BE THVs. CONCLUSIONS:AA no longer plays a role with new-generation BE or SE THVs in contemporary TAVR practice. AA ≥48° did not affect procedural success or in-hospital outcomes and should no longer be a consideration when determining THV selection.