Publications by authors named "John Webb"

680 Publications

Impact of Annular Oversizing on Paravalvular Regurgitation and Valve Hemodynamics: New Insights From PARTNER 3.

JACC Cardiovasc Interv 2021 Oct;14(19):2158-2169

Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada; Department of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada. Electronic address:

Objectives: This study sought to investigate the impact of computed tomography (CT)-based area and perimeter oversizing on the incidence of paravalvular regurgitation (PVR) and valve hemodynamics in patients treated with the SAPIEN 3 transcatheter heart valve (THV).

Background: The incremental value of considering annular perimeter or left ventricular outflow tract measurements and the impact of THV oversizing on valve hemodynamics are not well defined.

Methods: The PARTNER 3 (Placement of Aortic Transcatheter Valves 3) trial included 495 low-surgical-risk patients with severe aortic stenosis who underwent THV implantation. THV sizing was based on annular area assessed by CT. Area- and perimeter-based oversizing was determined using systolic annular CT dimensions and nominal dimensions of the implanted THV. PVR, effective orifice area, and mean gradient were assessed on 30-day transthoracic echocardiography.

Results: Of 485 patients with available CT and echocardiography data, mean oversizing was 7.9 ± 8.7% for the annulus area and 2.1 ± 4.1% for the perimeter. A very low incidence of ≥moderate PVR (0.6%) was observed, including patients with minimal annular oversizing. Incidence of ≥mild PVR and need for procedural post-dilatation were inversely related to the degree of oversizing. For patients with annular dimensions suitable for 2 THV sizes, the larger THV with both area and perimeter oversizing was associated with the lowest incidence of ≥mild PVR (12.0% vs 43.4%; P < 0.0001). Left ventricular outflow tract area oversizing was not associated with PVR. THV prosthesis size, rather than degree of oversizing, had greatest impact on effective orifice area and mean gradient.

Conclusions: In low-surgical-risk patients, a low incidence of ≥moderate PVR was observed, including patients with minimal THV oversizing. The degree of prosthesis oversizing had the greatest impact on reducing mild PVR and incidence of post-dilatation, without impacting valve hemodynamics. In selected patients with annular dimensions in between 2 valve sizes, the larger THV device oversized to both the annular area and perimeter reduced PVR and optimized THV hemodynamics.
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http://dx.doi.org/10.1016/j.jcin.2021.07.018DOI Listing
October 2021

Leaflet and Neoskirt Height in Transcatheter Heart Valves: Implications for Repeat Procedures and Coronary Access.

JACC Cardiovasc Interv 2021 Sep 22. Epub 2021 Sep 22.

Centre for Cardiovascular Innovation, St Paul's and Vancouver General Hospital, Vancouver, British Columbia, Canada; Centre for Heart Valve Innovation, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada; Cardiovascular Translational Laboratory, St. Paul's Hospital, Vancouver, British Columbia, Canada. Electronic address:

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http://dx.doi.org/10.1016/j.jcin.2021.07.034DOI Listing
September 2021

Temporal Changes in Mortality After Transcatheter and Surgical Aortic Valve Replacement: Retrospective Analysis of US Medicare Patients (2012-2019).

J Am Heart Assoc 2021 Sep 28:e021748. Epub 2021 Sep 28.

Sunnybrook Health Sciences University of Toronto Canada.

Background The treatment of aortic stenosis is evolving rapidly. Pace of change in the care of patients undergoing transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) differs. We sought to determine differences in temporal changes in 30-day mortality, 30-day readmission, and length of stay after TAVR and SAVR. Methods and Results We conducted a retrospective cohort study of patients treated in the United States between 2012 and 2019 using data from the Medicare Data Set Analytic File 100% Fee for Service database. We included consecutive patients enrolled in Medicare Parts A and B and aged ≥65 years who had SAVR or transfemoral TAVR. We defined 3 study cohorts, including all SAVR, isolated SAVR (without concomitant procedures), and elective isolated SAVR and TAVR. The primary end point was 30-day mortality; secondary end points were 30-day readmission and length of stay. Statistical models controlled for patient demographics, frailty measured by the Hospital Frailty Risk Score, and comorbidities measured by the Elixhauser Comorbidity Index (ECI). Cox proportional hazard models were developed with TAVR versus SAVR as the main covariates with a 2-way interaction term with index year. We repeated these analyses restricted to full aortic valve replacement hospitals offering both SAVR and TAVR. The main study cohort included 245 269 patients with SAVR and 188 580 patients with TAVR, with mean±SD ages 74.3±6.0 years and 80.7±6.9 years, respectively, and 36.5% and 46.2% female patients, respectively. Patients with TAVR had higher ECI scores (6.4±3.6 versus 4.4±3) and were more frail (55.4% versus 33.5%). Total aortic valve replacement volumes increased 61% during the 7-year span; TAVR volumes surpassed SAVR in 2017. The magnitude of mortality benefit associated with TAVR increased until 2016 in the main cohort (2012: hazard ratio [HR], 0.76 [95% CI, 0.67-0.86]; 2016: HR, 0.39 [95% CI, 0.36-0.43]); although TAVR continued to have lower mortality rates from 2017 to 2019, the magnitude of benefit over SAVR was attenuated. A similar pattern was seen with readmission, with a lower risk of readmission from 2012 to 2016 for patients with TAVR (2012: HR, 0.68 [95% CI, 0.63-0.73]; 2016: HR, 0.43 [95% CI, 0.41-0.45]) followed by a lesser difference from 2017 to 2019. Year over year, TAVR was associated with increasingly shorter lengths of stay compared with SAVR (2012: HR, 1.91 [95% CI, 1.84-1.98]; 2019: HR, 5.34 [95% CI, 5.22-5.45]). These results were consistent in full aortic valve replacement hospitals. Conclusions The rate of improvement in TAVR outpaced SAVR until 2016, with the recent presence of U-shaped phenomena suggesting a narrowing gap between outcomes. Future longitudinal research is needed to determine the long-term implications of lowering risk profiles across treatment options to guide case selection and clinical care.
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http://dx.doi.org/10.1161/JAHA.120.021748DOI Listing
September 2021

5-Year Outcomes Comparing Surgical Versus Transcatheter Aortic Valve Replacement in Patients With Chronic Kidney Disease.

JACC Cardiovasc Interv 2021 Sep;14(18):1995-2005

Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec, Québec, Canada.

Objectives: The aim of this study was to compare 5-year cardiovascular, renal, and bioprosthetic valve durability outcomes in patients with severe aortic stenosis (AS) and chronic kidney disease (CKD) undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR).

Background: Patients with severe AS and CKD undergoing TAVR or SAVR are a challenging, understudied clinical subset.

Methods: Intermediate-risk patients with moderate to severe CKD (estimated glomerular filtration rate <60 mL/min/m) from the PARTNER (Placement of Aortic Transcatheter Valve) 2A trial (patients randomly assigned to SAPIEN XT TAVR or SAVR) and SAPIEN 3 Intermediate Risk Registry were pooled. The composite primary outcome of death, stroke, rehospitalization, and new hemodialysis was evaluated using Cox regression analysis. Patients with and without perioperative acute kidney injury (AKI) were followed through 5 years. A core laboratory-adjudicated analysis of structural valve deterioration and bioprosthetic valve failure was also performed.

Results: The study population included 1,045 TAVR patients (512 SAPIEN XT, 533 SAPIEN 3) and 479 SAVR patients. At 5 years, SAVR was better than SAPIEN XT TAVR (52.8% vs 68.0%; P = 0.04) but similar to SAPIEN 3 TAVR (52.8% vs 58.7%; P = 0.89). Perioperative AKI was more common after SAVR than TAVR (26.3% vs 10.3%; P < 0.001) and was independently associated with long-term outcomes. Compared with SAVR, bioprosthetic valve failure and stage 2 or 3 structural valve deterioration were significantly greater for SAPIEN XT TAVR (P < 0.05) but not for SAPIEN 3 TAVR.

Conclusions: In intermediate-risk patients with AS and CKD, SAPIEN 3 TAVR and SAVR were associated with a similar risk for the primary endpoint at 5 years. AKI was more common after SAVR than TAVR, and SAPIEN 3 valve durability was comparable with that of surgical bioprostheses.
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http://dx.doi.org/10.1016/j.jcin.2021.07.004DOI Listing
September 2021

Long-term outcome after surgical treatment of Scheuermann's Kyphosis (SK).

Spine Deform 2021 Sep 17. Epub 2021 Sep 17.

Park Hospital, Nottingham, UK.

Study Design: A retrospective observational cohort study with a minimum follow-up of 10 years of patients who underwent surgery for Scheurmann Kyphosis (SK).

Objective: Evaluate the long-term clinical and radiological outcome of patients with SK who either underwent combined anterior-posterior surgery or posterior instrumented fusion alone. There is paucity of literature for long-term outcome studies on SK. The current trend is towards only posterior (PSF) surgical correction for SK. The combined strategy of anterior release, fusion and posterior spinal fusion (AF/PSF) for kyphosis correction has become historic relic. Long-term outcome studies comparing the two procedures are lacking in literature.

Methods: 51 patients (30 M: 21F) who underwent surgery for SK at a single centre were reviewed. Nineteen had posterior instrumentation alone (PSF) (Group 1) and 32 underwent combined anterior release, fusion with posterior instrumentation (AF/PSF) (Group 2). The clinical data included age at surgery, gender, flexibility of spine, instrumented spinal levels, use of cages and morcellised rib grafts (in cases where anterior release was done), posterior osteotomies and instrumentation, complications and indications for revision surgery. Preoperative flexibility was determined by hyperextension radiographs. The radiological indices were evaluated in the pre-operative, 2-year post-operative and final follow-up [Thoracic Kyphosis (TK), Lumbar lordosis (LL), Voustinas index (VI), Sacral inclination (SI) and Sagittal vertical axis (SVA)]. The loss of correction and incidence of JK (Junctional Kyphosis) and its relation to fusion levels were assessed. Complications and difference in outcome between the two groups were analyzed.

Results: The mean age at surgery for 51 patients was 20.6 years who were followed up for a minimum of 10 years (mean: 14 years; range 10-16 years). The mean age was 18.5 ± 2.2 years and 21.9 ± 4.8 years in groups 1 and 2, respectively. The mean pre- and 2-year post-operative ODIs were 32.6 ± 12.8 and 8.4 ± 5.4, respectively, in group 1 (p < 0.0001) and 30.7 ± 11.7 and 6.4 ± 5.7, respectively, in group 2 (p < 0.0001). The final SRS-22 scores in group 1 and 2 were 4.1 ± 0.4 and 4.0 ± 0.35, respectively (p = 0.88). The preoperative flexibility index was 49.2 ± 4.2 and 43 ± 5.6 in groups 1 and 2, respectively (p < 0.0001). The mean TKs were 81.4° ± 3.8° and 86.1° ± 6.0° for groups 1 and 2, respectively, which corrected to 45.1° ± 2.6° and 47.3° ± 4.8°, respectively, at final follow-up (p < 0.0001). The mean pre-operative LL angle was 60.0° ± 5.0° and 62.4° ± 7.6° in groups 1 and 2, respectively, which at final follow-up was 45.1° ± 4.4° and 48.1° ± 4.8°, respectively (p < 0.0001). The mean pre-operative and final follow-up Voustinas index (VI) in group 1 were 22.9 ± 2.9 and 11.2 ± 1.2, respectively, and in group 2 was 25.9 ± 3.5 and 14.0 ± 2.3, respectively. The mean pre-operative and final follow-up SI angle were 43.6° ± 3.3° and 31.2° ± 2.5° in group 1, respectively, and 44.3° ± 3.5° and 32.1° ± 3.5° in group 2, respectively (p < 0.0001). The pre-operative and final follow-up SVA in group 1 were - 3.3 ± 1.0 cms and - 1.3 ± 0.5 cms, respectively, and in group 2 was - 4.0 ± 1.3cms and - 1.9 ± 1.1cms, respectively (p < 0.0001). Though the magnitude of curve correction in the groups 1 and 2 was significant 36° vs 39° (p = 0.05), there was no significant difference in correction between the two groups. Proximal JK was seen in seven and distal JK in five patients were observed in the whole cohort.

Conclusion: The long-term clinical outcomes for both PSF and AF/PSF are comparable with reproducible results. No difference was noted in loss of correction and outcome scores between the two groups. The correction of thoracic kyphosis (TK) had a good correlation with ODI. AF/PSF had much higher complications than PSF group. The objective of correcting the sagittal profile and balancing the whole spinal segment on the pelvis can be achieved through single posterior approach with fewer complications.
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http://dx.doi.org/10.1007/s43390-021-00410-7DOI Listing
September 2021

International Consensus Statement on Nomenclature and Classification of the Congenital Bicuspid Aortic Valve and Its Aortopathy, for Clinical, Surgical, Interventional and Research Purposes.

Radiol Cardiothorac Imaging 2021 Aug 22;3(4):e200496. Epub 2021 Jul 22.

St Paul's Hospital, University of British Columbia, Vancouver, Canada.

This International Consensus Classification and Nomenclature for the congenital bicuspid aortic valve condition recognizes 3 types of bicuspid valves: 1. The fused type (right-left cusp fusion, right-non-coronary cusp fusion and left-non-coronary cusp fusion phenotypes); 2. The 2-sinus type (latero-lateral and antero-posterior phenotypes); and 3. The partial-fusion (forme fruste) type. The presence of raphe and the symmetry of the fused type phenotypes are critical aspects to describe. The International Consensus also recognizes 3 types of bicuspid valve-associated aortopathy: 1. The ascending phenotype; 2. The root phenotype; and 3. Extended phenotypes. ©  2021 Jointly between the RSNA, the European Association for Cardio-Thoracic Surgery, The Society of Thoracic Surgeons, and the American Association for Thoracic Surgery. The articles are identical except for minor stylistic and spelling differences in keeping with each journal's style. All rights reserved. Bicuspid Aortic Valve, Aortopathy, Nomenclature, Classification.
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http://dx.doi.org/10.1148/ryct.2021200496DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8424700PMC
August 2021

Quality-of-Life Outcomes After Transcatheter Aortic Valve Implantation in a "Real World" Population: Insights From a Prospective Canadian Database.

CJC Open 2021 Aug 24;3(8):1033-1042. Epub 2021 Apr 24.

St. Paul's Hospital and Vancouver General Hospital, Vancouver, British Columbia, Canada.

Background: Documentation of quality of life (QOL) of patients after transcatheter aortic valve implantation (TAVI) is a Canadian Cardiovascular Society quality indicator. National results have not been reported to date.

Methods: We conducted an observational cohort study including all TAVI patients, irrespective of surgical risk, treated between January 2016 and June 2019 as documented in the British Columbia TAVI Registry. QOL was measured at baseline, 30 days, and 1 year, using the Kansas City Cardiomyopathy Questionnaire overall score (KCCQ-OS). We used linear regression modelling to examine factors associated with 30-day changes in QOL, logistic regression modelling to identify predictors of sustaining a poor outcome, and Cox regression modelling to ascertain risk estimates of the effect of QOL on 1-year mortality.

Results: The cohort included 1706 patients (742 women [43.5%]); median age 83 years (interquartile range [IQR]: 77, 86). Median (IQR) baseline KCCQ-OS was 45 (28.2, 67), indicating severe impairment. Patients alive at 1 year (91.3%) reported a mean improvement of 24.1 (95% confidence interval [CI], 22.7-25.6) points in the KCCQ-OS at 30 days, which was sustained at 1 year (25.3; 95% CI, 23.8, 26.8). Older age, lower baseline health status, lower aortic valve gradient, lower hemoglobin, atrial fibrillation, and non-transfemoral access were associated with worse 30-day QOL. At 1 year, 65% of patients had a favorable outcome; additional risk factors for 1-year mortality (8.7%) were male sex, New York Heart Association Class IV, severe pulmonary and renal disease, diabetes, and in-patient status.

Conclusions: TAVI is associated with significant early improvement in QOL, which is sustained at 1 year. The inclusion of QOL can support treatment decisions and patient-centred evaluation.
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http://dx.doi.org/10.1016/j.cjco.2021.04.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8413231PMC
August 2021

Nationally Representative Repeat Transcatheter Aortic Valve Replacement Outcomes: Report From the Centers for Medicare and Medicaid Services.

JACC Cardiovasc Interv 2021 Aug;14(15):1717-1726

Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. Electronic address:

Objectives: The aim of this study was to examine real-world experience with repeat transcatheter aortic valve replacement (TAVR) in a population-based national database.

Background: Repeat TAVR is a growing option in patients requiring reintervention for TAVR. However, large-scale studies with longitudinal follow-up are limited.

Methods: All Medicare beneficiaries who underwent TAVR from 2012 to 2017 were included. Outcomes included 30-day and longitudinal mortality and major adverse cardiovascular events, defined as death, stroke, pacemaker insertion, major bleeding, acute kidney injury, or cardiac arrest. Outcomes of repeat TAVR were compared with surgical explantation after TAVR (TAVR explantation) in a matched analysis.

Results: Of 133,250 patients who underwent TAVR, 617 (0.46%) underwent subsequent repeat TAVR at a median interval of 154 days (interquartile range: 58-537 days). Mortality at 30 days and 1 year was 6.0% and 22.0%, respectively. Rates of 30-day stroke and pacemaker insertion were 1.8% and 4.2%. Mortality at 30 days was lower in those who underwent their first TAVR during the later era (2015-2017) compared with earlier years (2012-2014) (4.6% vs 8.7%; P = 0.049). Repeat TAVR was associated with lower 30-day mortality compared with a matched group undergoing TAVR explantation (6.2% vs 12.3%; P = 0.05), although 1-year mortality was similar (21.0% vs 20.8%; P = 1.000). The incidence of 30-day major adverse cardiovascular events was higher with TAVR explantation compared with repeat TAVR (risk ratio: 2.92; 95% CI: 1.88-4.99; P ≤ 0.001).

Conclusions: Repeat TAVR was performed with acceptable 30-day mortality in this high-risk population. Short-term outcomes were superior to surgical explantation, but 1-year outcomes were similar. Repeat TAVR will likely be an important option for aortic valve reintervention after TAVR.
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http://dx.doi.org/10.1016/j.jcin.2021.06.011DOI Listing
August 2021

Repeat Transcatheter Aortic Valve Replacement and Follow-Up of Embolized Transcatheter Heart Valve After 13 Years.

JACC Case Rep 2021 Apr 10;3(4):633-635. Epub 2021 Feb 10.

Centres for Heart Valve Innovation and for Cardiovascular Innovation, St. Paul's and Vancouver General Hospitals, Vancouver, Canada.

A 79-year-old woman was treated with a 23-mm balloon-expandable transcatheter heart valve (THV) that was initially complicated by an embolized THV requiring deployment in the descending aorta. She presented 13-years later with a degenerated bioprosthesis requiring redo THV. Pre-procedural computed tomography was important in highlighting underexpansion of the initial THV and open leaflets in the embolized valve. ().
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http://dx.doi.org/10.1016/j.jaccas.2020.12.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8302774PMC
April 2021

International consensus statement on nomenclature and classification of the congenital bicuspid aortic valve and its aortopathy, for clinical, surgical, interventional and research purposes.

J Thorac Cardiovasc Surg 2021 Sep 22;162(3):e383-e414. Epub 2021 Jul 22.

St Paul's Hospital, University of British Columbia, Vancouver, Canada.

This International Consensus Classification and Nomenclature for the congenital bicuspid aortic valve condition recognizes 3 types of bicuspid valves: 1. The fused type (right-left cusp fusion, right-non-coronary cusp fusion and left-non-coronary cusp fusion phenotypes); 2. The 2-sinus type (latero-lateral and antero-posterior phenotypes); and 3. The partial-fusion (forme fruste) type. The presence of raphe and the symmetry of the fused type phenotypes are critical aspects to describe. The International Consensus also recognizes 3 types of bicuspid valve-associated aortopathy: 1. The ascending phenotype; 2. The root phenotype; and 3. Extended phenotypes.
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http://dx.doi.org/10.1016/j.jtcvs.2021.06.019DOI Listing
September 2021

Summary: International consensus statement on nomenclature and classification of the congenital bicuspid aortic valve and its aortopathy, for clinical, surgical, interventional, and research purposes.

J Thorac Cardiovasc Surg 2021 09 22;162(3):781-797. Epub 2021 Jul 22.

St Paul's Hospital, University of British Columbia, Vancouver, Canada; aeCedars Sinai Heart Institute, Los Angeles, Calif; afDivision of Cardiology, Columbia University Irving Medical Center/NY Presbyterian Hospital, New York, NY.

This International evidence-based nomenclature and classification consensus on the congenital bicuspid aortic valve and its aortopathy recognizes 3 types of bicuspid aortic valve: 1. Fused type, with 3 phenotypes: right-left cusp fusion, right-non cusp fusion and left-non cusp fusion; 2. 2-sinus type with 2 phenotypes: Latero-lateral and antero-posterior; and 3. Partial-fusion or forme fruste. This consensus recognizes 3 bicuspid-aortopathy types: 1. Ascending phenotype; root phenotype; and 3. extended phenotypes.
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http://dx.doi.org/10.1016/j.jtcvs.2021.05.008DOI Listing
September 2021

Summary: International Consensus Statement on Nomenclature and Classification of the Congenital Bicuspid Aortic Valve and Its Aortopathy, for Clinical, Surgical, Interventional and Research Purposes.

Ann Thorac Surg 2021 09 22;112(3):1005-1022. Epub 2021 Jul 22.

St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.

This International evidence-based nomenclature and classification consensus on the congenital bicuspid aortic valve and its aortopathy recognizes 3 types of bicuspid aortic valve: 1. Fused type, with 3 phenotypes: right-left cusp fusion, right-non cusp fusion and left-non cusp fusion; 2. 2-sinus type with 2 phenotypes: Latero-lateral and antero-posterior; and 3. Partial-fusion or forme fruste. This consensus recognizes 3 bicuspid-aortopathy types: 1. Ascending phenotype; root phenotype; and 3. extended phenotypes.
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http://dx.doi.org/10.1016/j.athoracsur.2021.05.001DOI Listing
September 2021

International Consensus Statement on Nomenclature and Classification of the Congenital Bicuspid Aortic Valve and Its Aortopathy, for Clinical, Surgical, Interventional and Research Purposes.

Ann Thorac Surg 2021 09 22;112(3):e203-e235. Epub 2021 Jul 22.

St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.

This International Consensus Classification and Nomenclature for the congenital bicuspid aortic valve condition recognizes 3 types of bicuspid valves: 1. The fused type (right-left cusp fusion, right-non-coronary cusp fusion and left-non-coronary cusp fusion phenotypes); 2. The 2-sinus type (latero-lateral and antero-posterior phenotypes); and 3. The partial-fusion (forme fruste) type. The presence of raphe and the symmetry of the fused type phenotypes are critical aspects to describe. The International Consensus also recognizes 3 types of bicuspid valve-associated aortopathy: 1. The ascending phenotype; 2. The root phenotype; and 3. Extended phenotypes.
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http://dx.doi.org/10.1016/j.athoracsur.2020.08.119DOI Listing
September 2021

Feasibility of Coronary Access in Patients With Acute Coronary Syndrome and Previous TAVR.

JACC Cardiovasc Interv 2021 Jul;14(14):1578-1590

Department of Cardiology, St. Johannes Hospital, Dortmund, Germany.

Objectives: The aim of this study was to characterize the feasibility of coronary angiography (CA) and percutaneous coronary intervention (PCI) in acute settings among patients who have undergone transcatheter aortic valve replacement (TAVR).

Background: Impaired coronary access after TAVR may be challenging and particularly in acute settings could have deleterious consequences.

Methods: In this international registry, data from patients with prior TAVR requiring urgent or emergent CA were retrospectively collected. A total of 449 patients from 25 sites with acute coronary syndromes (89.1%) and other acute cardiovascular situations (10.9%) were included.

Results: Success rates were high for CA of the right coronary artery (98.3%) and left coronary artery (99.3%) and were higher among patients with short stent-frame prostheses (SFPs) than in those with long SFPs for CA of the right coronary artery (99.6% vs 95.9%; P = 0.005) but not for CA of the left coronary artery (99.7% vs 98.7%; P = 0.24). PCI of native coronary arteries was successful in 91.4% of cases and independent of valve type (short SFP 90.4% vs long SFP 93.4%; P = 0.44). Guide engagement failed in 6 patients, of whom 3 underwent emergent coronary artery bypass grafting and another 3 died in the hospital. Among patients requiring revascularization of native vessels, independent predictors of 30-day all-cause mortality were prior diabetes, cardiogenic shock, and failed PCI but not valve type or success of coronary engagement.

Conclusions: CA or PCI after TAVR in acute settings is usually successful, but selective coronary engagement may be more challenging in the presence of long SFPs. Among patients requiring PCI, prior diabetes, cardiogenic shock, and failed PCI were predictors of early mortality.
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http://dx.doi.org/10.1016/j.jcin.2021.05.007DOI Listing
July 2021

Postoperative Atrial Fibrillation or Flutter Following Transcatheter or Surgical Aortic Valve Replacement: PARTNER 3 Trial.

JACC Cardiovasc Interv 2021 Jul;14(14):1565-1574

Cardiovascular Research Foundation, New York, New York, USA; NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA. Electronic address:

Objectives: The aim of this study was to assess the incidence and prognostic impact of early and late postoperative atrial fibrillation or flutter (POAF) in patients with severe aortic stenosis (AS) treated with transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR).

Background: There is an ongoing controversy regarding the incidence, recurrence rate, and prognostic impact of early (in-hospital) POAF and late (postdischarge) POAF in patients with AS undergoing TAVR or SAVR.

Methods: In the PARTNER (Placement of Aortic Transcatheter Valve) 3 trial, patients with severe AS at low surgical risk were randomized to TAVR or SAVR. Analyses were performed in the as-treated population excluding patients with preexistent atrial fibrillation or flutter.

Results: Among 781 patients included in the analysis, early POAF occurred in 152 (19.5%) (18 of 415 [4.3%] and 134 of 366 [36.6%] following TAVR and SAVR, respectively). Following discharge, 58 new or recurrent late POAF events occurred within 1 year following the index procedure in 55 of 781 patients (7.0%). Early POAF was not an independent predictor of late POAF following discharge (odds ratio: 1.04; 95% CI: 0.52-2.08; P = 0.90). Following adjustment, early POAF was not an independent predictor of the composite outcome of death, stroke, or rehospitalization (hazard ratio: 1.10; 95% CI: 0.64-1.92; P = 0.72), whereas late POAF was associated with an increased adjusted risk for the composite outcome (hazard ratio: 8.90; 95% CI: 5.02-15.74; P < 0.0001), irrespective of treatment modality.

Conclusions: In the PARTNER 3 trial, early POAF was more frequent following SAVR compared with TAVR. Late POAF, but not early POAF, was significantly associated with worse outcomes at 2 years, irrespective of treatment modality.
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http://dx.doi.org/10.1016/j.jcin.2021.05.026DOI Listing
July 2021

International consensus statement on nomenclature and classification of the congenital bicuspid aortic valve and its aortopathy, for clinical, surgical, interventional and research purposes.

Eur J Cardiothorac Surg 2021 09;60(3):448-476

St Paul's Hospital, University of British Columbia, Vancouver, Canada.

This International Consensus Classification and Nomenclature for the congenital bicuspid aortic valve condition recognizes 3 types of bicuspid valves: 1. The fused type (right-left cusp fusion, right-non-coronary cusp fusion and left-non-coronary cusp fusion phenotypes); 2. The 2-sinus type (latero-lateral and antero-posterior phenotypes); and 3. The partial-fusion (forme fruste) type. The presence of raphe and the symmetry of the fused type phenotypes are critical aspects to describe. The International Consensus also recognizes 3 types of bicuspid valve-associated aortopathy: 1. The ascending phenotype; 2. The root phenotype; and 3. Extended phenotypes.
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http://dx.doi.org/10.1093/ejcts/ezab038DOI Listing
September 2021

Summary: international consensus statement on nomenclature and classification of the congenital bicuspid aortic valve and its aortopathy, for clinical, surgical, interventional and research purposes.

Eur J Cardiothorac Surg 2021 09;60(3):481-496

St Paul's Hospital, University of British Columbia, Vancouver, Canada.

This International evidence-based nomenclature and classification consensus on the congenital bicuspid aortic valve and its aortopathy recognizes 3 types of bicuspid aortic valve: 1. Fused type, with 3 phenotypes: right-left cusp fusion, right-non cusp fusion and left-non cusp fusion; 2. 2-sinus type with 2 phenotypes: Latero-lateral and antero-posterior; and 3. Partial-fusion or forme fruste. This consensus recognizes 3 bicuspid-aortopathy types: 1. Ascending phenotype; root phenotype; and 3. extended phenotypes.
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http://dx.doi.org/10.1093/ejcts/ezab039DOI Listing
September 2021

Stent Frame Fracture and Late Atrial Migration of a Mitral SAPIEN 3 Transcatheter Valve.

JACC Cardiovasc Interv 2021 Jul 30;14(14):1610-1612. Epub 2021 Jun 30.

Centre for Heart Valve Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada. Electronic address:

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http://dx.doi.org/10.1016/j.jcin.2021.05.031DOI Listing
July 2021

Outcomes of Valve-in-Valve Transcatheter Aortic Valve Implantation with and without Bioprosthetic Valve Fracture.

EuroIntervention 2021 05 25. Epub 2021 May 25.

MVZ Department Structural Heart Disease, Asklepios St. Georg, Hamburg, Germany.

Background: Bioprosthetic valve fracture (BVF) is a technique to reduce gradients in valve-in-valve transcatheter aortic valve implantation (VIV-TAVI) procedures. Outcome of VIV-TAVI with BVF has not been compared with VIV-TAVI without BVF.

Aims: To evaluate the outcome of VIV-TAVI with BVF compared to VIV-TAVI without BVF.

Methods: In total, 81 cases of BVF-VIV-TAVI (BVF-group) from 14 centres were compared to 79 cases of VIV-TAVI without BVF (control-group).

Results: VARC-2 defined device success was 93% in the BVF- and 68.4% in the control-group (p<0.001). The mean transvalvular gradient decreased from 37 ± 13mmHg to 10.8 ± 5.9mmHg (p<0.001) in the BVF- and from 35 ± 16mmHg to 15.8 ± 6.8mmHg (p<0.001) in the control-group with a significantly higher final gradient in control (p<0.001). The transvalvular gradients did not significantly change over time. In-hospital major adverse events occurred in 3.7% in BVF- and 7.6% in control-group (p=0.325). A linear mixed model identified BVF, self-expanding transcatheter heart valves (THVs) and other surgical aortic valve (SAV) types other than Mitroflow as predictors for lower transvalvular gradients.

Conclusions: Compared to VIV-TAVI alone, VIV-TAVI with BVF resulted in a significantly lower transvalvular gradient acutely and at follow-up. Independent predictors for lower gradients were the use of self-expanding THVs and the treatment of SAVs other than Mitroflow, irrespective of BVF-performance. BVF significantly reduced the gradient independently from transcatheter or surgical valve type.
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http://dx.doi.org/10.4244/EIJ-D-21-00254DOI Listing
May 2021

2-Year Outcomes for Transcatheter Repair in Patients With Mitral Regurgitation From the CLASP Study.

JACC Cardiovasc Interv 2021 Jul 18;14(14):1538-1548. Epub 2021 May 18.

Department of Cardiovascular Medicine, University of Virginia Health System Hospital, Charlottesville, Virginia, USA.

Objectives: This study reports 2-year outcomes from the multicenter, prospective, single-arm CLASP study with functional mitral regurgitation (FMR) and degenerative MR (DMR) analysis.

Background: Transcatheter repair is a favorable option to treat MR. Long-term prognostic impact of the PASCAL transcatheter valve repair system in patients with clinically significant MR remains to be established.

Methods: Patients had clinically significant MR ≥3+ as evaluated by the echocardiographic core laboratory and were deemed candidates for transcatheter repair by the heart team. Assessments were performed by clinical events committee to 1 year (site-reported thereafter) and core laboratory to 2 years.

Results: A total of 124 patients (69% FMR, 31% DMR) were enrolled with a mean age of 75 years, 56% were male, 60% were New York Heart Association functional class III to IVa, and 100% had MR ≥3+. At 2 years, Kaplan-Meier estimates showed 80% survival (72% FMR, 94% DMR) and 84% freedom from heart failure (HF) hospitalization (78% FMR, 97% DMR), with 85% reduction in annualized HF hospitalization rate (81% FMR, 98% DMR). MR ≤1+ was achieved in 78% of patients (84% FMR, 71% DMR) and MR ≤2+ was achieved in 97% (95% FMR, 100% DMR) (all p < 0.001). Left ventricular end-diastolic volume decreased by 33 ml (p < 0.001); 93% of patients were in New York Heart Association functional class I to II (p < 0.001).

Conclusions: The PASCAL repair system demonstrated sustained favorable outcomes at 2 years in FMR and DMR patients. Results showed high survival and freedom from HF rehospitalization rates with a significantly reduced annualized HF hospitalization rate. Durable MR reduction was achieved with evidence of left ventricular reverse remodeling and significant improvement in functional status. The CLASP IID/IIF randomized pivotal trial is ongoing.
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http://dx.doi.org/10.1016/j.jcin.2021.04.001DOI Listing
July 2021

Incidence, Causes, and Outcomes Associated With Urgent Implantation of a Supplementary Valve During Transcatheter Aortic Valve Replacement.

JAMA Cardiol 2021 Aug;6(8):936-944

Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands.

Importance: Transcatheter aortic valve replacement (TAVR) failure is often managed by an urgent implantation of a supplementary valve during the procedure (2-valve TAVR [2V-TAVR]). Little is known about the factors associated with or sequelae of 2V-TAVR.

Objective: To examine the incidence, causes, and outcomes of 2V-TAVR.

Design, Setting, And Participants: A retrospective cohort study was performed using data from an international registry of 21 298 TAVR procedures performed from January 1, 2014, through February 28, 2019. Among the 21 298 patients undergoing TAVR, 223 patients (1.0%) undergoing 2V-TAVR were identified. Patient-level data were available for all the patients undergoing 2V-TAVR and for 12 052 patients (56.6%) undergoing 1V-TAVR. After excluding patients with missing 30-day follow-up or data inconsistencies, 213 2V-TAVR and 10 010 1V-TAVR patients were studied. The 2V-TAVR patients were compared against control TAVR patients undergoing a 1-valve TAVR (1V-TAVR) using 1:4 17 propensity score matching. Final analysis included 1065 (213:852) patients.

Exposures: Urgent implantation of a supplementary valve during TAVR.

Main Outcomes And Measures: Mortality at 30 days and 1 year.

Results: The 213 patients undergoing 2V-TAVR had similar age (mean [SD], 81.3 [0.5] years) and sex (110 [51.6%] female) as the 10 010 patients undergoing 1V-TAVR (mean [SD] age, 81.2 [0.5] years; 110 [51.6%] female). The 2V-TAVR incidence decreased from 2.9% in 2014 to 1.0% in 2018 and was similar between repositionable and nonrepositionable valves. Bicuspid aortic valve (odds ratio [OR], 2.20; 95% CI, 1.17-4.15; P = .02), aortic regurgitation of moderate or greater severity (OR, 2.02; 95% CI, 1.49-2.73; P < .001), atrial fibrillation (OR, 1.43; 95% CI, 1.07-1.93; P = .02), alternative access (OR, 2.59; 95% CI, 1.72-3.89; P < .001), early-generation valve (OR, 2.32; 95% CI, 1.69-3.19; P < .001), and self-expandable valve (OR, 1.69; 95% CI, 1.17-2.43; P = .004) were associated with higher 2V-TAVR risk. In 165 patients (80%), the supplementary valve was implanted because of residual aortic regurgitation after primary valve malposition (94 [46.4%] too high and 71 [34.2%] too low). In the matched 2V-TAVR vs 1V-TAVR cohorts, the rate of device success was 147 (70.4%) vs 783 (92.2%) (P < .001), the rate of coronary obstruction was 5 (2.3%) vs 3 (0.4%) (P = .10), stroke rate was 9 (4.6%) vs 13 (1.6%) (P = .09), major bleeding rates were 25 (11.8%) vs 46 (5.5%) (P = .03) and annular rupture rate was 7 (3.3%) vs 3 (0.4%) (P = .03). The hazard ratios for mortality were 2.58 (95% CI, 1.04-6.45; P = .04) at 30 days, 1.45 (95% CI, 0.84-2.51; P = .18) at 1 year, and 1.20 (95% CI, 0.77-1.88; P = .42) at 2 years. Nontransfemoral access and certain periprocedural complications were independently associated with higher risk of death 1 year after 2V-TAVR.

Conclusions And Relevance: In this cohort study, valve malposition was the most common indication for 2V-TAVR. Incidence decreased over time and was low overall, although patients with a bicuspid or regurgitant aortic valve, nontransfemoral access, and early-generation or self-expandable valve were at higher risk. These findings suggest that compared with 1V-TAVR, 2V-TAVR is associated with high burden of complications and mortality at 30 days but not at 1 year.
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http://dx.doi.org/10.1001/jamacardio.2021.1145DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8135057PMC
August 2021

The COVID-19 Pandemic and Coronary Angiography for ST-Elevation Myocardial Infarction, Use of Mechanical Support, and Mechanical Complications in Canada: A Canadian Association of Interventional Cardiology National Survey.

CJC Open 2021 Sep 12;3(9):1125-1131. Epub 2021 May 12.

Division of Cardiology, Thunder Bay Regional Health Sciences Centre, Thunder Bay, Ontario, Canada.

Background: As a result of the COVID-19 pandemic first wave, reductions in ST-elevation myocardial infarction (STEMI) invasive care, ranging from 23% to 76%, have been reported from various countries. Whether this change had any impact on coronary angiography (CA) volume or on mechanical support device use for STEMI and post-STEMI mechanical complications in Canada is unknown.

Methods: We administered a Canada-wide survey to all cardiac catheterization laboratory directors, seeking the volume of CA use for STEMI performed during the period from March 1 2020 to May 31, 2020 (pandemic period), and during 2 control periods (March 1, 2019 to May 31, 2019 and March 1, 2018 to May 31, 2018). The number of left ventricular support devices used, as well as the number of ventricular septal defects and papillary muscle rupture cases diagnosed, was also recorded. We also assessed whether the number of COVID-19 cases recorded in each province was associated with STEMI-related CA volume.

Results: A total of 41 of 42 Canadian catheterization laboratories (98%) provided data. There was a modest but statistically significant 16% reduction (incidence rate ratio [IRR] 0.84; 95% confidence interval 0.80-0.87) in CA for STEMI during the first wave of the pandemic, compared to control periods. IRR was not associated with provincial COVID-19 caseload. We observed a 26% reduction (IRR 0.74; 95% confidence interval 0.61-0.89) in the use of intra-aortic balloon pump use for STEMI. Use of an Impella pump and mechanical complications from STEMI were exceedingly rare.

Conclusions: We observed a modest 16% decrease in use of CA for STEMI during the pandemic first wave in Canada, lower than the level reported in other countries. Provincial COVID-19 caseload did not influence this reduction.
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http://dx.doi.org/10.1016/j.cjco.2021.04.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8114614PMC
September 2021

Bioprosthetic valve fracture: Predictors of outcome and follow-up. Results from a multicenter study.

Catheter Cardiovasc Interv 2021 Oct 15;98(4):756-764. Epub 2021 May 15.

MVZ Department Structural Heart Disease, Asklepios St. Georg, Hamburg, Germany.

Objectives: To evaluate outcome and its predictors of bioprosthetic valve fracture (BVF) in patients undergoing valve-in-valve transcatheter aortic valve replacement (VIV-TAVR).

Background: BVF is feasible and reduces transvalvular gradients in VIV-TAVR-procedures, but follow-up-data and information on factors influencing the outcome are missing.

Methods: The 81 cases of BVF-VIV-TAVR were collected from 14 international centers.

Results: Predominantly transcatheter heart valve (THV) was implanted first, followed by BVF. VARC-2 defined device success was 93%, most failures were attributed to residual high gradients. Mean gradients decreased from 37 ± 13 mmHg to 10.8 ± 5.9 mmHg (p < 0.001). BVF reduced the gradient by 16 mmHg. During follow-up (FU, 281 ± 164 days) mean gradient remained stable (10.8 ± 5.9 mmHg at discharge, 12.4 ± 6.3 mmHg at FU, p = ns). In-hospital major adverse events occurred in 3.7%. Event-free survival at 276 ± 237.6 days was 95.4%. The linear mixed model identified balloon-expandable valves (BEV), Mitroflow surgical valve, stenotic surgical bioprostheses and balloon only 1 mm larger than the true internal diameter of the surgical valve as predictors for higher gradients.

Conclusions: BVF is safe and can significantly reduce gradients, which remain stable at FU. BEV, Mitroflow surgical valve, stenotic bioprostheses and balloon larger than the true internal diameter of the surgical valve of only 1 mm are predictors for higher final gradients.
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http://dx.doi.org/10.1002/ccd.29755DOI Listing
October 2021

Implementation Fidelity in the Replication of Tuning in to Teens (TINT) Adapted for Adoptive Parents and Guardians in the US.

J Evid Based Soc Work (2019) 2021 May 10:1-16. Epub 2021 May 10.

School of Social Work, McGill University, Montreal, Quebec, Canada.

: Clear explication of the conditions necessary to reproduce results is imperative in the development of evidence-based interventions. This study used a fidelity framework to guide the exploration of implementation fidelity in a study of the Tuning in to Teens (TINT) intervention in New Jersey. TINT is an evidence-based prevention program - previously tested with parents of pre-adolescents to reduce emotionally dismissive parenting - that was adapted for use with adoptive and guardianship families. The review of intervention design adaptation and protocols; intervention training; and monitoring of intervention delivery revealed extensive efforts by an adoption clinician, the purveyor of the program, and an implementation team to support the implementation efforts. Results of the monitoring of intervention receipt indicate that the intervention was implemented with high fidelity. Future intervention research should consider assessing the effects of implementation efforts on outcomes to improve replication under real-world conditions. Regardless, this exploration of fidelity has implications for public and private organizations seeking to implement an evidence-based intervention. The framework developed by Gearing and Colleagues and the TIDieR checklist could provide useful guidance when planning for and reporting on implementation fidelity in the furtherance of developing and disseminating evidence-based interventions.
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http://dx.doi.org/10.1080/26408066.2021.1924912DOI Listing
May 2021

Single-cell Profiles and Prognostic Impact of Tumor-Infiltrating Lymphocytes Coexpressing CD39, CD103, and PD-1 in Ovarian Cancer.

Clin Cancer Res 2021 Jul 7;27(14):4089-4100. Epub 2021 May 7.

Deeley Research Centre, BC Cancer, Victoria, British Columbia, Canada.

Purpose: Tumor-infiltrating lymphocytes (TIL) are strongly associated with survival in most cancers; however, the tumor-reactive subset that drives this prognostic effect remains poorly defined. CD39, CD103, and PD-1 have been independently proposed as markers of tumor-reactive CD8 TIL in various cancers. We evaluated the phenotype, clonality, and prognostic significance of TIL expressing various combinations of these markers in high-grade serous ovarian cancer (HGSC), a malignancy in need of more effective immunotherapeutic approaches.

Experimental Design: Expression of CD39, CD103, PD-1, and other immune markers was assessed by high-dimensional flow cytometry, single-cell sequencing, and multiplex immunofluorescence of primary and matched pre/post-chemotherapy HGSC specimens.

Results: Coexpression of CD39, CD103, and PD-1 ("triple-positive" phenotype) demarcated subsets of CD8 TIL and CD4 regulatory T cells (Treg) with a highly activated/exhausted phenotype. Triple-positive CD8 TIL exhibited reduced T-cell receptor (TCR) diversity and expressed genes involved in both cytolytic and humoral immunity. Triple-positive Tregs exhibited higher TCR diversity and a tumor-resident phenotype. Triple-positive TIL showed superior prognostic impact relative to TIL expressing other combinations of these markers. TIGIT was uniquely upregulated on triple-positive CD8 effector cells relative to their CD4 Treg counterparts.

Conclusions: Coexpression of CD39, CD103, and PD-1 demarcates highly activated CD8 and CD4 TIL with inferred roles in cytolytic, humoral, and regulatory immune functions. Triple-positive TIL demonstrate exceptional prognostic significance and express compelling targets for combination immunotherapy, including PD-1, CD39, and TIGIT.
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http://dx.doi.org/10.1158/1078-0432.CCR-20-4394DOI Listing
July 2021

Percutaneous mechanical circulatory support from the collaborative multicenter Mechanical Unusual Support in TAVI (MUST) Registry.

Catheter Cardiovasc Interv 2021 May 7. Epub 2021 May 7.

Department of Cardiology, Rabin Medical Center, Petach Tikva, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Objectives: To evaluate the use and outcomes of percutaneous mechanical circulatory support (pMCS) utilized during transcatheter aortic valve implantation (TAVI) from high-volume centers.

Methods And Results: Our international multicenter registry including 13 high-volume TAVI centers with 87 patients (76.5 ± 11.8 years, 63.2% men) who underwent TAVI for severe aortic stenosis and required pMCS (75.9% VA-ECMO, 19.5% Impella CP, 4.6% TandemHeart) during the procedure (prior to TAVI 39.1%, emergent rescue 50.6%, following TAVI 10.3%). The procedures were considered high-risk, with 50.6% having severe left ventricular dysfunction, 24.1% biventricular dysfunction, and 32.2% severe pulmonary hypertension. In-hospital and 1-year mortality were 27.5% and 49.4%, respectively. Patients with prophylactic hemodynamic support had lower periprocedural mortality compared to patients with rescue insertion of pMCS (log rank = 0.013) and patients who did not undergo cardiopulmonary resuscitation during the TAVI procedure had better short and long term survival (log rank <0.001 and 0.015, respectively).

Conclusions: Given the overall survival rate and low frequency of pMCS-related complications, our study results support the use of pMCS prophylactically or during the course of TAVI (bailout) in order to improve clinical outcomes in high-risk procedures or in case of acute life-threatening hemodynamic collapse.
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http://dx.doi.org/10.1002/ccd.29747DOI Listing
May 2021

Stroke Complicating Infective Endocarditis After Transcatheter Aortic Valve Replacement.

J Am Coll Cardiol 2021 May;77(18):2276-2287

Emory University School of Medicine, Atlanta, Georgia, USA.

Background: Stroke is one of the most common and potentially disabling complications of infective endocarditis (IE). However, scarce data exist about stroke complicating IE after transcatheter aortic valve replacement (TAVR).

Objectives: The purpose of this study was to determine the incidence, risk factors, clinical characteristics, management, and outcomes of patients with definite IE after TAVR complicated by stroke during index IE hospitalization.

Methods: Data from the Infectious Endocarditis after TAVR International Registry (including 569 patients who developed definite IE following TAVR from 59 centers in 11 countries) was analyzed. Patients were divided into two groups according to stroke occurrence during IE admission (stroke [S-IE] vs. no stroke [NS-IE]).

Results: A total of 57 (10%) patients had a stroke during IE hospitalization, with no differences in causative microorganism between groups. S-IE patients exhibited higher rates of acute renal failure, systemic embolization, and persistent bacteremia (p < 0.05 for all). Previous stroke before IE, residual aortic regurgitation ≥moderate after TAVR, balloon-expandable valves, IE within 30 days after TAVR, and vegetation size >8 mm were associated with a higher risk of stroke during the index IE hospitalization (p < 0.05 for all). Stroke rate in patients with no risk factors was 3.1% and increased up to 60% in the presence of >3 risk factors. S-IE patients had higher rates of in-hospital mortality (54.4% vs. 28.7%; p < 0.001) and overall mortality at 1 year (66.3% vs. 45.6%; p < 0.001). Surgical treatment was not associated with improved outcomes in S-IE patients (in-hospital mortality: 46.2% in surgical vs. 58.1% in no surgical treatment; p = 0.47).

Conclusions: Stroke occurred in 1 of 10 patients with IE post-TAVR. A history of stroke, short time between TAVR and IE, vegetation size, valve prosthesis type, and residual aortic regurgitation determined an increased risk. The occurrence of stroke was associated with increased in-hospital and 1-year mortality rates, and surgical treatment failed to improve clinical outcomes.
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http://dx.doi.org/10.1016/j.jacc.2021.03.233DOI Listing
May 2021

Permanent Pacemaker Implantation Following Valve-in-Valve Transcatheter Aortic Valve Replacement: VIVID Registry.

J Am Coll Cardiol 2021 May;77(18):2263-2273

Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany.

Background: Permanent pacemaker implantation (PPI) remains one of the main drawbacks of transcatheter aortic valve replacement (TAVR), but scarce data exist on PPI after valve-in-valve (ViV) TAVR, particularly with the use of newer-generation transcatheter heart valves (THVs).

Objectives: The goal of this study was to determine the incidence, factors associated with, and clinical impact of PPI in a large series of ViV-TAVR procedures.

Methods: Data were obtained from the multicenter VIVID Registry and included the main baseline and procedural characteristics, in-hospital and late (median follow-up: 13 months [interquartile range: 3 to 41 months]) outcomes analyzed according to the need of periprocedural PPI. All THVs except CoreValve, Cribier-Edwards, Sapien, and Sapien XT were considered to be new-generation THVs.

Results: A total of 1,987 patients without prior PPI undergoing ViV-TAVR from 2007 to 2020 were included. Of these, 128 patients (6.4%) had PPI after TAVR, with a significant decrease in the incidence of PPI with the use of new-generation THVs (4.7% vs. 7.4%; p = 0.017), mainly related to a reduced PPI rate with the Evolut R/Pro versus CoreValve (3.7% vs. 9.0%; p = 0.002). There were no significant differences in PPI rates between newer-generation balloon- and self-expanding THVs (6.1% vs. 3.9%; p = 0.18). In the multivariable analysis, older age (odds ratio [OR]: 1.05 for each increase of 1 year; 95% confidence interval [CI]: 1.02 to 1.07; p = 0.001), larger THV size (OR: 1.10; 95% CI: 1.01 to 1.20; p = 0.02), and previous right bundle branch block (OR: 2.04; 95% CI: 1.00 to 4.17; p = 0.05) were associated with an increased risk of PPI. There were no differences in 30-day mortality between the PPI (4.7%) and no-PPI (2.7%) groups (p = 0.19), but PPI patients exhibited a trend toward higher mortality risk at follow-up (hazard ratio: 1.39; 95% CI: 1.02 to 1.91; p = 0.04; p = 0.08 after adjusting for age differences between groups).

Conclusions: In a contemporary large series of ViV-TAVR patients, the rate of periprocedural PPI was relatively low, and its incidence decreased with the use of new-generation THV systems. PPI following ViV-TAVR was associated with a trend toward increased mortality at follow-up.
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http://dx.doi.org/10.1016/j.jacc.2021.03.228DOI Listing
May 2021
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