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BACKGROUND: Raphe-type bicuspid aortic valve (BAV) is a potential hostile scenario in trans-catheter aortic valve replacement (TAVR) due to pronounced calcium burden, possibly associated with tapered valve configuration. Trans-Catheter heart valve (THV) sizing strategy (annular vs. supra-annular) is controversial in this valve subtype. OBJECTIVES: To describe the phenotypical characteristics of severe, tapered, raphe-type, BAV stenosis undergoing TAVR and to explore safety and efficacy of modern-generation THVs, analysing the impact of annular and supra-annular sizing strategies on short- and mid-terms outcomes. METHODS: This is a retrospective, multicenter registry enrolling consecutive stenotic Sievers type 1 BAV treated with TAVR. Study population was divided into tapered and non-tapered configuration according to MSCT analysis. Matched comparison between annular and supra-annular sizing groups was performed in tapered population. RESULTS: From January 2016 to June 2023, 897 patients were enrolled. Of them, 696 patients displayed a tapered configuration. Of those, 510 received a THV according to annular sizing. After propensity score matching 186 matched pairs were selected. Technical success (96.2 % vs 94.1 %, OR 1.61 [0.61-4.24], p = 0.34), 30-day device success (83.6 % in both groups, OR 1.42 [0.78-2.57], p = 0.25) and 30-day early safety (71.8 % vs 70.5 %, OR 1.07 [0.68-1.68], p = 0.78) were similar between the annular and supra-annular sizing groups; a higher post-TAVR gradient was observed in supra-annular group, although it was only 2 mmHg mean. At mid-term follow-up, the rate of clinical efficacy was 84.7 %. CONCLUSIONS: TAVR with modern-generation devices is safe and effective for tapered raphe-type BAV, showing comparable results for annular and supra-annular sizing strategies.

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Delayed coronary obstruction (DCO) occurs when there is obstruction of the coronary ostia following a transcatheter aortic valvular implantation (TAVI). It is an uncommon but serious complication that often leads to death, usually presents as severe hypotension after TAVI, and should be suspected if migration of the valve occurs. We report the case of a 70-year-old female patient with severe aortic stenosis who underwent TAVI using a 26-mm CoreValve Evolut Pro (Medtronic, Dublin, Ireland). Although the valve was implanted successfully, she experienced hypotension with intermittent ST elevations and had a cardiac arrest shortly after, requiring Advanced Cardiovascular Life Support (ACLS). An aortogram showed sealing of the sinotubular junction (STJ) by CoreValve, without coronary flow. CoreValve was then snared and repositioned in the ascending aorta recovering coronary flow and cardiac pulsatility. A second TAVI was performed and an Edwards 20 mm Sapiens 3 valve (Edwards Lifesciences, Irvine, CA, USA) was implanted as standard procedure.

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Non-occlusive mesenteric ischemia (NOMI) is a rare but well-known life-threatening disease. However, reports on NOMI following trans-catheter aortic valve implantation (TAVI) are limited. This report presents a case of NOMI after trans-apical (TA) TAVI with thyroid storm. A 73-year-old man was admitted for a planned aortic valve surgery. Because he had severe aortic calcification and a right renal tumor that was suspected to be malignant, TA-TAVI was performed. At 61 h after TAVI, the patient complained of abdominal pain, and contrast-enhanced computed tomography showed ischemic necrosis of the cecum to the ascending colon. An ileocecal resection was performed emergently. He was extubated 61 h postoperatively, but severe delirium, high fever, and atrial fibrillation persisted. Due to a history of Basedow's disease, he was diagnosed with thyroid storm and treated with thiamazole and supportive care. The general status gradually improved, and he was transferred to the rehabilitation unit on the 17th postoperative day. We encountered a case of NOMI following TA-TAVI with a thyroid storm, which made it difficult to understand the patient's medical condition. Learning objective: The occurrence of non-occlusive mesenteric ischemia after trans-catheter aortic valve implantation is rare but possible, and a thyroid storm could occur even after a less invasive surgery. It is important to perform postoperative management while considering the possible occurrence of this condition.

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BACKGROUND: Long-term survival after surgery for severe aortic stenosis (AS) provides important information regarding the choice between surgical (SAVR) and transcatheter (TAVR) aortic valve replacement. This study investigated the long-term survival of AS patients with low or intermediate surgical risk who underwent SAVR or TAVR in our institution versus that of the Japanese general population. METHODS: From 2009 to 2019, 1276 consecutive patients underwent SAVR or TAVR for severe AS. Among them, we retrospectively investigated those with low (n = 383) or intermediate (n = 137) surgical risk treated with SAVR and those with low (n = 86) or intermediate (n = 333) surgical risk treated with TAVR. Their post-intervention survival was compared with that of an age- and gender-matched Japanese general population. RESULTS: The overall 5-year survival rate of SAVR for patients with low surgical risk (mean age, 72 ±â€¯9 years) was not significantly different from that of the general population (90 % vs. 89 %, respectively; p = 0.58), whereas that of patients with intermediate surgical risk (77 ±â€¯6 years) was significantly lower than that of the general population (77 % vs. 84 %, respectively; p = 0.03). After TAVR, the 5-year survival of patients with low (78 ±â€¯8 years) or intermediate (83 ±â€¯5 years) surgical risk was significantly lower than that of the general population (low risk, 64 % vs. 81 %, p < 0.01; intermediate risk, 66 % vs. 71 %, respectively, p = 0.01). CONCLUSIONS: Our study demonstrated that long-term survival after SAVR for AS patients with low surgical risk was as good as that of the age- and gender-matched general population, while the long-term survival after SAVR for intermediate-risk or TAVR for low- or intermediate-risk patients was lower than that of the general population. These findings suggest that SAVR is an appropriate option for AS patients with low surgical risk and good life expectancy, especially in Japan, where the life expectancy is the longest worldwide.

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El implante de la válvula aórtica transcatéter es una alternativa al tratamiento de pacientes con estenosis aórtica severa, se realiza convencionalmente en anestesia general o anestesia local más sedación. Presentamos el primer caso de implante valvular aórtico transcatéter por vía transfemoral realizado en nuestro hospital en un paciente con estenosis aórtica severa con riesgo quirúrgico alto. La anestesia consistió en la combinación de bloqueo bilateral selectivo de los nervios iliohipogástrico, ilioinguinal y genitofemoral con el paciente despierto sin sedación, mediante el abordaje guiado por ecografía. El implante valvular aórtico transcatéter fue exitoso y transcurrió sin incidencias, el paciente se mantuvo inmóvil, tranquilo, no refirió dolor y no fue necesario suministrar sedantes/hipnóticos durante la dilatación de los accesos vasculares con los introductores. La monitorización estándar mostró estabilidad hemodinámica sin repercusión cardiovascular y no requirió apoyo de fármacos vasopresores o inotropos. Tras la intervención el paciente fue enviado a la Unidad de Cuidados Intensivos Cardiológicos, donde se mantuvo asintomático y estable. Posteriormente el paciente ingresó en la sala de cardiología de la que fue dado de alta sin complicaciones.(AU)

Transcatheter aortic valve implantation is an alternative treatment for patients with severe aortic stenosis, it is conventionally performed under general anaesthesia or local anaesthesia plus sedation. We present the first case of trans-femoral, trans-catheter aortic valve implantation, performed in our hospital in a patient with severe aortic stenosis, who was a high surgical risk. Anaesthesia consisted of a combination of bilateral selective blockade of the iliohypogastric, ilioinguinal and genitofemoral nerves with the patient awake without sedation, using an ultrasound-guided approach. Transcatheter aortic valve implantation was successful and passed without incident, the patient remained immobile, calm, did not report pain, and sedation or hypnotics were not necessary during dilation of the vascular accesses with the introducer. Standard monitoring demonstrated haemodynamic stability, without cardiovascular repercussions and did not necessitate vasopressor or inotropic drug support. After the intervention, the patient was sent to the Cardiac Intensive Care Unit, where he remained asymptomatic and stable. Subsequently, the patient was admitted to the cardiology ward from where he was discharged without complications.(AU)

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Transcatheter aortic valve implantation is an alternative treatment for patients with severe aortic stenosis, it is conventionally performed under general anaesthesia or local anaesthesia plus sedation. We present the first case of trans-femoral, trans-catheter aortic valve implantation, performed in our hospital in a patient with severe aortic stenosis, who was a high surgical risk. Anaesthesia consisted of a combination of bilateral selective blockade of the iliohypogastric, ilioinguinal and genitofemoral nerves with the patient awake without sedation, using an ultrasound-guided approach. Transcatheter aortic valve implantation was successful and passed without incident, the patient remained immobile, calm, did not report pain, and sedation or hypnotics were not necessary during dilation of the vascular accesses with the introducer. Standard monitoring demonstrated haemodynamic stability, without cardiovascular repercussions and did not necessitate vasopressor or inotropic drug support. After the intervention, the patient was sent to the Cardiac Intensive Care Unit, where he remained asymptomatic and stable. Subsequently, the patient was admitted to the cardiology ward from where he was discharged without complications.

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Reliable femoral artery closure devices are essential for the success of trans-femoral Transcatheter Aortic Valve Implantation (TAVI) procedures. Accordingly, device choice might affect vascular complications and bleeding rates. This was a retrospective analysis, comparing vascular complication rates among patients who underwent trans-femoral TAVI with vascular access closure using either the ProGlide parallel suture or Prostar closure devices. We included 191 patients: 106 were treated with Prostar and 85 with ProGlide. The ProGlide group had higher rate of diabetes, chronic kidney disease, peripheral arterial disease, and significantly smaller femoral arteries that were treated via larger sheaths. Valve Academic Research Consortium (VARC)-2 major complications were similar between the groups. (4.7% for ProGlide vs 3.8% for Prostar, P=1), with similar incidence of closure device failure (2 vs 3, P=1). No differences were found after univariant analysis and propensity-score matching in the incidence of major and minor bleeding nor in the rate of in-hospital mortality between ProGlide and Prostar (4.7 vs 2.8%, P=.7, 1.2 vs 2.8%, P=.63, and 1.2 vs .0%, P=.45, respectively). Parallel suture technique using two ProGlide sutures showed comparable rates of vascular complications to the Prostar closure device in higher risk population of TAVI patients.

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BACKGROUND: Complication rates of paravalvular aortic regurgitation (PVR) and permanent pacemaker insertion remain high in patients undergoing trans-catheter aortic valve insertion for severe aortic stenosis. The spatial distribution of calcium between individual aortic valve leaflets, and its potential role in these complications is gaining interest. We aimed to assess the accuracy of individual aortic valve leaflet calcium quantification, and to determine its effect on the frequency of these complications. METHODS: This was a retrospective study of 251 patients who underwent trans-catheter aortic valve insertion using the Evolut RTM valve. The off-line Terarecon software platform was used for Agatston scoring the short axis views. RESULTS: There was a correlation between the sum of the individual leaflet and the total aortic valve calcium score. There was a univariate association between an increase [per 100 Agatston unit (AU)] in both right coronary leaflet (RCL) and left coronary leaflet (LCL) calcium with the risk of PVR. There was an association between an increase in LCL calcium score (per 100 AU) and need for post-implantation balloon aortic valvuloplasty (BAV). There was no association between individual leaflet calcification on the risk of permanent pacemaker insertion. CONCLUSIONS: This study supports the idea that a quantifiable and reproducible method of individual valve leaflet calcification score may serve as an independent risk factor for paravalvular regurgitation, beyond visual assessment of asymmetry. However, the same may not be true of spatial calcium distribution and permanent pacemaker implantation (PPI).

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Over the last half century, surgical aortic valve replacement (SAVR) has evolved to offer a durable and efficient valve haemodynamically, with low procedural complications that allows favourable remodelling of left ventricular (LV) structure and function. The latter has become more challenging among elderly patients, particularly following trans-catheter aortic valve implantation (TAVI). Precise understanding of myocardial adaptation to pressure and volume overloading and its responses to valve surgery requires comprehensive assessments from aortic valve energy loss, valvular-vascular impedance to myocardial activation, force-velocity relationship, and myocardial strain. LV hypertrophy and myocardial fibrosis remains as the structural and morphological focus in this endeavour. Early intervention in asymptomatic aortic stenosis or regurgitation along with individualised management of hypertension and atrial fibrillation is likely to improve patient outcome. Physiological pacing via the His-Purkinje system for conduction abnormalities, further reduction in para-valvular aortic regurgitation along with therapy of angiotensin receptor blockade will improve patient outcome by facilitating hypertrophy regression, LV coordinate contraction, and global vascular function. TAVI leaflet thromboses require anticoagulation while impaired access to coronary ostia risks future TAVI-in-TAVI or coronary interventions. Until comparable long-term durability and the resolution of TAVI related complications become available, SAVR remains the first choice for lower risk younger patients.

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BACKGROUND: The aim of this research is to describe the performance over time of transcatheter aortic valve implantations (TAVIs) in a high-volume center with a contemporary, real-world population. METHODS: Patients referred for TAVIs at the University Hospital of Verona were prospectively enrolled. By cumulative sum failures analysis (CUSUM), procedural-control curves for standardized combined endpoints-as defined by the Valve Academic Research Consortium-2 (VARC-2)-were calculated and analyzed over time. Acceptable and unacceptable limits were derived from recent studies on TAVI in intermediate and low-risk patients to fit the higher required standards for current indications. RESULTS: A total of 910 patients were included. Baseline risk scores significantly reduced over time. Complete procedural control was obtained after approximately 125 and 190 cases for device success and early safety standardized combined endpoints, respectively. High risk patients (STS ≥ 8) had poorer outcomes, especially in terms of VARC-2 clinical efficacy, and required a higher case load to maintain in-control and proficient procedures. Clinically relevant single endpoints were all influenced by operator's experience as well. CONCLUSIONS: Quality-control analysis for contemporary TAVI interventions based on standardized endpoints suggests the need for relevant operator's experience to achieve and maintain optimal clinical results, especially in higher-risk subjects.

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Over the last half century, surgical aortic valve replacement (SAVR) has evolved to offer a durable and efficient valve haemodynamically, with low procedural complications that allows favourable remodelling of left ventricular (LV) structure and function. The latter has become more challenging among elderly patients, particularly following trans-catheter aortic valve implantation (TAVI). Precise understanding of myocardial adaptation to pressure and volume overloading and its responses to valve surgery requires comprehensive assessments from aortic valve energy loss, valvular-vascular impedance to myocardial activation, force-velocity relationship, and myocardial strain. LV hypertrophy and myocardial fibrosis remains as the structural and morphological focus in this endeavour. Early intervention in asymptomatic aortic stenosis or regurgitation along with individualised management of hypertension and atrial fibrillation is likely to improve patient outcome. Physiological pacing via the His-Purkinje system for conduction abnormalities, further reduction in para-valvular aortic regurgitation along with therapy of angiotensin receptor blockade will improve patient outcome by facilitating hypertrophy regression, LV coordinate contraction, and global vascular function. TAVI leaflet thromboses require anticoagulation while impaired access to coronary ostia risks future TAVI-in-TAVI or coronary interventions. Until comparable long-term durability and the resolution of TAVI related complications become available, SAVR remains the first choice for lower risk younger patients.

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Trans-catheter valve-in-valve (ViV) is a treatment option for patients affected by bioprosthetic heart valve (BHV) failure. Both aortic and mitral ViV procedures present several challenges compared to native valve replacement. To date, no data concerning the balloon-expandable MyVal (Meril, Vapi, India) trans-catheter heart valve (THV) use in ViV procedure have been provided. In this case series, we described for the first time its use in five different BHV failures.

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Since trans-catheter valve implantation (TAVI) has emerged for severe symptomatic aortic stenosis treatment, infective endocarditis (IE) appears as a rare but severe complication. Like surgical aortic valve remplacement infective endocarditis (SAVR-IE), TAVI-IE has a noxious impact on morbidity and mortality. Compared to SAVR-IE, TAVI-IE present some similarities as well as differences. Most TAVI-IE occurred during the first year and enterococcus is the more common pathogen. A multimodality imaging approach including echocardiography, multislice computed tomography (CT) and positron emission tomography-CT with blood culture is necessary for the diagnosis. In this high-risk population, the vast majority of TAVI-IE patients are treated with antibiotic therapy alone. Consequently to the expanded indication, the increasing number of TAVI-IE will appear more frequently. If initially only few clinical cases of IE were reported, sparse observational multicenter registries have now been published. Relevant differences were noted on these registries, but some recent publications have provided new informations on IE. The present review reports incidence, symptoms, microbiological profil, risk factors and clinicals outcomes of TAVI-IE. Eventually, we describe the management and the treatment of IE in the context of TAVI.

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Trans-catheter aortic valve implantation (TAVI) has recently emerged as a less invasive alternative to surgical aortic valve replacement (SAVR) in high risk patients. Although several procedures have been performed worldwide, infective endocarditis (IE) has been reported to be a rare TAVI complication, nevertheless if IE occurs it represents a life-threatening condition and treatment is challenging. TAVI-IE are thus normally treated conservatively by targeted antibiotic therapy with a high reported mortality (40%). Surgical explant represent the definitive strategy but, the intervention is at a high risk (risk of complication 87%, with an in hospital mortality of about 47%). In the present paper, we report the case of a 71-year-old patient affected by an early endocarditis after TAVI (TAVI-IE) treated at our Institution by surgical explant. The case highlights a paradox: if TAVI procedures are indicated over traditional surgical valve replacement in treatment of high surgical risk patients, what should be the best management when TAVI-IE occurs in these same population of patients?

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BACKGROUND: Coronary artery disease (CAD) is a common finding among patients undergoing trans-catheter aortic valve implantation (TAVI), who often present severely calcified coronary lesions. Evidence is scarce about the use of rotational atherectomy (RA) in this setting, in particular regarding long-term outcome. METHODS: RA was performed on severely calcified coronary lesions concomitant with TAVI in a consecutive series of patients treated between 2010 and 2020. Immediate and long-term clinical outcomes are reported. RESULTS: A concomitant CAD (coronary stenosis visually > 50%) was observed in 402/845 (47.6%) consecutive patients undergoing TAVI at the University Hospital of Verona. Angioplasty was performed in 104 patients (12.3%). Among these, 19 patients (18.3%, 20 coronary arteries), were treated with RA after TAVI: 10 after implantation of a balloon-expandable trans-catheter valve and 9 after a self-expandable valve. All procedures were successful. Hypotension occurred in 3 patients (15.8%), with rapid recovery after the procedure; CI-AKI (contrast-induced acute kidney injury) in 3 patients (15.8%), of which two recovered within discharge. At a median follow-up of 21.5 months (Q1-3: 6-36) event free survival was 83.3%. Only one patient suffered a target vessel failure >2 years after RA. Neither stroke nor peri-procedural infarctions were detected. CONCLUSIONS: RA concomitant with TAVI was feasible and safe in patients treated with implantation of either self-expandable, or balloon-expandable trans-catheter aortic valves. Long-term clinical events related to the coronary procedure were extremely infrequent and the survival rate at median follow-up of 21.5 months was 83.3%.

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BACKGROUND: Thrombocytopenia has been shown to occur soon after surgical biological aortic valve replacement (AVR), and recently reported also after transcatheter valve implantation (TAVI). The mechanism underlying this phenomenon is still unknown, and its clinical impact on the peri-operative outcome has been poorly investigated. METHODS: A systematic review and a meta-analysis of all available studies reporting data about peri-procedural thrombocytopenia on isolated bio-AVR, comparing rapid-deployment (RDV), stentless (stentless-AVR), and TAVI vs. stented (stented-AVR) valves, have been performed. RESULTS: Fifteen trials (2.163 patients) were included in the meta-analysis. Perioperative platelet reduction ranged from 35% to 55% in stented-AVR, from 60% to 77% in stentless-AVR, from 53% to 60% in RDV, and from to 21% to 72% in TAVI (apparently, balloon-expandable valves more frequently associated to thrombocytopenia). Stented-AVR required more red blood cells transfusion than stentless-AVR (P < 0.0001), whereas no difference has been found between RDV and stented-AVR. Platelet transfusion rate was very low in all surgical groups. No difference has been found in RDV and stentless-AVR vs. stented-AVR, in terms of reoperation for bleeding, and length-of-intensive care unit or hospital stay. CONCLUSIONS: Thrombocytopenia-related major adverse events were mainly reported in TAVI patients, whereas clinically meaningless in surgical patients. Transient peri-procedural thrombocytopenia is common after bio-AVR, regardless of prosthesis's type or implant modality. It should receive appropriate monitoring and focused investigations.

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Trans-catheter aortic valve implantation (TAVI) has become an established treatment for inoperable and high-surgical risk patients with severe, symptomatic aortic stenosis (AS). Post-procedural acute kidney injury (AKI) is a frequent complication following TAVI and is associated with increased mortality. Patients with pre-existing chronic renal impairment are at particularly high risk. The etiology of post-TAVI AKI is multi-factorial, but the principal procedural issues are contrast-induced nephropathy, and renal hypoperfusion secondary to intra-procedural hypotension. We report a case of a TAVI in an 80-year-old patient with severe AS and significant chronic kidney disease (CKD), which was carried out without the use of contrast and with minimal procedural hypotension. Pre-procedural imaging was carried out using 3D trans-esophageal echocardiography (TEE) rather than computed tomography (CT) to avoid contrast administration. The Lotus valve (Boston Scientific, Marlborough, MA, USA) was chosen due to a number of design features which minimize both the need for contrast injection and procedural hypotension during valve positioning and deployment. The procedure was carried out successfully and produced an excellent result with no decline in renal function. We believe that the approach of using TEE and the mechanically-expanded Lotus valve illustrates an important therapeutic approach in patients with severe CKD. .

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Objectives: The aim of this retrospective series is to describe the prevalence and clinical significance of the incidental findings found during pre-transcatheter aortic valve implantation (TAVI) work-up and to ascertain the clinical course of such patients. Methods: Consecutive patients undergoing TAVI from 2013 to 2015 where a TAVI CT assessment was performed (n=138) were included in the study. All incidental findings that were not expected from the patient's history were discussed at the TAVI multidisciplinary meeting in order to ascertain the clinical significance of said findings and whether they would alter the proposed course of treatment. Mortality data were determined by careful retrospective case note and follow-up appointment analysis. Results: Seventy-eight patients (57%) were found to have incidental findings on pre-TAVI CT scan. The majority of patients had benign pathology with high incidence in particular of diverticular disease, pleural effusions, gallstones, hiatus hernia and degenerative spinal disease. Vascular pathology such as superior mesenteric, renal and iliac artery stenoses and abdominal aortic aneurysm was detected in seven patients. In terms of long-term mortality data, we found no significant difference between those with incidental findings and those without (p=0.48). Survival as assessed by Kaplan-Meier analysis showed no significant difference between those with and without incidental abnormal CT scan findings (p=0.98). Conclusions: Incidental findings with potential for malignancy are common in an elderly, comorbid population. Ultimately, clinical correlation and prognosis must be swiftly ascertained in order to streamline the patients down the appropriate management pathway while avoiding unnecessary delay for treatment of their aortic stenosis.

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INTRODUCTION: Concomitant mitral-regurgitation (MR) is frequently observed in patients undergoing trans-catheter aortic valve implantation (TAVI). The predictive value of MR etiology remains to be elucidated. METHODS: 600 patients with coincidental MR (≥moderate) undergoing TAVI were categorized according to a modified Carpentier classification [Groups: no/mild MR, n = 477; left atrial (LA) functional MR, n = 18; MR due to left ventricular dilatation, n = 29; degenerative MR, n = 50; MR with restricted leaflet motion n = 26]. MR improvement and patient outcome was compared among the groups in a retrospective analysis. RESULTS: MR regression was most pronounced in patients with restricted leaflet motion after 6 months, although a significant improvement was observed in all subgroups. MR relief was predominantly observed within the first 30 days after TAVI. Only patients with restricted leaflet motion experienced further improvement thereafter.In the entire cohort a total of 15 strokes (2.5%) during the first 30 days after TAVI were observed, with the highest incidence in the LA functional cohort (3 events, 17%; p = 0.008). In multivariate analysis, organic etiology was associated with an increased 1-year mortality.In conclusion, despite significant MR regression in all MR groups, some individuals may require additional mitralvalve repair after TAVI. According to our data the timing of these procedures should be based on the underlying MR etiology. The Carpentier classification in patients with coincidental MR undergoing TAVI for severe AS may also have prognostic implications as we found an increased incidence of strokes in our LA functional cohort and a worse mortality rates in organic MR.

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