With the rising global health burden of aortic valve diseas and growing awareness of the consequences of severe AS, more patients are expected to be referred for aortic valve replacement.... Show moreWith the rising global health burden of aortic valve diseas and growing awareness of the consequences of severe AS, more patients are expected to be referred for aortic valve replacement. Multimodality imaging remains of paramount importance for proper patient selection, determining optimal timing of intervention and in the evaluation of therapy. For risk stratification and defining optimal timing of intervention, conventional and advanced echocardiography and computed tomography are crucial. Conventional echocardiography can be used to assess extra-aortic valvular cardiac damage in patients with severe AS. On top of conventional echocardiography, advanced echocardiography can provide additional insights. Left ventricular GLS by speckle tracking echocardiography has been suggested as a more sensitive marker of LV systolic dysfunction. LV GLS may be of help to define more optimal timing of intervention in asymptomatic patients with severe AS. Also, LV GLS may be of incremental value on top of conventional echocardiographic parameters for the assessment of cardiac injury. For the evaluation of prothesis function and durability after aortic valve implantation and detection of possible (late) complications, echocardiography is the mainstay imaging modality. Also, both conventional and advanced echocardiography can provide additional information on the effects of therapy on LV function and remodelling. Show less
In this PhD thesis we have studied left ventricular systolic deformation with novel cardiovascular magnetic resonance (CMR) algorithm called feature-tracking in patients with acute myocardial... Show moreIn this PhD thesis we have studied left ventricular systolic deformation with novel cardiovascular magnetic resonance (CMR) algorithm called feature-tracking in patients with acute myocardial infarction (MI). We have shown that left ventricular strain with feature-tracking CMR offers an incremental value above conventional imaging parameters in the assessment of prognosis of patients with acute MI. In addition, left ventricular strain analysis confirmed a clear clinical benefit of early intravenous betablocker treatment in patients with acute MI. Moreover, we have explored the feasibility of novel automated 3D echocardiographic algorithm in the assessment of the aortic root anatomy in patients with severe aortic stenosis prior to transcatheter aortic valve replacement (TAVR). The 3D echocardiographic algorithm performed excellent against the gold standard multidetector row computed tomography to determine the aortic annulus size and to choose the correct TAVR prosthesis size; however, the accuracy was a bit lower in patients with severely calcified aortic valves. In addition, we have explored the advantages and limitations of different cardiac imaging techniques in the assessment of patients with TAVR, the role of multimodality imaging in patients with combined valvular heart disease and heart failure, and the role of myocardial fibrosis assessment with CMR in valvular heart disease. Show less
Aims The Valve Academic Research Consortium (VARC), founded in 2010, was intended to (i) identify appropriate clinical endpoints and (ii) standardize definitions of these endpoints for... Show moreAims The Valve Academic Research Consortium (VARC), founded in 2010, was intended to (i) identify appropriate clinical endpoints and (ii) standardize definitions of these endpoints for transcatheter and surgical aortic valve clinical trials. Rapid evolution of the field, including the emergence of new complications, expanding clinical indications, and novel therapy strategies have mandated further refinement and expansion of these definitions to ensure clinical relevance. This document provides an update of the most appropriate clinical endpoint definitions to be used in the conduct of transcatheter and surgical aortic valve clinical research.Methods and results Several years after the publication of the VARC-2 manuscript, an in-person meeting was held involving over 50 independent clinical experts representing several professional societies, academic research organizations, the US Food and Drug Administration (FDA), and industry representatives to (i) evaluate utilization of VARC endpoint definitions in clinical research, (ii) discuss the scope of this focused update, and (iii) review and revise specific clinical endpoint definitions. A writing committee of independent experts was convened and subsequently met to further address outstanding issues. There were ongoing discussions with FDA and many experts to develop a new classification schema for bioprosthetic valve dysfunction and failure. Overall, this multi-disciplinary process has resulted in important recommendations for data reporting, clinical research methods, and updated endpoint definitions. New definitions or modifications of existing definitions are being proposed for repeat hospitalizations, access site-related complications, bleeding events, conduction disturbances, cardiac structural complications, and bioprosthetic valve dysfunction and failure (including valve leaflet thickening and thrombosis). A more granular 5-class grading scheme for paravalvular regurgitation (PVR) is being proposed to help refine the assessment of PVR. Finally, more specific recommendations on quality-of-life assessments have been included, which have been targeted to specific clinical study designs.Conclusions Acknowledging the dynamic and evolving nature of less-invasive aortic valve therapies, further refinements of clinical research processes are required. The adoption of these updated and newly proposed VARC-3 endpoints and definitions will ensure homogenous event reporting, accurate adjudication, and appropriate comparisons of clinical research studies involving devices and new therapeutic strategies. Show less
Aims Permanent pacemaker implantation (PPI) may be required after transcatheter aortic valve implantation (TAVI). Evidence on PPI prediction has largely been gathered from high-risk patients... Show moreAims Permanent pacemaker implantation (PPI) may be required after transcatheter aortic valve implantation (TAVI). Evidence on PPI prediction has largely been gathered from high-risk patients receiving first-generation valve implants. We undertook a meta-analysis of the existing literature to examine the incidence and predictors of PPI after TAVI according to generation of valve, valve type, and surgical risk.Methods and results We made a systematic literature search for studies with >= 100 patients reporting the incidence and adjusted predictors of PPI after TAVI. Subgroup analyses examined these features according to generation of valve, specific valve type, and surgical risk. We obtained data from 43 studies, encompassing 29 113 patients. Permanent pacemaker implantation rates ranged from 6.7% to 39.2% in individual studies with a pooled incidence of 19% (95% CI 16-21). Independent predictors for PPI were age [odds ratio (OR) 1.05, 95% confidence interval (CI) 1.01-1.09], left bundle branch block (LBBB) (OR 1.45, 95% CI 1.12-1.77), right bundle branch block (RBBB) (OR 4.15, 95% CI 3.23-4.88), implantation depth (OR 1.18, 95% CI 1.11-1.26), and self-expanding valve prosthesis (OR 2.99, 95% CI 1.39-4.59). Among subgroups analysed according to valve type, valve generation and surgical risk, independent predictors were RBBB, self-expanding valve type, first-degree atrioventricular block, and implantation depth.Conclusions The principle independent predictors for PPI following TAVI are age, RBBB, LBBB, self-expanding valve type, and valve implantation depth. These characteristics should be taken into account in pre-procedural assessment to reduce PPI rates. Show less
Faquir, N. el; Vollema, M.E.; Delgado, V.; Ren, B.; Spitzer, E.; Rasheed, M.; ... ; Mieghem, N.M. van 2020
Background The integration of computed tomography (CT)-derived left ventricular outflow tract area into the echocardiography-derived continuity equation results in the reclassification of a... Show moreBackground The integration of computed tomography (CT)-derived left ventricular outflow tract area into the echocardiography-derived continuity equation results in the reclassification of a significant proportion of patients with severe aortic stenosis (AS) into moderate AS based on aortic valve area indexed to body surface area determined by fusion imaging (fusion AVA(i)). The aim of this study was to evaluate AS severity by a fusion imaging technique in patients with low-gradient AS and to compare the clinical impact of reclassified moderate AS versus severe AS. Methods We included 359 consecutive patients who underwent transcatheter aortic valve implantation for low-gradient, severe AS at two academic institutions and created a joint database. The primary endpoint was a composite of all-cause mortality and rehospitalisations for heart failure at 1 year. Results Overall, 35% of the population (n= 126) were reclassified to moderate AS [median fusion AVAi 0.70 (interquartile range, IQR 0.65-0.80)cm(2)/m(2)] and severe AS was retained as the classification in 65% [median fusion AVAi 0.49 (IQR 0.43-0.54) cm(2)/m(2)]. Lower body mass index, higher logistic EuroSCORE and larger aortic dimensions characterised patients reclassified to moderate AS. Overall, 57% of patients had a left ventricular ejection fraction (LVEF) <50%. Clinical outcome was similar in patients with reclassified moderate or severe AS. Among patients reclassified to moderate AS, non-cardiac mortality was higher in those with LVEF <50% than in those with LVEF >= 50% (log-rankp= 0.029). Conclusions The integration of CT and transthoracic echocardiography to obtain fusion AVAi led to the reclassification of one third of patients with low-gradient AS to moderate AS. Reclassification did not affect clinical outcome, although patients reclassified to moderate AS with a LVEF <50% had worse outcomes owing to excess non-cardiac mortality. Show less
Transcatheter aortic valve replacement (TAVR) has grown exponentially worldwide in the last decade. Due to the higher bleeding risks associated with oral anticoagulation and in patients undergoing... Show moreTranscatheter aortic valve replacement (TAVR) has grown exponentially worldwide in the last decade. Due to the higher bleeding risks associated with oral anticoagulation and in patients undergoing TAVR, antiplatelet therapy is currently considered first-line antithrombotic treatment after TAVR. Recent studies suggest that some patients can develop subclinical transcatheter heart valve (THV) thrombosis after the procedure, whereby thrombus forms on the leaflets that can be a precursor to leaflet dysfunction. Compared with echocardiography, multidetector computed tomography is more sensitive at detecting THV thrombosis. Transcatheter heart valve thrombosis can occur while on dual antiplatelet therapy with aspirin and thienopyridine but significantly less with anticoagulation. This review summarizes the incidence and diagnostic criteria for THV thrombosis and discusses the pathophysiological mechanisms that may lead to thrombus formation, its natural history, potential clinical implications and treatment for these patients.[GRAPHICS]. Show less
Jaegere, P.P.T. de; Weger, A. de; Heijer, P. den; Verkroost, M.; Baan, J.; Kroon, T. de; ... ; Bruinsma, G.J.B.B. 2020
The current paper presents a position statement of the Dutch Working Group of Transcatheter Heart Valve Interventions that describes which patients with aortic stenosis should be considered for... Show moreThe current paper presents a position statement of the Dutch Working Group of Transcatheter Heart Valve Interventions that describes which patients with aortic stenosis should be considered for transcatheter aortic valve implantation and how this treatment proposal/decision should be made. Given the complexity of the disease and the assessment of its severity, in particular in combination with the continuous emergence of new clinical insights and evidence from physiological and randomised clinical studies plus the introduction of novel innovative treatment modalities, the gatekeeper of the treatment proposal/decision and, thus, of qualification for cost reimbursement is the heart team, which consists of dedicated professionals working in specialised centres. Show less
Transcatheter aortic valve replacement (TAVR) is a safe and efficient alternative for surgical valve aortic replacement in patients with symptomatic severe aortic stenosis who are inoperable or... Show moreTranscatheter aortic valve replacement (TAVR) is a safe and efficient alternative for surgical valve aortic replacement in patients with symptomatic severe aortic stenosis who are inoperable or have a high risk for surgery. Randomised clinical trials have shown that TAVR is not inferior to surgical aortic valve replacement in intermediate-risk patients and ongoing trials will demonstrate the effects of TAVR in asymptomatic severe aortic stenosis patients and in patients with heart failure and moderate aortic stenosis. Continuous developments in procedural and post-procedural management along with increased operator experience and technical improvements and ongoing advances in imaging modalities (particularly in three-dimensional techniques), have reduced the procedural risks and the incidence of complications such as paravalvular aortic regurgitation. Importantly, proper selection of both patient and prosthesis, procedural guidance and follow-up of prosthesis performance remain paramount for the success of the TAVR. In all these steps, echocardiography plays a crucial role. An overview of the clinical applications and current role of echocardiographic techniques in patient selection, prosthesis sizing, periprocedural guidance and postprocedural follow-up will be provided in this review article. Show less
Gegenava, T.; Vollema, E.M.; Rosendael, A. van; Abou, R.; Goedemans, L.; Kley, F. van der; ... ; Delgado, V. 2019
Background: After transcatheter aortic valve replacement (TAVR), changes in left ventricular (LV) function are partly influenced by the vascular afterload. The burden of thoracic aorta... Show moreBackground: After transcatheter aortic valve replacement (TAVR), changes in left ventricular (LV) function are partly influenced by the vascular afterload. The burden of thoracic aorta calcification is a component of vascular afterload.Objective: To assess changes in LV systolic function measured with global longitudinal strain (GLS) in relation to the burden of thoracic aorta calcification in patients with severe aortic stenosis treated with TAVR.Results: At baseline, patients within the first tertile of thoracic aorta calcification (0-1,395 Hounsfield Units, HU) had better LV systolic function (LV ejection fraction [LVEF], 47% +/- 9%; and LV GLS, -15% +/- 5%) as compared with the second tertile (1,396-4,634 HU; LVEF, 46% +/- 10%; and LV GLS, -14% +/- 4%), and the third tertile (>4,634 HU; LVEF, 44% +/- 10%; and LV GLS, -12% +/- 4%). During follow-up, patients within tertile 1 of calcification of thoracic aorta achieved significantly better LV systolic function and larger regression of LV mass at 12 months of follow-up than patients within the other tertiles. This pattern was more pronounced in patients with reduced LVEF at baseline.Conclusion: After TAVR, LVEF and GLS improves and LV mass index is reduced significantly at 3-6 and 12 months of follow-up. Patients within the lowest burden of thoracic aorta calcification achieved the best values of LVEF and LV GLS at 1-year follow-up. Show less
Huygens, S.A.; Kley, F. van der; Bekkers, J.A.; Bogers, A.J.J.C.; Takkenberg, J.J.M.; Rutten-van Molken, M.P.M.H. 2019
OBJECTIVES Our aim was to provide estimates of patient-reported health-related quality of life (HRQoL), use of informal care and productivity in patients after surgical aortic and pulmonary valve... Show moreOBJECTIVES Our aim was to provide estimates of patient-reported health-related quality of life (HRQoL), use of informal care and productivity in patients after surgical aortic and pulmonary valve replacement and transcatheter aortic valve implantation.METHODS Consecutive cohorts of 1239 adult patients who had surgical aortic valve replacement or surgical pulmonary valve replacement and 433 patients who had transcatheter aortic valve implantation at 2 Dutch heart centres were cross-sectionally surveyed at a median time of 2.9 and 3.2years after the intervention, respectively. The survey included questions on HRQoL (EQ-5D-5L and SF-12-v2), use of informal care and productivity in paid and unpaid work. All outcomes were compared with age and sex-matched individuals from the general population.RESULTS The response rate was 56% (n=687) of patients who had surgical valve replacement and 59% (n=257) of those who had transcatheter aortic valve implantation. Compared with the general population, patients reported poorer HRQoL on physical health domains, whereas their scores were comparable for mental health domains. After a heart valve implantation, patients reported using informal care more frequently than the general population, but labour participation was comparable. Patients with late complications [antibiotic treatment for endocarditis (n=4), stroke (n=11), transient ischaemic attack (n=15)] reported lower HRQoL, greater use of informal care and greater productivity loss than patients without complications.CONCLUSIONS Patients who had aortic and pulmonary valve implantations experience relatively mild limitations in daily life compared to the general population. The consequences of a heart valve implantations beyond clinical outcomes should be considered to create realistic patient expectations of life after a heart valve implantation and unbiased resource allocation decisions at national levels. Show less
Transcatheter heart valve interventions have transformed the outcomes of patients with valvular heart disease (VHD) who are unfavourable candidates for surgery. Technological advances have allowed... Show moreTranscatheter heart valve interventions have transformed the outcomes of patients with valvular heart disease (VHD) who are unfavourable candidates for surgery. Technological advances have allowed extension of these interventions to younger or lower risk patients and those with other forms of VHD and may in the future permit earlier treatment of VHD in less symptomatic patients or those with moderate disease. The balance of risks and benefits is likely to differ between lower and higher risk patients, and more evidence is needed to evaluate the net benefit of transcatheter technology in these groups As academic researchers clinicians industry and patient stakeholders collaborate to research these broader indications for transcatheter valve interventions, it is essential to address (i) device durability and deliverability, (ii) specific anatomical needs (e.g. bicuspid aortic valves, aortic regurgitation, mitral and tricuspid valve disease), (iii) operator training, and (iv) the reinforced importance of the multidisciplinary Heart Team. Show less
The aim of this thesis is to develop image processing solutions that enable the fully automatic pre-operative planning of aorta-related procedures, such as Trans-catheter aortic valve... Show moreThe aim of this thesis is to develop image processing solutions that enable the fully automatic pre-operative planning of aorta-related procedures, such as Trans-catheter aortic valve replacement and aorta dilatation diagnosis. Hence, the objectives of this thesis are as follows: 1. To fully automatically quantify the aorto-iliac vascular access route, including the aortic root by image processing methods in CTA. 2. To broaden the scope of automatic methods into the detection of aorta dilatation. 3. To integrate the automatic quantification methods into applications which allow manual interactions and the calculation of clinically relevant parameters. 4. To demonstrate the accuracy and feasibility of the fully automatic planning and quantification methods in different patient cohorts. Show less
