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TAVI WITH A SINGLE FEMORAL APPROACH: PRELIMINARY SINGLE-CENTRE EXPERIENCE
Abstracts
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022 DEVICE POSITION AND PREDICTORS OF INCOMPLETE OCCLUSION AFTER LEFT ATRIAL APPENDAGE CLOSURE: INSIGHTS FROM 3D MULTI-SLICE COMPUTED TOMOGRAPHY FUSION IMAGING M Spaziano, L Fernandez Lopez, E Bouvier, J Horvilleur, P Garot Montréal, Québec BACKGROUND:
Incomplete occlusion (IO) after left atrial appendage closure is common and may be associated to adverse outcomes. Post-procedural MSCT is a valuable tool to evaluate the presence of IO, but assessment of final device position compared to planned position can be challenging. Fusion of pre- and post procedural MSCT provides better spatial orientation and may provide insight into mechanisms of IO. METHODS: A total of 36 patients had pre- and post-procedural MSCT (median 97 days after the procedure, IQR: 87 - 142 days) in our center. For each patient both pre- and postprocedural MSCTs were fused in a unique volume using AW VolumeShare 7 software (GE Healthcare) and analyzed for the presence and mechanisms of IO. Planned and achieved device positions were compared (Fig1). RESULTS: Twelve patients (33%) had IO, defined as contrast enhancement of the LAA behind device (a cutoff of 150 Hounsfield units difference between LA and LAA was used, along with a semi-quantitative visual appreciation). Of 30 Amulet patients, 9 had IO (30%), versus 3 of 6 Watchman patients (50%) (p¼NS). Device position was in a significantly larger area than planned. The area of the achieved landing zone was, on average, 29% larger than the planned landing zone (p < 0.0001). Consequently, planned versus achieved area oversizing were significantly different (37% vs. 10%; p¼0.05). In patients with IO, device area oversizing at achieved landing zone was lower than those without IO (2% vs. 16%), but this difference did not reach statistical significance (p¼0.14). In patients with IO, device orientation was significantly different from planned orientation (angle between planned and achieved position: 21 11 ; p¼0.0002). In these patients, the distance between planned and achieved landing zone ranged from 0.7 to 12.6 mm. The mechanisms of IO included the following: disk malapposition (n¼6), disk partially inside LAA (n¼2), lobe protrusion outside LAA (n¼2), device off-axis compared to neck of LAA (n¼1), unclear (n¼3). For the Amulet device, patients with IO had a significantly wider angle between the lobe and the disk (9.1 vs. 16.1 ; p¼0.03). CONCLUSION: As the LAA is a complex three-dimensional structure, closure devices do not necessarily position themselves as intended. Rather, they seem to follow a “path of least resistance”, and position themselves in way that results in lessthan-intended oversizing, which may have an impact on the occurrence of IO.
023 TAVI WITH A SINGLE FEMORAL APPROACH: PRELIMINARY SINGLE-CENTRE EXPERIENCE M Spaziano, L Fernandez Lopez, F Sawaya, H Benamer, B Chevalier, T Lefevre, P Garot, T Hovasse Montréal, Québec BACKGROUND:
To describe our initial experience with the transradial approach as secondary access site in TAVI. METHODS: As of April 2016, a strategy of systematic transradial approach as secondary access site for TAVI was adopted in our centre. A 5 F 125 cm multipurpose catheter was navigated from the left or right radial artery into the common iliac artery to assist in main access puncture. The catheter was then exchanged for a pigtail, which was positioned on the aortic valve to guide TAVI. The multipurpose catheter was used again at the end of the procedure to assess ilio-femoral integrity. In case of an iliac or femoral access complication, the radial sheath was exchanged for a 120 cm long 5F sheath. A 0.018’/400 cm nitinol guidewire was introduced beyond the lesion and a compatible long shaft (180 cm) 5F balloon or nitinol self-expandable stent was introduced and used accordingly. In case of a perforation, a balloon was inflated proximal to the lesion in order to stop the bleeding and contralateral femoral access was obtained in order to deploy a covered stent via a 6F sheath. RESULTS: From April 2016, 184 patients underwent TAVI using this strategy. Patients had a mean age of 835.9 years, 52.2% were male, mean Logistic Euroscore and STS score were 16.511.6% and 5.34.7%, respectively. 97 (52.7%) patients received a balloon-expandable valve and 87 (47.3%) received a self-expandable valve. Transradial access as secondary approach was not used in 30 of 184 patients (16.3%) for the following reasons: absence of radial pulse or unsuitable artery size (n¼14; 7.6%), prohibitive patient height (n¼1; 0.8%), physician preference n¼15; 8.1%). TAVI was successful in all cases. No complications occurred due to transradial access. Transfemoral vascular access site complications occurred in 8 cases (4.3 %): three
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occlusion, two flow-limiting stenoses and three perforations of the common femoral artery. Five complications were successfully managed using self-expanding stents from the transradial access. The 3 cases of perforation (1.6%) were successfully treated with a covered stent delivered via femoral crossover. There were no additional major vascular complications at 30 days. CONCLUSION: Use of the radial approach for secondary access in TAVI is safe and feasible. Most primary access site complications were manageable from the radial access site. A low rate of crossover to the contralateral femoral approach (1.6 %) was necessary. Further large-scale studies are necessary to confirm the benefits of this approach.
024 PROGNOSTIC IMPACT OF PRE AND POSTPROCEDURAL CARDIAC BIOMARKERS FOR TRANSCATHETER AORTIC VALVE IMPLANTATION M Spaziano, M Akodad, B Chevalier, T Hovasse, H Benamer, P Garot, T Lefevre Montréal, Québec BACKGROUND:
Both pre- and post-procedural cardiac biomarkers (troponin and NT-pro-BNP) were advocated as independent prognostic factors after transcatheter aortic valve implantation (TAVI), with an increased 1-month and 1-year mortality, but with contradictory results. The aim of this study was to assess the prognostic impact of these biomarkers in a large single-centre prospective TAVI database. METHODS: All consecutive patients undergoing TAVI at our institution between October 2006 and October 2015 were included prospectively. Pre-procedural troponin and NT-proBNP were assessed the day before the procedure and postprocedural measurements were performed the day after the procedure. These measurements were included in a Cox proportional hazards model along with other pre-procedural variables. Key endpoints were mortality at 1 month and 1 year. RESULTS: In total, 1390 patients were included in this study (66.8% transfemoral). Mean age was 83.436.8 years and 47.7% were female. Mean logistic EuroScore was 17.3 11.0%. Median pre- and post-procedural troponin levels were 0.33 ng/L (interquartile range: 0.02 - 2.90) and 0.25 ng/L (0.14 - 2.85), respectively (paired Wilcoxon test: p¼0.26). Median pre- and post-procedural NT-pro-BNP level were 1878 XXX (interquartile range: 739 - 4141) and 1714 XXX (684 - 4277), respectively (paired Wilcoxon test: p¼0.59). Mortality at 1 month and 1 year were 6.3% (n¼87) and 13.9 %(n¼190), respectively. Pre-procedural troponin was a predictor of 1-year mortality (HR¼ 1.07 per increase in 1 ng/ L; p¼0.021) but not of 1-month mortality. After adjustment for the logistic Euroscore, pre-procedural troponin remained an independent predictor of 1-year mortality (HR: 1.05 per increase in 1 ng/L; p¼0.05). Post-procedural troponin, change in troponin, pre- and post-procedural NT-pro-BNP
Canadian Journal of Cardiology Volume 33 2017
were not predictive of mortality (all p¼ns). Four independent predictors of elevated pre-procedural troponin levels were identified: elevated pre-procedural BNP levels, male sex, atrial fibrillation and low glomerular filtration rate. CONCLUSION: Pre-procedural troponin is associated with 1year mortality after TAVI. This measurement could be performed to further risk-stratify patients before the procedure.
Canadian Cardiovascular Society (CCS) ePosters NEW TOOLS TO ENHANCE EDUCATION IN CARDIOVASCULAR DISEASE: HOW ARE WE DOING NOW AND WHAT DOES THE FUTURE HOLD? Saturday, October 21, 2017 025 NOVEL TECHNOLOGY-ENABLED PHARMACIST AND PATIENT EDUCATION PROGRAM ENHANCES ADHERENCE TO STROKE PREVENTION MEDICATIONS K Leblanc, A Jaffer, J Papastergiou, B Semchuk Toronto, Ontario
Atrial fibrillation (AF), the most common heart rhythm disturbance in Canadians, increases the risk of fatal and permanently disabling stroke. Antithrombotic treatment decreases this risk by up to 65%. The Canadian Cardiovascular Society (CCS) AF guidelines indicate that Non-vitamin K oral anticoagulants (NOACs) are the preferred agents for stroke prevention in eligible patients. Optimizing the protection conferred by these agents requires both high adherence and persistence. Registries and claims database evaluations indicate that persistence rates with NOACs range from 60% to over 90%; decreases in persistence have been associated with increased stroke and death. METHODS: Pharmacists were invited to participate in a webbased education program, PAACT-AF, with the goal of helping counsel and educate patients with AF taking NOACS. Pharmacists were asked to assess up to 20 patients each, and for each patient a structured questionnaire measured knowledge and adherence. The platform outputted a counselling checklist based on the individual patient being assessed. Patients were followed for 1-4 months and a subsequent questionnaire was completed. Medication adherence was calculated using Medication Possession Ratio (MPR), the sum of day’s supply for all fills in a period over the number of days in the period. RESULTS: Upon interim data analysis (April 2017), 70 pharmacists from 6 provinces (AB, BC, NB, NS, ON, QC) had participated in the program. 338 patients were counselled at an initial assessment, 242 returned for a follow-up assessment (72%). Patient knowledge of AF and NOAC use was assessed using five different questions, and all areas of patient BACKGROUND:
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022 DEVICE POSITION AND PREDICTORS OF INCOMPLETE OCCLUSION AFTER LEFT ATRIAL APPENDAGE CLOSURE: INSIGHTS FROM 3D MULTI-SLICE COMPUTED TOMOGRAPHY FUSION IMAGING M Spaziano, L Fernandez Lopez, E Bouvier, J Horvilleur, P Garot Montréal, Québec BACKGROUND:
Incomplete occlusion (IO) after left atrial appendage closure is common and may be associated to adverse outcomes. Post-procedural MSCT is a valuable tool to evaluate the presence of IO, but assessment of final device position compared to planned position can be challenging. Fusion of pre- and post procedural MSCT provides better spatial orientation and may provide insight into mechanisms of IO. METHODS: A total of 36 patients had pre- and post-procedural MSCT (median 97 days after the procedure, IQR: 87 - 142 days) in our center. For each patient both pre- and postprocedural MSCTs were fused in a unique volume using AW VolumeShare 7 software (GE Healthcare) and analyzed for the presence and mechanisms of IO. Planned and achieved device positions were compared (Fig1). RESULTS: Twelve patients (33%) had IO, defined as contrast enhancement of the LAA behind device (a cutoff of 150 Hounsfield units difference between LA and LAA was used, along with a semi-quantitative visual appreciation). Of 30 Amulet patients, 9 had IO (30%), versus 3 of 6 Watchman patients (50%) (p¼NS). Device position was in a significantly larger area than planned. The area of the achieved landing zone was, on average, 29% larger than the planned landing zone (p < 0.0001). Consequently, planned versus achieved area oversizing were significantly different (37% vs. 10%; p¼0.05). In patients with IO, device area oversizing at achieved landing zone was lower than those without IO (2% vs. 16%), but this difference did not reach statistical significance (p¼0.14). In patients with IO, device orientation was significantly different from planned orientation (angle between planned and achieved position: 21 11 ; p¼0.0002). In these patients, the distance between planned and achieved landing zone ranged from 0.7 to 12.6 mm. The mechanisms of IO included the following: disk malapposition (n¼6), disk partially inside LAA (n¼2), lobe protrusion outside LAA (n¼2), device off-axis compared to neck of LAA (n¼1), unclear (n¼3). For the Amulet device, patients with IO had a significantly wider angle between the lobe and the disk (9.1 vs. 16.1 ; p¼0.03). CONCLUSION: As the LAA is a complex three-dimensional structure, closure devices do not necessarily position themselves as intended. Rather, they seem to follow a “path of least resistance”, and position themselves in way that results in lessthan-intended oversizing, which may have an impact on the occurrence of IO.
023 TAVI WITH A SINGLE FEMORAL APPROACH: PRELIMINARY SINGLE-CENTRE EXPERIENCE M Spaziano, L Fernandez Lopez, F Sawaya, H Benamer, B Chevalier, T Lefevre, P Garot, T Hovasse Montréal, Québec BACKGROUND:
To describe our initial experience with the transradial approach as secondary access site in TAVI. METHODS: As of April 2016, a strategy of systematic transradial approach as secondary access site for TAVI was adopted in our centre. A 5 F 125 cm multipurpose catheter was navigated from the left or right radial artery into the common iliac artery to assist in main access puncture. The catheter was then exchanged for a pigtail, which was positioned on the aortic valve to guide TAVI. The multipurpose catheter was used again at the end of the procedure to assess ilio-femoral integrity. In case of an iliac or femoral access complication, the radial sheath was exchanged for a 120 cm long 5F sheath. A 0.018’/400 cm nitinol guidewire was introduced beyond the lesion and a compatible long shaft (180 cm) 5F balloon or nitinol self-expandable stent was introduced and used accordingly. In case of a perforation, a balloon was inflated proximal to the lesion in order to stop the bleeding and contralateral femoral access was obtained in order to deploy a covered stent via a 6F sheath. RESULTS: From April 2016, 184 patients underwent TAVI using this strategy. Patients had a mean age of 835.9 years, 52.2% were male, mean Logistic Euroscore and STS score were 16.511.6% and 5.34.7%, respectively. 97 (52.7%) patients received a balloon-expandable valve and 87 (47.3%) received a self-expandable valve. Transradial access as secondary approach was not used in 30 of 184 patients (16.3%) for the following reasons: absence of radial pulse or unsuitable artery size (n¼14; 7.6%), prohibitive patient height (n¼1; 0.8%), physician preference n¼15; 8.1%). TAVI was successful in all cases. No complications occurred due to transradial access. Transfemoral vascular access site complications occurred in 8 cases (4.3 %): three
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occlusion, two flow-limiting stenoses and three perforations of the common femoral artery. Five complications were successfully managed using self-expanding stents from the transradial access. The 3 cases of perforation (1.6%) were successfully treated with a covered stent delivered via femoral crossover. There were no additional major vascular complications at 30 days. CONCLUSION: Use of the radial approach for secondary access in TAVI is safe and feasible. Most primary access site complications were manageable from the radial access site. A low rate of crossover to the contralateral femoral approach (1.6 %) was necessary. Further large-scale studies are necessary to confirm the benefits of this approach.
024 PROGNOSTIC IMPACT OF PRE AND POSTPROCEDURAL CARDIAC BIOMARKERS FOR TRANSCATHETER AORTIC VALVE IMPLANTATION M Spaziano, M Akodad, B Chevalier, T Hovasse, H Benamer, P Garot, T Lefevre Montréal, Québec BACKGROUND:
Both pre- and post-procedural cardiac biomarkers (troponin and NT-pro-BNP) were advocated as independent prognostic factors after transcatheter aortic valve implantation (TAVI), with an increased 1-month and 1-year mortality, but with contradictory results. The aim of this study was to assess the prognostic impact of these biomarkers in a large single-centre prospective TAVI database. METHODS: All consecutive patients undergoing TAVI at our institution between October 2006 and October 2015 were included prospectively. Pre-procedural troponin and NT-proBNP were assessed the day before the procedure and postprocedural measurements were performed the day after the procedure. These measurements were included in a Cox proportional hazards model along with other pre-procedural variables. Key endpoints were mortality at 1 month and 1 year. RESULTS: In total, 1390 patients were included in this study (66.8% transfemoral). Mean age was 83.436.8 years and 47.7% were female. Mean logistic EuroScore was 17.3 11.0%. Median pre- and post-procedural troponin levels were 0.33 ng/L (interquartile range: 0.02 - 2.90) and 0.25 ng/L (0.14 - 2.85), respectively (paired Wilcoxon test: p¼0.26). Median pre- and post-procedural NT-pro-BNP level were 1878 XXX (interquartile range: 739 - 4141) and 1714 XXX (684 - 4277), respectively (paired Wilcoxon test: p¼0.59). Mortality at 1 month and 1 year were 6.3% (n¼87) and 13.9 %(n¼190), respectively. Pre-procedural troponin was a predictor of 1-year mortality (HR¼ 1.07 per increase in 1 ng/ L; p¼0.021) but not of 1-month mortality. After adjustment for the logistic Euroscore, pre-procedural troponin remained an independent predictor of 1-year mortality (HR: 1.05 per increase in 1 ng/L; p¼0.05). Post-procedural troponin, change in troponin, pre- and post-procedural NT-pro-BNP
Canadian Journal of Cardiology Volume 33 2017
were not predictive of mortality (all p¼ns). Four independent predictors of elevated pre-procedural troponin levels were identified: elevated pre-procedural BNP levels, male sex, atrial fibrillation and low glomerular filtration rate. CONCLUSION: Pre-procedural troponin is associated with 1year mortality after TAVI. This measurement could be performed to further risk-stratify patients before the procedure.
Canadian Cardiovascular Society (CCS) ePosters NEW TOOLS TO ENHANCE EDUCATION IN CARDIOVASCULAR DISEASE: HOW ARE WE DOING NOW AND WHAT DOES THE FUTURE HOLD? Saturday, October 21, 2017 025 NOVEL TECHNOLOGY-ENABLED PHARMACIST AND PATIENT EDUCATION PROGRAM ENHANCES ADHERENCE TO STROKE PREVENTION MEDICATIONS K Leblanc, A Jaffer, J Papastergiou, B Semchuk Toronto, Ontario
Atrial fibrillation (AF), the most common heart rhythm disturbance in Canadians, increases the risk of fatal and permanently disabling stroke. Antithrombotic treatment decreases this risk by up to 65%. The Canadian Cardiovascular Society (CCS) AF guidelines indicate that Non-vitamin K oral anticoagulants (NOACs) are the preferred agents for stroke prevention in eligible patients. Optimizing the protection conferred by these agents requires both high adherence and persistence. Registries and claims database evaluations indicate that persistence rates with NOACs range from 60% to over 90%; decreases in persistence have been associated with increased stroke and death. METHODS: Pharmacists were invited to participate in a webbased education program, PAACT-AF, with the goal of helping counsel and educate patients with AF taking NOACS. Pharmacists were asked to assess up to 20 patients each, and for each patient a structured questionnaire measured knowledge and adherence. The platform outputted a counselling checklist based on the individual patient being assessed. Patients were followed for 1-4 months and a subsequent questionnaire was completed. Medication adherence was calculated using Medication Possession Ratio (MPR), the sum of day’s supply for all fills in a period over the number of days in the period. RESULTS: Upon interim data analysis (April 2017), 70 pharmacists from 6 provinces (AB, BC, NB, NS, ON, QC) had participated in the program. 338 patients were counselled at an initial assessment, 242 returned for a follow-up assessment (72%). Patient knowledge of AF and NOAC use was assessed using five different questions, and all areas of patient BACKGROUND: