- Email: [email protected]
TCT-386 Outcome of TAVR procedures in patients with severely impaired left ventricular ejection fraction
B158
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 70, NO. 18, SUPPL B, 2017
TCT-384 The Myocardial Contraction Fraction Predicts Adverse Events after Aortic Valve Replacement: An Analysis of 3,259 Patients from the Pooled PARTNER 2 Database Mahesh Madhavan,1 Matthew Maurer,2 Bjorn Redfors,3 Wael Jaber,4 Philippe Pibarot,5 Pamela Douglas,6 Raj Makkar,7 Vinod Thourani,8 Howard Herrmann,9 Nimesh Desai,10 Michael Mack,11 Sammy Elmariah,12 William Fearon,13 Brian Lindman,14 Philipp Blanke,15 Jonathon Leipsic,15 Yiran Zhang,3 Thomas McAndrew,3 Maria Alu,16 Susheel Kodali,17 Martin Leon,18 Rebecca Hahn19 1 New York-Presbyterian Hospital/ Columbia University Medical Center, New York, New York, United States; 2Columbia University Medical Center; 3Cardiovascular Research Foundation, New York, New York, United States; 4MUW; 5Quebec Heart and Lung Institute, Quebec City, Quebec, Canada; 6Duke Clinical Research Institute, Durham, North Carolina, United States; 7Cedars-Sinai Medical Center, Los Angeles, California, United States; 8Emory University Hospital Midtown, Atlanta, Georgia, United States; 9University of Pennsylvania, Philadelphia, Pennsylvania, United States; 10University of Pennsylvannia, Philadelphia, Pennsylvania, United States; 11The Heart Hospital Baylor Plano, Plano, Texas, United States; 12Massachusetts General Hospital, Boston, Massachusetts, United States; 13Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, United States; 14Vanderbilt University, Nashville, Tennessee, United States; 15Centre for Heart Valve Innovation, St. Paul’s and Vancouver General Hospital, Vancouver, British Columbia, Canada; 16Columbia University Medical Center, Chicago, Illinois, United States; 17Columbia, Hastings on Hudson, New York, United States; 18Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York, United States; 19New York-Presbyterian Hospital, New York, New York, United States BACKGROUND Myocardial contraction fraction (MCF; stroke volume O myocardial volume) has outperformed ejection fraction (EF) in several clinical settings. We sought to assess the relationship between MCF and adverse events after valve replacement (VR) for severe aortic stenosis (AS). METHODS Baseline MCF, EF, and stroke volume index (SVI) were assessed before transcatheter and surgical aortic VR in a pooled database of intermediate risk, high risk, and inoperable patients enrolled in the PARTNER 2 study. Patients were grouped by MCF, EF, and SVI quartiles, and event rates after VR were calculated. The primary composite endpoint was all-cause death, rehospitalization, and stroke at two years. Cox proportional hazard modeling (stratified by study) was performed to assess whether the MCF, EF, and SVI (as continuous variables) were independently associated with two-year adverse event rates. C-statistics were calculated to determine predictive utility of these parameters. RESULTS In 3,259 patients who underwent VR with the SAPIEN, SAPIEN XT, SAPIEN3, and surgical bioprosthetic valves, there were significant overall trends for the primary endpoint, all-cause death, rehospitalization, and cardiac death by MCF and EF quartiles. Allcause death was significant by SVI quartiles. By multivariable analysis, the MCF (HR 0.51 [0.30,0.87], p¼0.01) and EF (HR 0.92 [0.88, 0.97, p¼0.002]) were significantly associated with two-year rates of the primary endpoint, but SVI was not. C-statistics for association with the primary endpoint were as follows: MCF: (0.55 [0.53,0.58]), EF: (0.55 [0.53,0.57]), and SVI: (0.52 [0.50,0.54]). C-statistics for EF and MCF did not differ significantly, but both had stronger associations with the primary endpoint compared with SVI (p¼0.01 and p¼0.03, respectively). MCF also was independently associated with two-year rates of rehospitalization and stroke, and EF with two-year rates of all-cause death and rehospitalization. CONCLUSION MCF and EF predicted long-term adverse events in this large study of intermediate or higher risk patients undergoing VR for severe AS. Further studies evaluating the prognostic utility of MCF as a risk-stratifying tool in patients with severe AS are indicated. CATEGORIES IMAGING: Imaging: Non-Invasive TCT-385 Prognostic Value of Right Ventricular Dysfunction on Clinical Outcomes Following Transcatheter Aortic Valve Replacement Masahiko Asami,1 Stefan Stortecky,2 Fabien Praz,3 Jonas Lanz,4 Joe Lee,1 Raffaele Piccolo,1 George Siontis,5 Dik Heg,6 Ernest Spitzer,7 Eva Roost,8 Stephan Windecker,2 Thomas Pilgrim9 1 Swiss Cardiovascular Center, Inselspital, Bern University Hospital, Bern, Switzerland; 2University Hospital Bern, Bern, Switzerland;
3 Columbia University Medical Center, New York City, New York, United States; 4Inselspital Bern, Bern, Switzerland; 5University Hospital of Bern, Bern, Switzerland; 6Clinical Trials Unit, Department of Clinical Research, Institute of Social and, Bern, Switzerland; 7Erasmus MC, Rotterdam, Netherlands; 8Department of Cardiac Surgery, Swiss Cardiovascular Center, Bern University Hospital, Bern, Switzerland; 9 Bern University Hospital, Berne, Switzerland
BACKGROUND There is limited evidence on the impact of right ventricular dysfunction (RVD) on clinical outcomes after transcatheter aortic valve replacement (TAVR). The objective of the present analysis was to investigate the association between RVD and all-cause mortality after TAVR. METHODS A total of 1116 TAVR patients underwent detailed preoperative assessment of RV function, and were dichotomized into two groups (RVD vs. normal RV function). RVD was assessed by use of fractional area change (<35%), tricuspid annular plane systolic excursion (<1.7cm), and systolic movement of the RV lateral wall by tissue Doppler (<9.5cm/s). The primary outcome was all-cause mortality at 1-year. RESULTS RVD was found in 325 (29.1%) patients. Patients with RVD were younger compared to patients with normal RV function (81.37.1 years vs. 82.55.5 years, p¼0.002), more commonly male (56.6% vs. 45.8%, p¼0.001), more commonly in NYHA functional class III/IV (76.2% vs. 64.1%, p<0.001), and had a higher STS score (7.24.7% vs. 5.63.9%, p<0.001), lower left ventricular ejection fraction (45.116.5% vs. 56.612.5%, p<0.001), and a higher brain natriuretic peptide prior to intervention (1165.01342.2 pg/ml vs. 522.4704.5 pg/ ml, p<0.001). There were no significant differences with regard to access route or valve type used between the two groups. After adjustment for comorbidities, patients with RVD had a higher risk of death at 1 year as compared to patients with normal RV function (26.2% vs 11.1%, HRadj 2.48, 95% CI 1.82-3.38, p<0.001). The difference emerged within the first 30 days after TAVR (9.9% vs. 2.7%, HRadj 4.09, 95% CI 2.33-7.18, p<0.001) and was driven by a difference in cardiovascular death (9.0% vs. 2.2%, HRadj 4.62, 95% CI 2.51-8.50, p<0.001). In a multivariable analysis, RVD was the strongest independent predictor of 1-year mortality (HRadj 2.20, 95% CI 1.54-3.31), followed by diabetes (HRadj 1.89, 95% CI 1.34-2.67), and history of cerebrovascular events (HRadj 1.73, 95% CI 1.13-2.65). CONCLUSION RVD at baseline was associated with a more than twofold increased risk of all-cause mortality at 1 year after TAVR. CATEGORIES STRUCTURAL: Valvular Disease: Aortic TCT-386 Outcome of TAVR procedures in patients with severely impaired left ventricular ejection fraction Tobias Schmidt,1 Jury Schewel,1 Michael Schlüter,2 Hannes Alessandrini,3 Michael Schmoeckel,1 Karl-Heinz Kuck,1 Christian Frerker1 1 Asklepios Klinik St. Georg, Hamburg, Germany; 2Asklepios proresearch, Hamburg, Germany; 3Asklepios Hospital, Hamburg, Germany BACKGROUND Only limited data exists for transcatheter aortic valve replacement (TAVR) in patients with severe aortic stenosis (AS) and severely reduced left ventricular ejection fraction (LVEF). We report on TAVR procedures in patients with severe AS and LVEF 20%. METHODS 1505 TAVR procedures were performed between 07/2008 and 07/2016 at our center. 33 patients (mean age 797 years; 24 men; median logisticEuroSCORE (log.ES) 38% (interquantil range 24;63); NYHA II, III and IV in 4, 15 and 14 pts, respectively) had a LVEF 20%. Access way was mainly transfemoral with 91% (30/33). RESULTS Echocardiographic mean LVEF increased from 192% before the procedure to 2711% (p¼0.0001) at discharge. Right heart catheterization showed an increase in cardiac output (CO) from 3.91.0 to 4.31.2l/min (p¼0.0048) and stroke volume (SV) from 5620 to 6218ml (p¼0.028). Transvalvular aortic gradient decreased from 2912mmHg to 63mmHg (mean gradient) and 3118mmHg to 12mmHg (peak-to-peak gradient; both p¼0.0001). Device success was achieved in 94% (31/33). Two patients died during or <72h after the procedure. Overall 8 patients (24%) were in cardiogenic shock before the procedure. Patients were followed for a median of 4.8 (IQR, 1.2-16.3) months. 30-day mortality was 18% (6/33), while 4 of these patients were in cardiogenic shock prior to the procedure. Separating patients to higher and lower than the median log.ES of 38%, 30-day mortality is 0% (0/16) for patients with log.ES <38 compared to 37.5% (6/16) with log.ES 38 (one patient missing for 30-day follow up). CONCLUSION TAVR in patients with severe AS and severe reduced LVEF show high 30-day mortality. 30-day mortality was driven by
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 70, NO. 18, SUPPL B, 2017
collateral quality decay
Collateral quality decay
Collateral quality improvement
LVEF B
LVEF 4M
LVEDV B
LVEDV
(%)
(%)
p-value
(ml)
4M (ml)
p-value
41.1
45.5
0.022*
232.4
208 [171-
0.845*
[29.8-
[35.3-
[189-265]
252]
47.3]
55.0]
21.4 [7.6-
36.2
21.4]
[27.9-
0.180
ˇ
CATEGORIES STRUCTURAL: Valvular Disease: Aortic
Table 1. CMR measurements at baseline (B) and 4 month (4m) follow-up in patients with and without
312.1[305-
271.8
312]
[193-359]
190 [166-
205 [169-
247]
245]
0.180
ˇ
cardiogenic shock and high log.ES. Indication for TAVR in these patients (high log.ES and cardiogenic shock) needs to be intensively discussed before the procedure specifically for each patient. Patients with lower log.ES seem to have a low 30-day mortality. High device success shows that the procedure in this very sick patient population is feasible and safe. Overall, echocardiographic LVEF and hemodynamic CO and SV improved directly after TAVR despite very sick patients with severe reduced LV function.
B159
47.8] No collateral quality change
OUTCOMES AFTER PRIMARY PCI - II
43.4
45.1
[32.6-
[37.6-
51.1]
52.3]
0.006#
0.063#
ˇ
*n¼18, n¼2, #n¼67
Abstract nos: 387 - 391 TCT-387 Collateral quality decay several days after primary PCI: a novel observation from the EXPLORE trial. Ivo M. van Dongen,1 Joelle Elias,2 K. Gert van Houwelingen,3 Pierfrancesco Agostoni,4 Bimmer EPM Claessen,1 Loes P. Hoebers,1 Dagmar Ouweneel,5 Rene van der Schaaf,6 Jan Tijssen,7 Jose PS Henriques1 1 Academic Medical Center - University of Amsterdam, Amsterdam, Netherlands; 2Academic Medical Centre (AMC) - University of Amsterdam, Amsterdam, Netherlands; 3Thoraxcentrum Twente, MST Enschede, Enschede, Netherlands; 4Department of Cardiology, St. Antonius Ziekenhuis, Nieuwegein, Netherlands; 5Academic Medical Center - University of Amsterdam, Amsterdam, Netherlands; 6OLVG, Amsterdam, Netherlands; 7AMC, Naarden, Netherlands BACKGROUND Collaterals towards a concomitant CTO are associated with improved outcome.In the EXPLORE trial, a novel observation was encountered: a decrease in collateral quality to the CTO right before CTO PCI. We have assessed the impact of this on functional and clinical outcome. METHODS All angiograms were corelab analyzed.Well-developed (Rentrop grade 2-3) and poorly-developed (grade 0-1) collaterals were identified.LVF was measured with CMR.Long-term follow-up (median 3.9 years) was collected prospectively. RESULTS Before CTO PCI, a decay in collateral quality compared to primary PCI was observed in 34 of patients randomized to CTO PCI, and in 4 patients an increase was seen.CMR outcomes are shown in table 1.KM curves of MACE and all-cause death are shown in figure 1.
CONCLUSION An unique notion was made in the EXPLORE trial: 23.1% of patients with well-developed collaterals to the CTO during STEMI PCI show quality decay of the collateralization within one week.This is associated with a modest difference in cardiac function and long-term outcomes (mainly MACE) compared to patients without any change in collateral quality, which could suggest that the capability to improve quality of collaterals to a CTO during STEMI may have a protective role.However, this should be further investigated in a larger CTO population. CATEGORIES CORONARY: PCI Outcomes TCT-388 Does ST Segment Elevation in Lead aVR Correlate with Left Main Occlusion? Ahmed Harhash,1 Sridhar Reddy,1 Jennifer Huang-Tsang,1 Balaji Natarajan,1 Mahesh Balakrishnan,1 Ranjith Shetty,1 Mathew Hutchinson,1 Karl Kern2 1 University of Arizona, Tucson, Arizona, United States; 2Univ of Arizona, Tucson, Arizona, United States BACKGROUND Prompt identification of ST-elevation myocardial infarction (STEMI) on ECG is critical as early reperfusion can be lifesaving. The ACCF/AHA guidelines established that ST elevation (STE) must be present in at least 2 contiguous leads to qualify for a diagnosis of STEMI. STE in aVR, co-existent with multi-lead ST depression (STD), was endorsed as a sign for left main (LM) or proximal LAD occlusion. Previous studies have described the association of multivessel disease with STD in the inferolateral leads with reciprocal STE in aVR. We sought to investigate the incidence of an acutely occluded vessel (i.e. STEMI) versus severe multi-vessel CAD without a total occlusion (i.e. NSTEMI) in patients (pts) presenting with STE-aVR. METHODS STEMI activations between January 2014 and November 2016 were identified by retrospective chart review. Patients with admission ECG showing STE-aVR co-existent with multi-lead STD were enrolled. All ECGs and coronary angiograms were blindly analyzed by experienced cardiologists. Patients’ demographics, presenting complaint, labs, hospital course, and in-hospital mortality were collected. Descriptive analysis was performed using STATA 12.0. RESULTS Among 604 STEMI activations, 66 pts (11%) were identified with STE-aVR. Of those, 24 (36%) presented with cardiac arrest, and 53 (80%) underwent emergent coronary angiography. Culprit coronary occlusion was identified in only 5 pts (9%). Thirty-four pts (64%) were found to have severe diffuse CAD but with distal TIMI 3 flow and 19 pts (36%) had mild or no disease. It was unclear whether the occlusion was acute or chronic in 3 pts. STE-aVR was associated with 32% inhospital mortality, compared to only 6.2% in a 190 randomly sampled STEMIs in the same study period(p<0.001). CONCLUSION STE-aVR was associated with acutely thrombotic coronary occlusion in only 9% of pts. These patients had a five-fold higher in-hospital mortality compared to the overall STEMI population. Majority had severe diffuse disease with extensive comorbidities and prior PCI or CABG. Urgent cardiology evaluation is warranted but routine STEMI activation based on this ECG finding alone should be reconsidered in pts presenting with critical illness. CATEGORIES CORONARY: Acute Coronary Syndromes TCT-389 Does well-developed coronary collateral circulation have an influence on myocardial viability in late presentation myocardial infarction? Alejandro Gutierrez-Barrios,1 Dolores Cañadas,2 Enrique Diaz-Retamino,3 German Calle Perez,4 Rafael Vázquez-García1 1 Hospital Puerta del Mar, Cádiz, Spain; 2Hospital de Jerez, Jerez de la
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 70, NO. 18, SUPPL B, 2017
TCT-384 The Myocardial Contraction Fraction Predicts Adverse Events after Aortic Valve Replacement: An Analysis of 3,259 Patients from the Pooled PARTNER 2 Database Mahesh Madhavan,1 Matthew Maurer,2 Bjorn Redfors,3 Wael Jaber,4 Philippe Pibarot,5 Pamela Douglas,6 Raj Makkar,7 Vinod Thourani,8 Howard Herrmann,9 Nimesh Desai,10 Michael Mack,11 Sammy Elmariah,12 William Fearon,13 Brian Lindman,14 Philipp Blanke,15 Jonathon Leipsic,15 Yiran Zhang,3 Thomas McAndrew,3 Maria Alu,16 Susheel Kodali,17 Martin Leon,18 Rebecca Hahn19 1 New York-Presbyterian Hospital/ Columbia University Medical Center, New York, New York, United States; 2Columbia University Medical Center; 3Cardiovascular Research Foundation, New York, New York, United States; 4MUW; 5Quebec Heart and Lung Institute, Quebec City, Quebec, Canada; 6Duke Clinical Research Institute, Durham, North Carolina, United States; 7Cedars-Sinai Medical Center, Los Angeles, California, United States; 8Emory University Hospital Midtown, Atlanta, Georgia, United States; 9University of Pennsylvania, Philadelphia, Pennsylvania, United States; 10University of Pennsylvannia, Philadelphia, Pennsylvania, United States; 11The Heart Hospital Baylor Plano, Plano, Texas, United States; 12Massachusetts General Hospital, Boston, Massachusetts, United States; 13Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, United States; 14Vanderbilt University, Nashville, Tennessee, United States; 15Centre for Heart Valve Innovation, St. Paul’s and Vancouver General Hospital, Vancouver, British Columbia, Canada; 16Columbia University Medical Center, Chicago, Illinois, United States; 17Columbia, Hastings on Hudson, New York, United States; 18Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York, United States; 19New York-Presbyterian Hospital, New York, New York, United States BACKGROUND Myocardial contraction fraction (MCF; stroke volume O myocardial volume) has outperformed ejection fraction (EF) in several clinical settings. We sought to assess the relationship between MCF and adverse events after valve replacement (VR) for severe aortic stenosis (AS). METHODS Baseline MCF, EF, and stroke volume index (SVI) were assessed before transcatheter and surgical aortic VR in a pooled database of intermediate risk, high risk, and inoperable patients enrolled in the PARTNER 2 study. Patients were grouped by MCF, EF, and SVI quartiles, and event rates after VR were calculated. The primary composite endpoint was all-cause death, rehospitalization, and stroke at two years. Cox proportional hazard modeling (stratified by study) was performed to assess whether the MCF, EF, and SVI (as continuous variables) were independently associated with two-year adverse event rates. C-statistics were calculated to determine predictive utility of these parameters. RESULTS In 3,259 patients who underwent VR with the SAPIEN, SAPIEN XT, SAPIEN3, and surgical bioprosthetic valves, there were significant overall trends for the primary endpoint, all-cause death, rehospitalization, and cardiac death by MCF and EF quartiles. Allcause death was significant by SVI quartiles. By multivariable analysis, the MCF (HR 0.51 [0.30,0.87], p¼0.01) and EF (HR 0.92 [0.88, 0.97, p¼0.002]) were significantly associated with two-year rates of the primary endpoint, but SVI was not. C-statistics for association with the primary endpoint were as follows: MCF: (0.55 [0.53,0.58]), EF: (0.55 [0.53,0.57]), and SVI: (0.52 [0.50,0.54]). C-statistics for EF and MCF did not differ significantly, but both had stronger associations with the primary endpoint compared with SVI (p¼0.01 and p¼0.03, respectively). MCF also was independently associated with two-year rates of rehospitalization and stroke, and EF with two-year rates of all-cause death and rehospitalization. CONCLUSION MCF and EF predicted long-term adverse events in this large study of intermediate or higher risk patients undergoing VR for severe AS. Further studies evaluating the prognostic utility of MCF as a risk-stratifying tool in patients with severe AS are indicated. CATEGORIES IMAGING: Imaging: Non-Invasive TCT-385 Prognostic Value of Right Ventricular Dysfunction on Clinical Outcomes Following Transcatheter Aortic Valve Replacement Masahiko Asami,1 Stefan Stortecky,2 Fabien Praz,3 Jonas Lanz,4 Joe Lee,1 Raffaele Piccolo,1 George Siontis,5 Dik Heg,6 Ernest Spitzer,7 Eva Roost,8 Stephan Windecker,2 Thomas Pilgrim9 1 Swiss Cardiovascular Center, Inselspital, Bern University Hospital, Bern, Switzerland; 2University Hospital Bern, Bern, Switzerland;
3 Columbia University Medical Center, New York City, New York, United States; 4Inselspital Bern, Bern, Switzerland; 5University Hospital of Bern, Bern, Switzerland; 6Clinical Trials Unit, Department of Clinical Research, Institute of Social and, Bern, Switzerland; 7Erasmus MC, Rotterdam, Netherlands; 8Department of Cardiac Surgery, Swiss Cardiovascular Center, Bern University Hospital, Bern, Switzerland; 9 Bern University Hospital, Berne, Switzerland
BACKGROUND There is limited evidence on the impact of right ventricular dysfunction (RVD) on clinical outcomes after transcatheter aortic valve replacement (TAVR). The objective of the present analysis was to investigate the association between RVD and all-cause mortality after TAVR. METHODS A total of 1116 TAVR patients underwent detailed preoperative assessment of RV function, and were dichotomized into two groups (RVD vs. normal RV function). RVD was assessed by use of fractional area change (<35%), tricuspid annular plane systolic excursion (<1.7cm), and systolic movement of the RV lateral wall by tissue Doppler (<9.5cm/s). The primary outcome was all-cause mortality at 1-year. RESULTS RVD was found in 325 (29.1%) patients. Patients with RVD were younger compared to patients with normal RV function (81.37.1 years vs. 82.55.5 years, p¼0.002), more commonly male (56.6% vs. 45.8%, p¼0.001), more commonly in NYHA functional class III/IV (76.2% vs. 64.1%, p<0.001), and had a higher STS score (7.24.7% vs. 5.63.9%, p<0.001), lower left ventricular ejection fraction (45.116.5% vs. 56.612.5%, p<0.001), and a higher brain natriuretic peptide prior to intervention (1165.01342.2 pg/ml vs. 522.4704.5 pg/ ml, p<0.001). There were no significant differences with regard to access route or valve type used between the two groups. After adjustment for comorbidities, patients with RVD had a higher risk of death at 1 year as compared to patients with normal RV function (26.2% vs 11.1%, HRadj 2.48, 95% CI 1.82-3.38, p<0.001). The difference emerged within the first 30 days after TAVR (9.9% vs. 2.7%, HRadj 4.09, 95% CI 2.33-7.18, p<0.001) and was driven by a difference in cardiovascular death (9.0% vs. 2.2%, HRadj 4.62, 95% CI 2.51-8.50, p<0.001). In a multivariable analysis, RVD was the strongest independent predictor of 1-year mortality (HRadj 2.20, 95% CI 1.54-3.31), followed by diabetes (HRadj 1.89, 95% CI 1.34-2.67), and history of cerebrovascular events (HRadj 1.73, 95% CI 1.13-2.65). CONCLUSION RVD at baseline was associated with a more than twofold increased risk of all-cause mortality at 1 year after TAVR. CATEGORIES STRUCTURAL: Valvular Disease: Aortic TCT-386 Outcome of TAVR procedures in patients with severely impaired left ventricular ejection fraction Tobias Schmidt,1 Jury Schewel,1 Michael Schlüter,2 Hannes Alessandrini,3 Michael Schmoeckel,1 Karl-Heinz Kuck,1 Christian Frerker1 1 Asklepios Klinik St. Georg, Hamburg, Germany; 2Asklepios proresearch, Hamburg, Germany; 3Asklepios Hospital, Hamburg, Germany BACKGROUND Only limited data exists for transcatheter aortic valve replacement (TAVR) in patients with severe aortic stenosis (AS) and severely reduced left ventricular ejection fraction (LVEF). We report on TAVR procedures in patients with severe AS and LVEF 20%. METHODS 1505 TAVR procedures were performed between 07/2008 and 07/2016 at our center. 33 patients (mean age 797 years; 24 men; median logisticEuroSCORE (log.ES) 38% (interquantil range 24;63); NYHA II, III and IV in 4, 15 and 14 pts, respectively) had a LVEF 20%. Access way was mainly transfemoral with 91% (30/33). RESULTS Echocardiographic mean LVEF increased from 192% before the procedure to 2711% (p¼0.0001) at discharge. Right heart catheterization showed an increase in cardiac output (CO) from 3.91.0 to 4.31.2l/min (p¼0.0048) and stroke volume (SV) from 5620 to 6218ml (p¼0.028). Transvalvular aortic gradient decreased from 2912mmHg to 63mmHg (mean gradient) and 3118mmHg to 12mmHg (peak-to-peak gradient; both p¼0.0001). Device success was achieved in 94% (31/33). Two patients died during or <72h after the procedure. Overall 8 patients (24%) were in cardiogenic shock before the procedure. Patients were followed for a median of 4.8 (IQR, 1.2-16.3) months. 30-day mortality was 18% (6/33), while 4 of these patients were in cardiogenic shock prior to the procedure. Separating patients to higher and lower than the median log.ES of 38%, 30-day mortality is 0% (0/16) for patients with log.ES <38 compared to 37.5% (6/16) with log.ES 38 (one patient missing for 30-day follow up). CONCLUSION TAVR in patients with severe AS and severe reduced LVEF show high 30-day mortality. 30-day mortality was driven by
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 70, NO. 18, SUPPL B, 2017
collateral quality decay
Collateral quality decay
Collateral quality improvement
LVEF B
LVEF 4M
LVEDV B
LVEDV
(%)
(%)
p-value
(ml)
4M (ml)
p-value
41.1
45.5
0.022*
232.4
208 [171-
0.845*
[29.8-
[35.3-
[189-265]
252]
47.3]
55.0]
21.4 [7.6-
36.2
21.4]
[27.9-
0.180
ˇ
CATEGORIES STRUCTURAL: Valvular Disease: Aortic
Table 1. CMR measurements at baseline (B) and 4 month (4m) follow-up in patients with and without
312.1[305-
271.8
312]
[193-359]
190 [166-
205 [169-
247]
245]
0.180
ˇ
cardiogenic shock and high log.ES. Indication for TAVR in these patients (high log.ES and cardiogenic shock) needs to be intensively discussed before the procedure specifically for each patient. Patients with lower log.ES seem to have a low 30-day mortality. High device success shows that the procedure in this very sick patient population is feasible and safe. Overall, echocardiographic LVEF and hemodynamic CO and SV improved directly after TAVR despite very sick patients with severe reduced LV function.
B159
47.8] No collateral quality change
OUTCOMES AFTER PRIMARY PCI - II
43.4
45.1
[32.6-
[37.6-
51.1]
52.3]
0.006#
0.063#
ˇ
*n¼18, n¼2, #n¼67
Abstract nos: 387 - 391 TCT-387 Collateral quality decay several days after primary PCI: a novel observation from the EXPLORE trial. Ivo M. van Dongen,1 Joelle Elias,2 K. Gert van Houwelingen,3 Pierfrancesco Agostoni,4 Bimmer EPM Claessen,1 Loes P. Hoebers,1 Dagmar Ouweneel,5 Rene van der Schaaf,6 Jan Tijssen,7 Jose PS Henriques1 1 Academic Medical Center - University of Amsterdam, Amsterdam, Netherlands; 2Academic Medical Centre (AMC) - University of Amsterdam, Amsterdam, Netherlands; 3Thoraxcentrum Twente, MST Enschede, Enschede, Netherlands; 4Department of Cardiology, St. Antonius Ziekenhuis, Nieuwegein, Netherlands; 5Academic Medical Center - University of Amsterdam, Amsterdam, Netherlands; 6OLVG, Amsterdam, Netherlands; 7AMC, Naarden, Netherlands BACKGROUND Collaterals towards a concomitant CTO are associated with improved outcome.In the EXPLORE trial, a novel observation was encountered: a decrease in collateral quality to the CTO right before CTO PCI. We have assessed the impact of this on functional and clinical outcome. METHODS All angiograms were corelab analyzed.Well-developed (Rentrop grade 2-3) and poorly-developed (grade 0-1) collaterals were identified.LVF was measured with CMR.Long-term follow-up (median 3.9 years) was collected prospectively. RESULTS Before CTO PCI, a decay in collateral quality compared to primary PCI was observed in 34 of patients randomized to CTO PCI, and in 4 patients an increase was seen.CMR outcomes are shown in table 1.KM curves of MACE and all-cause death are shown in figure 1.
CONCLUSION An unique notion was made in the EXPLORE trial: 23.1% of patients with well-developed collaterals to the CTO during STEMI PCI show quality decay of the collateralization within one week.This is associated with a modest difference in cardiac function and long-term outcomes (mainly MACE) compared to patients without any change in collateral quality, which could suggest that the capability to improve quality of collaterals to a CTO during STEMI may have a protective role.However, this should be further investigated in a larger CTO population. CATEGORIES CORONARY: PCI Outcomes TCT-388 Does ST Segment Elevation in Lead aVR Correlate with Left Main Occlusion? Ahmed Harhash,1 Sridhar Reddy,1 Jennifer Huang-Tsang,1 Balaji Natarajan,1 Mahesh Balakrishnan,1 Ranjith Shetty,1 Mathew Hutchinson,1 Karl Kern2 1 University of Arizona, Tucson, Arizona, United States; 2Univ of Arizona, Tucson, Arizona, United States BACKGROUND Prompt identification of ST-elevation myocardial infarction (STEMI) on ECG is critical as early reperfusion can be lifesaving. The ACCF/AHA guidelines established that ST elevation (STE) must be present in at least 2 contiguous leads to qualify for a diagnosis of STEMI. STE in aVR, co-existent with multi-lead ST depression (STD), was endorsed as a sign for left main (LM) or proximal LAD occlusion. Previous studies have described the association of multivessel disease with STD in the inferolateral leads with reciprocal STE in aVR. We sought to investigate the incidence of an acutely occluded vessel (i.e. STEMI) versus severe multi-vessel CAD without a total occlusion (i.e. NSTEMI) in patients (pts) presenting with STE-aVR. METHODS STEMI activations between January 2014 and November 2016 were identified by retrospective chart review. Patients with admission ECG showing STE-aVR co-existent with multi-lead STD were enrolled. All ECGs and coronary angiograms were blindly analyzed by experienced cardiologists. Patients’ demographics, presenting complaint, labs, hospital course, and in-hospital mortality were collected. Descriptive analysis was performed using STATA 12.0. RESULTS Among 604 STEMI activations, 66 pts (11%) were identified with STE-aVR. Of those, 24 (36%) presented with cardiac arrest, and 53 (80%) underwent emergent coronary angiography. Culprit coronary occlusion was identified in only 5 pts (9%). Thirty-four pts (64%) were found to have severe diffuse CAD but with distal TIMI 3 flow and 19 pts (36%) had mild or no disease. It was unclear whether the occlusion was acute or chronic in 3 pts. STE-aVR was associated with 32% inhospital mortality, compared to only 6.2% in a 190 randomly sampled STEMIs in the same study period(p<0.001). CONCLUSION STE-aVR was associated with acutely thrombotic coronary occlusion in only 9% of pts. These patients had a five-fold higher in-hospital mortality compared to the overall STEMI population. Majority had severe diffuse disease with extensive comorbidities and prior PCI or CABG. Urgent cardiology evaluation is warranted but routine STEMI activation based on this ECG finding alone should be reconsidered in pts presenting with critical illness. CATEGORIES CORONARY: Acute Coronary Syndromes TCT-389 Does well-developed coronary collateral circulation have an influence on myocardial viability in late presentation myocardial infarction? Alejandro Gutierrez-Barrios,1 Dolores Cañadas,2 Enrique Diaz-Retamino,3 German Calle Perez,4 Rafael Vázquez-García1 1 Hospital Puerta del Mar, Cádiz, Spain; 2Hospital de Jerez, Jerez de la