The following science presented at EuroPCR 2023 in Paris, France, was published Tuesday, May 16 in JACC, JACC: Cardiovascular Interventions and JACC: Case Reports.

Transcatheter tricuspid valve replacement (TTVR) using the EVOQUE system was associated with high rates of procedural success, symptomatic improvement and survival in addition to low complication rates, according to a retrospective analysis of two-year outcomes simultaneously published in JACC.

Of the 38 patients in the analysis (age, 77±12 years; EuroSCORE II, 7.9% ± 6.5%; 74% women) from eight centers, tricuspid regurgitation (TR) severity was identified as 5+ in 21 (55%), 4+ in 13 (34%), and 3+ in four patients (11%). Lukas Stolz, MD, et al., found that the tricuspid annular plane systolic excursion (TAPSE) was reduced to <17 mm in 53% of patients (TAPSE 18±11 mm).

Following the procedure, TR was successfully reduced to ≤1+ in 97% of patients, and this was maintained in 94% at the latest available follow-up (median 520 days, IQR 360-730 days; maximum 1,074 days). Survival rates were 86% at one year post procedure and 71% at the two-year mark, with cardiac causes for mortality reported in six of 10 patients.

The authors noted significant symptomatic improvement with 92% of patients identified as NYHA functional class ≥3 pre-procedure vs. 20% at follow-up.

No myocardial infarction, stroke or pulmonary embolism events were reported at follow-up; however, major bleeding events were reported in four patients, one patient experienced early device migration and four patients developed new conduction disturbances requiring permanent pacemaker implantation.

In a head-to-head comparison analyzing the diagnostic accuracy of five angiography-derived fractional flow reserve (angio-FFR) software programs simultaneously published in JACC: Cardiovascular Interventions, Kai Ninomiya, MD, et al., found these methods to be useful in predicting pressure wire-derived fractional flow reserve (PW-FFR) with higher discrimination when compared to 2D quantitative coronary angiography (QCA) percent diameter stenosis (%DS).

Nevertheless, their findings did not reach the same level of accuracy reported in validation studies of multiple vendors, indicating the need for large clinical trials to assess the clinical value of angio-FFR.

The study authors used an independent core lab that assessed 390 vessels in the prospective cohort.  “One ‘matcher investigator’ colocalized on angiography the sites of pressure wire measurement with angio-FFR measurements and provided the same two optimal angiographic views and frame selection to independent analysts who were blinded to invasive physiological results and results from other software.” The area under the receiver-operating characteristic curve (AUC) for each angio-FFR was calculated using anonymized and randomly presented results and compared with 2D QCA %DS.

All five software programs evaluated showed a high proportion of analyzable vessels (A, 100%; B, 100%; C, 92.1%; D, 99.5%; E, 92.1%). The calculated AUC for each angio-FFR ranged from 0.75 to 0.73 and was significantly greater than the AUC for 2D QCA %DS (0.65).

“There may be scenarios in which angio-FFR may be appealing, such as in post-PCI FFR, side branch evaluation after provisional bifurcation stenting and off-line angio-FFR measurement from available angiographic studies for decisions regarding revascularization,” write Salman S. Allana, MD, FACC, Yader Sandoval, MD, FACC, and Emmanouil S. Brilakis, MD, PhD, FACC, in an accompanying editorial comment. “Angio-FFR will hopefully continue to improve using artificial intelligence and deep learning algorithms, resulting in higher accuracy and shorter processing time.”

Two case studies simultaneously published in JACC: Case Reports were also presented at EuroPCR 2023.

The first explored the benefits of TTVR for patients with lead-related TR. Rodrigo Estevez-Loureiro, MD, PhD, et al., presented a case of a 79-year-old woman with a history of dilated cardiomyopathy requiring a permanent pacemaker that was recently upgraded to an ICD CRT and was admitted due to right heart failure.

After finding torrential TR with two leads across the valve on echocardiography and completing multidisciplinary evaluation, the treating physicians opted to implant a dedicated transcatheter valve replacement, reporting that the patient was stable with improvement in functional class at the three-month follow-up.

“Recently, TTVR has become an alternative to repair techniques,” the case authors write. “These devices could represent a better alternative to lead-associated TR, as they are less dependent on the position or interference of the lead with the valvular apparatus.”

In the other case study, Sarah Verhemel, MD, MRCP, et al., demonstrated a solution to a rare complication of transcatheter aortic valve implantation (TAVI): transcatheter valve migration and frame infolding. They presented a case of an 86-year-old man with progressive dyspnea (NYHA class IV), angina (CCS class 3) and syncope secondary to critical aortic stenosis at high operative risk (STS PROM 8.16%) who underwent TAVI.

During the procedure, the self-expanding heart valve migrated toward the left ventricular outflow tract (LVOT) during deployment and convoluted when released from its delivery catheter. Treating physicians fixed the complication by rewiring and revalving. They successfully recrossed the infolded frame with a 0.035 inch straight wire, confirmed using fluoroscopy, and then exchanged the infolded frame for a pre-shaped wire, which was re-expanded with a 22 mm balloon and remained stable in the LVOT. Then they deployed a 26 mm SAPIEN 3 Ultra device at the level of the native annulus and locked the migrated valve in place. At the 30-day follow-up, the patient reported marked symptom improvement including greater exercise tolerance and quality of life.

The study authors write, “The deeply implanted [transcatheter heart valve] did not interact with the mitral valve apparatus. In the matter of mitral valve interference, cardiac surgery would be contingent on clinical picture and operation risk.”

Access all JACC Journals publications throughout the meeting on JACC.org.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: Angiography

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