Zero-contrast imaging for the assessment of transcatheter aortic valve implantation in candidates with renal dysfunction

Figures & data

Figure 1. Multimodality imaging for the assessment of TAVI candidates with renal dysfunction. Femoro-iliac-aortic endovascular access (A) was evaluated by duplex scan ultrasound (upper panel showing the left and right femoral arteries), computed tomography (arrowheads in the mid-upper panel indicate the left and right femoral arteries), and nuclear magnetic resonance imaging (arrowheads in the mid-upper panel indicate the left and right femoral arteries). The aortic root and aortic annulus (B) were evaluated using computed tomography (upper panel), nuclear magnetic resonance imaging (red asterisk in the middle panel indicates the aortic annulus region), and echocardiography (lower panel), which were reassessed for confirmation during the procedure (C, left panel). The final shape of the metallic frame of the prosthesis is shown in the right panel of panel C.

Table 1. Patients characteristics.

	Patient population (n = 10)
Age, years	81.26 (±12.2)
Male, n (%)	10 (100)
Body mass index, Kg/m^2	27.0 (±4.2)
Diabetes n (%)	7 (70.0)
Heart failure NYHA^§ class III or IV (%)	10 (100)
STS^ll score, %	10.9 (±8.7)
Baseline creatinine clearance, mL/min	26.8 (±12.5)
Echo LV^‡ ejection fraction, %	45.7 (±13.3)
Aortic valve area, cm²	0.81 (±0.20)
Mean pressure gradient, mmHg	33.2 (±10.4)
CT ^†Aortic valve calcium score, AU*	2709.5 (1601.75–4218.25)

Numbers are means (± standard deviations), medians (interquartile ranges), or counts (percentages).

*AU = Agatston units; ^†CT = computed tomography; ^‡Echo–LVEF = left ventricular ejection fraction determined by echocardiography; ^§NYHA = New York Heart Association; ^llSTS = Society of Thoracic Surgeons.

Table 2. Main findings of multi-modality imaging.

	Patient #1	Patient #2	Patient #3	Patient #4	Patient #5	Patient #6	Patient #7	Patient #8	Patient #9	Patient #10
Transesophageal echocardiogram
Aortic annulus area, mm²	549	554	314	663	443	372	544	415	460	427
Left ventricular ejection fraction, %	31	46	59	30	52	25	61	55	40	58
Mean pressure gradient, mmHg	27^a	16^a	41	34^a	53	25^a	43	28^b	31	34
Magnetic resonance
Sinus of Valsalva, mm	35	35.5	30.5	38	32	36.7	34.3	41	40.6	33
Aortic annulus perimeter, mm	83	94	70	93	83	85	84	77	84	72
Aortic annulus area, mm²	542	630	385	683	519	506	535	421	487	390
Femoral-iliac smallest diameter, mm	–	9	7	11	–	–	–	10	9	–
Lowest coronary ostium, mm	16	–	8	12	10	10	13	17	11	–
Computed tomography
Aortic valve calcium score, AU	1248	1565	1772	4399	4158	3946	3647	1614	5767	1628
Left ventricular outflow tract calcification	Yes	No	Yes	Yes	No	Yes	No	No	yes	No
Femoral-iliac smallest external diameter, mm	5	7	7	9	8	–	9	10	11	9
Lowest coronary ostium, mm	13	14	11	12	12	12	14	16	12	12
Severe calcification in proximal LCA*	Yes^c	Yes	No	No	Yes	Yes	No	Yes	No	Yes
Severe calcification in proximal RCA^†	Yes^c	No	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Lower limbs artery ultrasound
Stenosis > 50%	No	No	No	–	No	No	–	Yes	No	Yes

*LCA, left coronary artery; ^†RCA, right coronary artery.

^aLow-gradient/low flow.

^bParadoxical low-gradient severe aortic stenosis.

^cVisible patent left internal mammary artery graft to left anterior descending artery.

Table 3. Procedure characteristics.

	Patient #1	Patient #2	Patient #3	Patient #4	Patient #5	Patient #6	Patient #7	Patient #8	Patient #9	Patient #10
Procedural characteristics
Transfemoral access	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Prosthesis type	Sapien 3	Sapien 3	Evolut R	Corevalve	Evolut R	Sapien 3	Sapien 3	Sapien 3	Sapien 3	Sapien 3
Prosthesis size, mm	29	29	26	31	29	26	29	26	26	26
Valve embolization	No	No	No	No	No	No	No	No	No	No
Residual mean aortic gradient, mmHg	6	5	8	15	9	4	7	9	5	4
Residual aortic regurgitation	Trivial	Trivial	Mild	Mild-to moderate	Mild	Mild	None	None	Trivial	None
Volume of contrast, mL	40	160	77	60	40	45	35	35	33	45
Need for percutaneous coronary intervention	‘ No	No	No	No	Yes	Yes	No	No	No	No

Table 4. Renal function and in-hospital clinical outcomes.

	Patient #1	Patient #2	Patient #3	Patient #4	Patient #5	Patient #6	Patient #7	Patient #8	Patient #9	Patient #10
Death	No	No	No	No	No	No	No	No	No	No
Hospitalization length, days	4	13	3	4	4	18	6	12	4	5
Vascular complications	No	No	No	No	No	No	No	No	No	No
Bleeding complications	No	No	No	No	No	No	No	Yes^a	No	No
Renal Function
Baseline serum creatinine, md/dL	2.01	3.10	2.39	3.16	2.33	3.2	1.83	3.3	3.65	1.49
Baseline creatinine clearance, mL/min	50.19	18.32	23.72	41.10	24.62	17.49	26.9	18.03	9.91	38.26
Post imaging serum creatinine, md/dL	2.26	3.01	2.37	3.08	2.45	2.93	1.73	3.25	3.98	1.56
Post imaging creatinine clearance, mL/min	44.64	18.87	23.92	42.16	23.41	19.16	31.49	18.36	9.16	36.54
Post-TAVI* (at discharge) serum creatinine, mg/dL	2.24	4.00	2.27	2.37	1.71	2.34	1.62	4.01	2.54	1.46
Post-TAVI*(at discharge) creatinine clearance, mL/min	45.04	14.2	24.97	55.26	33.54	23.91	33.44	14.84	14.24	39.04
Need for dialysis	No	Yes^b	No	No	No	No	No	No	No	No

*TAVI = Transcatheter aortic valve implantation.

^aGastrointestinal bleeding associated with Clostridium difficile infection; VARC-3 type 1 of bleeding [12].

^bUltrafiltration modality due to congestive symptoms after transcatheter aortic valve implantation.

Khwaja A. KDIGO clinical practice guidelines for acute kidney injury. Nephron Clin Pract. 2012;120(4):c179–c184. doi: 10.1159/000339789.

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