Performance Of Transcatheter Aortic Valve Implantation Research Articles

Endovascular Recanalization and Carotid Stenting: The New Approach to Restore Cerebral Perfusion during Aortic Dissection.

Two clinical cases of TAAD complicated by cerebral malperfusion are described. The first patient is 73 years old and was admitted as planned to perform transcatheter aortic valve implantation (TAVI) for grade III aortic stenosis. The patient underwent transcatheter aortic valve implantation (TAVI) on the second day after admission. The second patient is 60 years old and was hospitalized by an ambulance with strong hypertension and ischemia. The surgical correction of aortic dissection was postponed until the neurological status assessment in both patients. The surgery to correct the aorta dissection was deemed inappropriate. The carotid arteries have been reanalyzed, and cerebral perfusion has been restored in a short time in both patients. Acute bilateral internal carotid occlusion is a potentially fatal TAAD outcome. Emergency endovascular recanalization and carotid stenting may be considered one of the few ways to restore cerebral perfusion.

Factors associated with hospitalization for aortic stenosis in Portugal from 2015 to 2017

Abstract Background Severe aortic stenosis prevalence has been growing worldwide and constitutes a public health challenge. The gold-standard treatment is Surgical Aortic Valve Replacement (SAVR) however Transcatheter Aortic Valve Implantation (TAVI) has been increasing, especially in high-risk surgical patients. This study aims identifying the factors associated to the implementation of TAVI to minimize possible disparities in access to health services. Methods This study used data on inpatient discharges from the Portuguese NHS, from 2015 to 2017. SAVR and TAVI, were classified according to the International Classification of Diseases (ICD). Chi-square test and independent T-tests with 1% significance level in the SPSS® were performed to identify the factors associated with both interventions. Results A total of 8398 hospitalizations were analysed, 88.5% SAVR and 11.5% TAVI. The mean (SD) age for SAVR was 70 (±11) years old and 81 (±7) years old for TAVI (p < 0.001), 56.9% were male among SAVR and 44.6% among TAVI (p < 0.001). Year (p < 0.001), type of admission (p < 0.001), geographic location (p < 0.001), severity (p < 0.001) and Charlson Comorbidity Index (CCI) (p < 0.001) were associated with the type of intervention. Conclusions TAVI was performed in more severe patients and there was an increase in TAVI over the years, which is consistent with the growing use of the technology among other patients, e.g., the high-risk surgical patients. We also found a geographic pattern in the use of SAVR and TAVI. This might reveal the existence of geographic disparities regarding availability and access to health services. Key messages • In Portugal, there is an increase in the performance of TAVI, with geographical concentration that reflects on access. • TAVI is more often performed in more severe patients as an alternative to SAVR with similar discharge outcomes.

Transcatheter Aortic Valve Implantation with ACURATE neo: Results from the PROGRESS PVL Registry.

Objectives The PROGRESS PVL registry evaluated transcatheter aortic valve implantation (TAVI) in patients treated with ACURATE neo, a supra-annular self-expanding bioprosthetic aortic valve. Background While clinical outcomes with TAVI are comparable with those achieved with surgery, residual aortic regurgitation (AR) and paravalvular leak (PVL) are common complications. The ACURATE neo valve has a pericardial sealing skirt designed to minimize PVL. Methods The primary endpoint was the rate of total AR over time, as assessed by a core echocardiographic laboratory. The study enrolled 500 patients (mean age: 81.8 ± 5.1 years; 61% female; mean baseline STS score: 6.0 ± 4.5%) from 22 centers in Europe and Canada; 498 patients were treated with ACURATE neo. Results The rate of ≥ moderate AR was 4.6% at discharge and 3.1% at 12 months; the rate of ≥ moderate PVL was 4.6% at discharge and 2.6% at 12 months. Paired analyses showed significant improvement in overall PVL between discharge and 12 months (P < 0.001); 64.6% of patients had no change in PVL grade, 24.9% improved, and 10.5% worsened. Patients also exhibited significant improvement in transvalvular gradient (P < 0.001) and effective orifice area (P=0.01). The mortality rate was 2.2% at 30 days and 11.3% at 12 months. The permanent pacemaker implantation (PPI) rate was 10.2% at 30 days and 12.2% at 12 months. Conclusions Results from PROGRESS PVL support the sustained safety and performance of TAVI with the ACURATE neo valve, showing excellent valve hemodynamics, good clinical outcomes, and significant interindividual improvement in PVL from discharge to 12-month follow-up.

Conduction delays after transcatheter aortic valve implantation with balloon-expandable prosthesis and high implantation technique

Performing transcatheter aortic valve implantation with high implantation technique, i.e. with an aorto-ventricular ratio > 60/40, reduces the need of permanent pacemaker implantation. Valve calcification and prosthesis oversizing are predictors of permanent pacemaker implantation, but there are no available data on their role when transcatheter aortic valve implantation is performed with an aorto-ventricular ratio > 60/40. The aim of this study was to evaluate the effect of leaflets/annulus calcification and prosthesis oversizing on the incidence of permanent pacemaker implantation after transcatheter aortic valve implantation with a high implantation technique. Transcatheter aortic valve implantation was performed in 48 patients implanting a balloon-expandable transcatheter heart valve with an aorto-ventricular ratio > 60/40. Calcium burden was assessed by preprocedural multidetector computed tomography. An invasive electrophysiological study was performed before and after transcatheter aortic valve implantation. Five patients (10.4%) needed permanent pacemaker implantation. At univariate analysis, baseline right bundle branch block and postprocedural PR, QRS and His-ventricular interval elongation significantly predicted permanent pacemaker implantation (p < 0.05). Receiver-operating characteristic curve analysis showed a correlation between transcatheter heart valve oversizing and permanent pacemaker implantation need, with the best cut-off being 17% (AUC = 0.72, p = 0.033). Linear regression analysis demonstrated that QRS complex elongation was related to total, left and non-coronary leaflet calcification (p < 0.05). This study demonstrates that, when transcatheter aortic valve implantation is performed using a balloon-expandable transcatheter heart valve deployed with an aorto-ventricular ratio > 60/40, the presence of leaflets/annulus calcification or the need to oversize the prosthesis correlate with the occurrence of pathological cardiac conduction delays.

Edwards SAPIEN Versus Medtronic Aortic Bioprosthesis in Women Undergoing Transcatheter Aortic Valve Implantation (from the Win-TAVI Registry)

We sought to analyze outcomes of women receiving balloon-expandable valves (BEV) or self-expanding valves (SEV) in contemporary transcatheter aortic valve implantation (TAVI). WIN TAVI (Women's INternational Transcatheter Aortic Valve Implantation) is the first all-female TAVI registry to study the safety and performance of TAVI in women. We compared women treated with BEV (n = 408, 46.9%) versus those treated with SEV (n = 461, 53.1%). The primary efficacy end point was the Valve Academic Research Consortium-2 (VARC-2) composite of 1-year all-cause death, stroke, myocardial infarction, hospitalization for valve-related symptoms or heart failure or valve-related dysfunction. Women receiving SEV had higher surgical risk scores, higher rate of previous stroke and pulmonary hypertension whereas women receiving BEV were more frequently denied surgical valve replacement due to frailty. BEV patients were less likely to require post-dilation and had significantly lower rates of residual aortic regurgitation grade ≥2 (9.8% vs 4.7%, p = 0.007). At 1 year, the crude incidence and adjusted risk of the primary VARC-2 efficacy end point was similar between groups (17.1% with SEV and 14.3% with BEV, p = 0.25; hazards ratio 1.09, 95% confidence interval 0.68 to 1.75). Conversely the crude rate and adjusted risk of new pacemaker implantation was higher with SEV than BEV (15% vs 8.6%, p = 0.001; hazards ratio 1.97, 95% confidence interval 1.13 to 3.43). A subanalysis on new generation valves showed no difference in the need for pacemaker implantation between the 2 devices (10.1% vs 8.0%, p = 0.56). In conclusion, in contemporary TAVI, SEV are used more frequently in women with greater co-morbidities. While there were no differences in unadjusted and adjusted risk of 1-year primary efficacy end point between the valve types, there was a greater need for permanent pacemakers after SEV implantation.

Safety and feasibility of balloon aortic valvuloplasty in non-TAVI centers: The "BAV for life" experience.

To evaluate the safety and the feasibility of balloon aortic valvuloplasty (BAV) procedure made by trained operators in centers not performing transcatheter aortic valve implantation (TAVI). BAV is a valuable therapeutic tool for patients with symptomatic severe aortic valve stenosis (AS) at prohibitive risk for TAVI or surgery. Consecutive high-risk AS patients underwent BAV in five non-TAVI centers, where BAV operators had completed a 6-month training period in high-volume TAVI centers (Group A). All clinical, echocardiographic, and procedural data were prospectively collected and compared with data of patients treated in TAVI center (Group B). Between June 2016 and June 2017, 55 patients (83.9 ± 7.0 years) were enrolled: 25 in Group A and 30 in Group B. After BAV, a substantial reduction of the peak-to-peak aortic valve gradient was obtained in both groups (-35.3 ± 15.2 vs -28.8 ± 13.9 mmHg, P =0.25). No major bleeding or vascular complications occurred. In-hospital death was observed in three patients of Group A and two patients of Group B (P =0.493). The mean follow-up time was 303 ± 188 days; no patients were lost. The 1-year survival free from overall death (Group A 75.8% vs Group B 68.8%; P =0.682) and heart failure rehospitalization (Group A 73.0% vs Group B 66.8%; P =0.687) was similar in the two groups. At multivariable analysis, low left ventricular (LV) ejection fraction (HR: 0.943; P = 0.011) and cardiogenic shock (HR: 5.128; P = 0.002) at admission were independent predictors of mortality. BAV is a safe and effective procedure that can be performed by trained operators in centers not performing TAVI.

Abordaje integral de la valvulopatía aórtica. Implante transcatéter de válvula aórtica. Posición y recomendaciones de la Sociedad Española de Cirugía Torácica y Cardiovascular

The present document describes the position of the Spanish Society of Thoracic and Cardiovascular Surgery as regards aortic valve disease and its medical-surgical approach. In particular, it establishes the embodiment of the european and american clinical practice guidelines in the particular context of aortic valve disease in Spain. Specifically, they explain the indication criteria and structural requirements, as well as the techniques and professionals needed to perform transcatheter aortic valve implantation, with the aim of achieving maximum quality and safety for the patient.

Transcatheter Aortic Valve Implantation in Morphologically Complex Root Aneurysms

Performing transcatheter aortic valve implantation in the presence of aneurysmatic aortopathy is widely contraindicated but needs to be taken into account as a bailout strategy in selected patients. Deliberate preoperative assessment of measurements becomes the crucial key element in this context. After meticulous valve selection, retrograde access is obtained through the right subclavian artery additionally serving as a backup arterial cannulation site in case of conversion. Transcatheter aortic valve implantation is then performed through the transapical route. Transcatheter aortic valve implantation in complex aneurysmatic aortic morphology is feasible in highly selected patients after comprehensive preoperative evaluation. The present article describes our initial experience, safeguards, and technical details.

Description of a Method to Obtain Complete One-Year Follow-Up in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry

The Centers for Medicare and Medicaid Services National Coverage Determination requires centers performing transcatheter aortic valve implantation (TAVI) to report clinical outcomes up to 1 year. Many sites encounter challenges in obtaining complete 1-year follow-up. We report our process to address this challenge. A multidisciplinary process involving clinical personnel, data and quality managers, and research coordinators was initiated to collect TAVI data at baseline, 30 days, and 1 year. This process included (1) planned clinical follow-up of all patients at 30 days and 1 year; (2) query of health-care system-wide integrated data warehouse (IDW) to ascertain last date of clinical contact within the system for all patients; (3) online obituary search, cross-referencing for unique patient identifiers to determine if mortality occurred in remaining unknown patients; and (4) phone calls to remaining unknown patients or patients' families. Between January 2012 and December 2016, 744 patients underwent TAVI. All 744 patients were eligible for 30-day follow-up and 546 were eligible for 1-year follow-up. At routine clinical follow-up of 22 of 744 (3%) patients at 30 days and 180 of 546 (33%) patients at 1 year had unknown survival status. The integrated data warehouse query confirmed status-alive for an additional 1 of 22 patients at 30 days (55%) and 91 of 180 patients at 1 year (51%). Obituaries were identified for 23 of 180 additional patients at 1 year (13%). Phone contact identified the remaining unknown patients at 30 days and 1 year, resulting in 100% known survival status for patients at 30 days (744 of 744) and at 1 year (546 of 546). In conclusion, using a comprehensive approach, we were able to determine survival status in 100% of patients who underwent TAVI.

Transcatheter Aortic Valve Implantation (TAVI) for Native Aortic Valve Regurgitation - A Systematic Review.

Transcatheter aortic valve implantation (TAVI) has become the standard of care for management of high-risk patients with aortic stenosis. Limited data is available regarding the performance of TAVI in patients with native aortic valve regurgitation (NAVR).Methods and Results:We performed a systematic review from 2002 to 2016. The primary outcome was device success as per VARC-2 criteria. Secondary endpoints included procedural complications, and 30-day and 1-year mortality rates. A total of 175 patients were included from 31 studies. Device success was reported in 86.3% of patients - with device failure driven by moderate aortic regurgitation (AR ≥3+) and/or need for a second device. Procedural complications were rare, with no procedural deaths, myocardial infarctions or annular ruptures reported. Procedural safety was acceptable with a low 30-day incidence of stroke (1.5%). The 30-day and 1-year overall mortality rates were 9.6% and 20.0% (cardiovascular death, 3.8% and 10.1%, respectively). Patients receiving 2nd-generation valves demonstrated similar safety profiles with greater device success compared with 1st-generation valves (96.2% vs. 78.4%). This was driven by the higher incidence of second-valve implantation (23.4% vs. 1.7%) and significant paravalvular leak (8.3% vs. 0.0%). TAVI demonstrates acceptable safety and efficacy in high-risk patients with severe NAVR. Second-generation valves may afford a similar safety profile with improved device success. Dedicated studies are needed to definitively establish the efficacy of TAVI in this population.

Outcomes of transfemoral transcatheter aortic valve implantation at hospitals with and without on-site cardiac surgery department: insights from the prospective German aortic valve replacement quality assurance registry (AQUA) in 17 919 patients.

Performing transcatheter aortic valve implantation (TAVI) at hospitals with only cardiology department but no cardiac surgery (CS) on-site is at great odds with current Guidelines. We analysed data from the official, prospective German Quality Assurance Registry on Aortic Valve Replacement to compare characteristics and in-hospital outcomes of patients undergoing transfemoral TAVI at hospitals with (n = 75) and without CS departments (n = 22). An interdisciplinary Heart Team was established at all centres (internal staff physicians at hospitals with on-site CS; in-house cardiologists and visiting cardiac surgical teams from collaborating hospitals at non-CS hospitals). In 2013 and 2014, 17 919 patients (81.2 ± 6.1 years, 55% females, German aortic valve (GAV) score 2.0 5.6 ± 5.8%, logistic EuroSCORE I 21.1 ± 15.4%) underwent transfemoral TAVI in Germany: 1332 (7.4%) at hospitals without on-site CS department. Patients in non-CS hospitals were older (82.1 ± 5.8 vs. 81.1 ± 6.1 years, P < 0.001), with more frequent co-morbidities. Predicted mortality risks per GAV-score 2.0 (6.1 + 5.5 vs. 5.5 ± 5.9%, P < 0.001) and logEuroSCORE I (23.2 ± 15.8 vs. 21.0 ± 15.4%, P < 0.001) were higher in patients at non-CS sites. Complications, including strokes (2.6 vs. 2.3%, P = 0.452) and in-hospital mortality (3.8 vs. 4.2%, P = 0.396), were similar in both groups. Matched-pair analysis of 555 patients in each group with identical GAV-score confirmed similar rates of intraprocedural complications (9.2 vs. 10.3%, P = 0.543), strokes (3.2% for both groups, P = 1.00), and in-hospital mortality (1.8 vs. 2.9%, P = 0.234). Although patients undergoing TAVI at hospitals without on-site CS department were older and at higher predicted perioperative death risk, major complications, and in-hospital mortality were not statistically different, suggesting the feasibility and safety of Heart Team-based TAVI at non-CS sites. These findings need confirmation in future randomized study.

Usefulness of Predilation Before Transcatheter Aortic Valve Implantation

Balloon predilation is historically considered a requirement before performing transcatheter aortic valve implantation (TAVI). As the procedure has evolved, it has been questioned whether it is actually needed, but data are lacking on mid-term outcomes. The aim of this study was to evaluate the effect of balloon predilation before TAVI. A total of 517 patients who underwent transfemoral TAVI from November 2007 to October 2015 were analyzed. The devices implanted included the Medtronic CoreValve (n= 216), Medtronic Evolut R (n= 30), Edwards SAPIEN XT (n= 210), and Edwards SAPIEN 3 (n= 61). Patients were divided into 2 groups depending on whether pre-implantation balloon aortic valvuloplasty (pre-BAV) was performed (n= 326) or not (n= 191). Major adverse cardiac and cerebrovascular events (MACCE) were primarily evaluated. Propensity score matching was used to adjust for differences in baseline characteristics and potential confounders (n= 113 pairs). In the overall cohort, patients without pre-BAV had a significantly higher MACCE rate at 30days, driven by a higher incidence of stroke (0.3% pre-BAV vs 3.7% no-pre-BAV, p <0.01). MACCE and mortality at 1year were, however, similar in both groups. Independent predictors of MACCE at 1year included serum creatinine, NYHA class 3 to 4, logistic European System for Cardiac Operative Risk Evaluation, and postdilation. Of note, the postdilation rate was higher in the no-pre-BAV group (21.5% pre-BAV vs 35.6% no-pre-BAV, p <0.001). After propensity score matching, there were no differences in MACCE between the 2 groups. In conclusion, this study showed that, in selected patients and with specific transcatheter valves, TAVI without pre-BAV appears to be associated with similar mid-term outcomes compared with TAVI with pre-BAV, but it may increase the need for postdilation.

A comparative study between propofol and dexmedetomidine as sedative agents during performing transcatheter aortic valve implantation

ObjectiveThe type of sedative drugs could play a major role in providing hemodynamic stability which is crucial during transcatheter aortic valve implantation (TAVI) procedure. The aim of this study is to compare propofol with dexmedetomidine for conscious sedation during TAVI. DesignA prospective randomized pilot study. PatientsFifty patients with a mean age of 74years, American Society of Anesthesiologists 3-4, complaining from severe aortic stenosis were enrolled in this study to undergo TAVI. InterventionsThe propofol group (group P; n=25) received a bolus dose of 0.5mg/kg propofol followed by a continuous intravenous infusion of propofol at a rate of 30 to 50μg kg−1 min−1, and the dexmedetomidine group (group D; n=25) received dexmedetomidine at a loading dose of 1μg/kg and then a continuous intravenous infusion of dexmedetomidine at a rate of 0.5μg kg−1 h−1. MeasurementsHeart rate, mean arterial blood pressure, number of phenylephrine boluses, oxygen saturation, sedation, and satisfaction scores were measured just after the start of infusion of the sedation drugs and at the end of the procedure. Postoperative complications were also recorded. ResultsThere was a statistically significant reduction in the heart rate in group D in comparison to group P where it was 67.28±6.9beats/min in the first group in comparison to 78±6.9beats/min in the last one (P<.001). The mean arterial blood pressure was statistically significant lower in group D in comparison to group P (58.12±5.4mm Hg in group D vs 68.24±11.4mm Hg in group P; P<.001). Also, the number of phenylephrine boluses was higher in group D than in group P (36.5±7.17 in group D vs 20.6±2.07 in group p; P<.001). No difference between the 2 groups regarding oxygen saturation, sedation, pain, satisfaction scores, and postoperative complications. ConclusionDuring TAVI, dexmedetomidine may be associated with significant hypotension and bradycardia rather than propofol.

3D Printing Model before and after Transcatheter Aortic Valve Implantation for a Better Understanding of the Anatomy of Aortic Root.

A 71-year-old woman had severe aortic stenosis (AS) (aortic valve area, 0.6 cm2; mean valve gradient, 47 mmHg; and peak velocity, 4.2 m/s) and cardiac symptoms. She had a history of stroke and paroxysmal atrial fibrillation. Our multidisciplinary heart team decided to perform transcatheter aortic valve implantation (TAVI). Before TAVI, computed tomography (CT) was performed, and the measurements of the aortic annulus were as follows: diameter, 25.4×19 mm; perimeter, 71.2 mm; area, 3.72 cm2; distance to the right coronary artery, 13.2 mm; and distance to the left coronary artery, 12.3 mm (Fig. 1A). Using the CT data, a 3D printing model was created (Materialise®, Luven, Belgium). 3D printing model provided the cardiologist with an intuitive perception of the cardiovascular anatomy and measurements in preparation for TAVI (Fig. 1B and C). Fig. 1 A 23-mm Edward-Sapien prosthetic valve (Edwards Lifesciences, Irvine, CA, USA) was selected. TAVI was successfully performed with mild paravalvular leakage of the left coronary sinus (Fig. 1D). A post-TAVI 3D model clearly showed the position of the replaced valve (Fig. 1E), change in the aortic annulus (i.e., from an oval to a round shape) (Fig. 1F), and the site of mild paravalvular leakage (Fig. 1G). CT is essential tool for TAVI.1),2),3),4) Although CT measurements increase the success rate of TAVI, its success is highly dependent on the operator's skill and expertise. A 3D printing model may offer a greater possibility for simulating patient specific complex structural characterization procedures5) and overcome the limitation of non-invasive TAVI-poor direct visualization.

Efficacy and Safety of Transcatheter Aortic Valve Implantation for Bicuspid Aortic Valves: A Systematic Review and Meta-Analysis.

To elucidate the performance of transcatheter aortic valve implantation (TAVI) in bicuspid aortic valve (BAV) patients through a systematic review and meta-analysis. A systematic literature review was performed by searching eligible articles in PubMed, Medline, EMBASE, Google Scholar and CNKI. Meta-analysis of included case-control/cohort studies was further conducted. Relative risks (RRs) and the corresponding 95% confidence intervals (CIs) were used to compare clinical outcomes of BAV patients and non-BAV patients. A total of 17 articles including eight case reports, four case series and five case-control/cohort studies with 166 BAV patients were analyzed. Device success rate achieved for TAVI in this cohort of BAV patients was 95.2%. The 30-day mortality rate was 8.4%, and the medium-term (range from 6 months to 2 years) mortality rate reported was 17.9%. Overall, the performance of TAVI in BAV patients was comparable to that in non-BAV patients, as reported by the included case-control/cohort studies (30-day mortality rate: RR = 1.05, 95%CI 0.57-1.95, p = 0.87; Device success rate: RR = 1.00, 95%CI 0.95-1.05, p = 0.94; Incidence of moderate to severe paravalvular regurgitation: RR = 1.25, 95%CI 0.85-1.84, p = 0.25). The present study suggested that TAVI may be a feasible and safe treatment modality for BAV patients.

Safety and Efficacy of Using the Viabahn Endoprosthesis for Percutaneous Treatment of Vascular Access Complications After Transfemoral Aortic Valve Implantation

Vascular access complications (VACs) remain one of the biggest challenges when performing transcatheter aortic valve implantation (TAVI). This study aimed to investigate the short- and medium-term safety and efficacy of the Viabahn endoprosthesis (Gore, Flagstaff, AZ) when used to treat TAVI-induced vascular injury. Over a 40-month period, 354 patients underwent true percutaneous transfemoral (TF)-TAVI using a CoreValve and Prostar-XL closure system; this was our study population. A VAC leading to acute intervention occurred in 72 patients (20.3%) - of these, 18 were managed by balloon angioplasty, 48 were treated by Viabahn stenting (technical success rate 98%), and 6 needed surgical intervention. Overall, this approach resulted in a major VAC rate of 3.1% (n = 11) in our study cohort. Length of hospitalization and 30-day mortality rates were comparable in patients with a VAC treated by Viabahn stenting versus patients without vascular complications. Two patients (4.5%) presented with new-onset claudication; one of them had the stent implanted covering the deep femoral artery (DFA). At medium-term follow-up (median 372 days; range 55 to 978 days) duplex ultrasound showed 100% patency of the Viabahn endoprostheses with no signs of stent fracture or in-stent stenosis/occlusion. In conclusion, the use of self-expanding covered stents is safe and effective in case of TF-TAVI-induced vascular injury, with good short- and medium-term outcomes. Importantly, coverage of the DFA should be avoided. If confirmed by long-term (>5 years) follow-up studies, this strategy for treating TAVI-induced VAC may be used routinely in high-risk patients.

Transcatheter aortic-valve implantation with one single minimal contrast media injection.

Performing transcatheter aortic valve implantation (TAVI) with the use of minimal contrast in patients at high-risk for acute kidney injury (AKI). Contrast-induced nephropathy (CIN) is a major cause of AKI following TAVI and is associated with increased morbidity and mortality. The amount of contrast media used increases the risk for CIN. Computed tomography was omitted during the screening process. For the procedure transfemoral access was default. The self-expanding CoreValve prosthesis was chosen in all patients to minimize the risk of annular rupture in case of oversizing. Valve sizing was based on echocardiography, aortography, calcification on fluoroscopy, as well as weight and height of the patient. A single contrast injection was performed to confirm correct position of the pigtail catheter at the level of the annulus. The pigtail then served as the marker for the device landing zone. Intraprocedural assessment of the implantation result relied on echocardiography and hemodynamics. Five patients with severe aortic stenosis and at high risk for developing CIN were included. Device success was achieved in all patients and no major complications occurred. The median dose of injected contrast media was 8 ml (4-9). All but one patient had improved renal function after the intervention compared to baseline. Our study shows feasibility of performing TAVI with a single minimal contrast media injection, using a self-expandable valve. This technique has the potential to reduce the incidence of CIN.

The role of the heart team in complicated transcatheter aortic valve implantation: a 7-year single-centre experience

European guidelines recommend to perform transcatheter aortic valve implantation (TAVI) within a multidisciplinary heart team. However, there is a strong drive--despite existing guidelines--to perform TAVI outside of specialized centres. The aim of this study was to clarify the necessity of on-site cardiac surgery by providing a clear insight into the complications during/after TAVI that needed surgical management. A total of 2287 (1523 transfemoral, 752 transapical and 12 transaortic) patients, with a mean age of 84.5 ± 5.3 years, and a mean log EuroSCORE of 21.7 ± 16.3, of which 205 were female (84%), underwent TAVI since February 2006 at our institution. All procedure-related complications that required surgical interventions, whether immediate or delayed but within the initial hospital stay, were recorded and retrospectively analysed. Out of this cohort, 245 (10.7%) patients required surgical treatment due to major complications. A total of 42 patients (1.8%) underwent conversion to full sternotomy and 27 (1.2%) were dependent on the short-term use of the heart-lung machine. Vascular complications with surgical intervention were seen in 85 patients (3.7%), 54 patients (2.4%) had to have a rethoracotomy within their initial stay and 15 (0.7%) required a cardiac reoperation. Severe complications during TAVI that can only be resolved surgically will continue to occur. Therefore, each TAVI procedure should be conducted or accompanied by a cardiac surgeon and an experienced team within a specialized centre.

Rotational angiography provides accurate positioning of the valve prosthesis during transcatheter aortic valve implantation

Purpose: To successfully perform transcatheter aortic valve implantation (TAVI) and to limit potential complications it is crucial to identify the optimal implant projection (OP), a view that aligns all three sinuses of Valsalva. The present study aims to investigate the value of intraoperative rotational angiography (DynaCT) for identification of the OP during TAVI. Methods: 29 patients, who underwent TAVI with the use of DynaCT, were compared to a comparable cohort of 29 patients, in whom the OP during TAVI was determined preoperatively using MSCT. In all patients an Edwards SAPIEN bioprosthesis was implanted. Results: DynaCT imaging allowed for immediate finding of OP in 26 out of 29 patients (90%). As opposed to the Dyna-CT group, in the MSCT group at least small correction of a few degrees was always needed to find the OP during the procedure. The use of DynaCT was associated with 44% decrease in amount of radiation and 24% increase in amount of contrast (p=0.002 and p=0.008, respectively) as compared to the MSCT group. The latter was as expected since for DynaCT on average 40ml more contrast is needed. However this extra amount of contrast is diluted (20 ml in 60 ml) and was not associated with a higher incidence of contrast nephropathy in our patients. Conclusions: DynaCT technique allows for easy image integration of a three-dimensional model of the aortic root with life fluoroscopy during TAVI. This technique increases the overall accuracy of specialized imaging during TAVI and diminishes the amount of radiation needed for these procedures.

Association of transaortic approach and transoesophageal echocardiography as the primary imaging technique for improved results in transcatheter valve implantation

The transaortic access has been proposed to perform transcatheter aortic valve implantation in patients with no other available access. We hypothesize that its coupling with transoesophageal echocardiographic guidance may further reduce procedure-related morbidity. Transoesophageal echocardiography was adopted as the primary imaging modality to produce high-resolution images and to guide the deployment of the transcatheter valve. This imaging modality allows continuous visualization not only of the prosthesis and of the delivery system, but also of the surrounding anatomical landmarks (aortic annulus, sinotubular junction and anterior mitral leaflet). We report an initial series of eight patients, who were treated by a transaortic delivery of the transcatheter valve (SAPIEN Valve, Edwards Lifesciences Inc., Irvine, CA, USA) through an upper mini-sternotomy and guided by transoesophageal echocardiography. The procedure was uneventful in all patients; there were no cases of access site morbidity, periprocedural stroke or renal failure. The association of the transaortic route and the transoesophageal echo guidance has the potential to improve the results of transcatheter valve implantation, and deserves further investigation.