Transaortic Access Research Articles

Longitudinal valvotomy of anterior leaflet for endoscopic transmitral myectomy for hypertrophic obstructive cardiomyopathy.

Transmitral myectomy for hypertrophic obstructive cardiomyopathy is compatible with minimally invasive surgery compared with traditional transaortic access. It has often been performed in conjunction with mitral valve replacement or temporary detachment of the anterior leaflet from its annulus. We present a novel approach: longitudinal incision at the midline of the anterior mitral leaflet for septal myectomy. The procedure is ideally conducted endoscopically or robotically through the right chest. Cardiopulmonary bypass is established in the usual manner. After cardioplegic arrest, the mitral valve is exposed, and the anterior mitral leaflet is incised longitudinally at the midline. Both parts of the leaflet are tentatively fixed to the atrial wall with sutures to keep them open. Using the look-up mode of a 30° scope, the right cusp of the aortic valve is observed. Myectomy is initiated close to the aortic annulus using the pure-cut mode of electrocautery and scissors, then extended apically as necessary. After myectomy, the anterior leaflet is reapproximated with interrupted sutures. This technique is simpler than the detachment of the anterior leaflet and does not require patch materials that could lead to durability issues for the reconstruction of the anterior leaflet.

Non-femoral focused transaxillary access in TAVI: GARY data analysis and future trends.

In patients not suitable for transfemoral transcatheter aortic valve implantation (TAVI), several access strategies can be chosen. To evaluate the use and patient outcomes of transaxillary (TAx), transapical (TA), and transaortic (TAo) as alternative access for TAVI in Germany; to further evaluate surgical cutdown vs. percutaneous TAx access. All patients entered the German Aortic Valve Registry (GARY) between 2011 and 2019 who underwent non-transfemoral TAVI were included in this analysis. Patients with TA, TAo, or TAx TAVI were compared using a weighted propensity score model. Furthermore, a subgroup analysis was performed for TAx regarding the percutaneous or surgical cutdown approach. Overall, 9686 patients received a non-transfemoral access. A total of 8918 patients (92.1%) underwent TA, 398 (4.1%) TAo, and 370 (3.8%) TAx approaches. Within the TAx subgroup, 141 patients (38.1%) received subclavian cutdown, while 200 (54.1%) underwent a percutaneous approach. The TA patients had a significantly lower 30-day survival than TAx patients (TA 90.92% vs. TAx 95.59%, p = 0.006; TAo 92.22% vs. TAx 95.59%, p = 0.102). Comparing percutaneous and cutdown TAx approaches, no significant differences were seen. However, more vascular complications occurred (TA 1.8%, TAo 2.4%, TAx 12.2%; p < .001), and the hospital length of stay was shorter (TA 12.9days, TAo 14.1days, TAx 12days; p < .001) after TAx access. It may be reasonable to consider TAx access first in patients not suitable for TF-TAVI, because the 30-day survival was higher compared with TA access and the 1-year survival was higher compared with TAo access. It remains important for the heart teams to offer alternative access modalities for patients not amenable to the standard TF-TAVI approaches.

Transcatheter Aortic Valve Implantation by Intercostal Access: Initial Experience with a No-Touch Technique.

Transcatheter aortic valve implantation (TAVI) is now a well-established therapeutic option in an elderly high-risk patient cohort with aortic valve disease. Although most commonly performed via a transfemoral route, alternative approaches for TAVI are constantly being improved. Instead of the classical mini-sternotomy, it is possible to achieve a transaortic access via a right anterior mini-thoracotomy in the second intercostal space. We describe our experience with this sternum- and rib-sparing technique in comparison to the classical transaortic approach. Our retrospective study includes 173 patients who were treated in our institution between January 2017 and April 2020 with transaortic TAVI via either upper mini-sternotomy or intercostal thoracotomy. The primary endpoint was 30-day mortality, and secondary endpoints were defined as major postoperative complications that included admission to the intensive care unit and overall hospital stay, according to the Valve Academic Research Consortium 3. Eighty-two patients were treated with TAo-TAVI by upper mini-sternotomy, while 91 patients received the intercostal approach. Both groups were comparable in age (mean age: 82 years) and in the proportion of female patients. The intercostal group had a higher rate of peripheral artery disease (41% vs. 22%, p = 0.008) and coronary artery disease (71% vs. 40%, p < 0.001) with a history of percutaneous coronary intervention or coronary artery bypass grafting, resulting in significantly higher preinterventional risk evaluation (EuroScore II 8% in the intercostal vs. 4% in the TAo group, p = 0.005). Successful device implantation and a reduction of the transvalvular gradient were achieved in all cases with a significantly lower rate of trace to mild paravalvular leakage in the intercostal group (12% vs. 33%, p < 0.001). The intercostal group required significantly fewer blood transfusions (0 vs. 2 units, p = 0.001) and tended to require less reoperation (7% vs. 15%, p = 0.084). Hospital stays (9 vs. 12 d, p = 0.011) were also shorter in the intercostal group. Short- and long-term survival in the follow-up showed comparable results between the two approaches (30-day, 6-month- and 2-year mortality: 7%, 23% and 36% in the intercostal vs. 9%, 26% and 33% in the TAo group) with acute kidney injury (AKI) and reintubation being independent risk factors for mortality. Transaortic TAVI via an intercostal access offers a safe and effective treatment of aortic valve stenosis.

Feasibility and safety of three-dimensional electroanatomical cardiac mapping, mapping-guided biopsy and transseptal puncture in dogs

Three-dimensional electroanatomical mapping (3D EAM) has expanded radiofrequency catheter ablation applications in humans to almost all complex arrhythmias and has drastically reduced fluoroscopy use, yet its potential in dogs is poorly investigated. The objectives of the current study were to assess the feasibility and safety of 3D EAM of all four heart chambers, 3D EAM-guided biopsies and transseptal puncture in dogs. Eight healthy purpose-bred Beagle dogs. Electroanatomical mapping was performed under general anaesthesia during sinus rhythm using a 22-electrode mapping catheter. Left heart catheterisation was achieved by either retrograde transaortic access (n = 4) or transseptal puncture (n = 4). Successful 3D EAM of the right atrium and ventricle was achieved in all dogs at a median time of 33 (13–40) min and 17 (3–52) min, respectively. Left atrial and ventricular 3D EAM was successful in six and seven dogs, at a median time of 17 (4–27) min and 8 min (4–19 min), respectively. Complications requiring intervention occurred in one dog only and were a transient third degree atrioventricular block and pericardial effusion following transseptal puncture, which was treated by pericardiocentesis. All dogs recovered uneventfully. Fluoroscopy time was limited to a median of 7 min (0–45 min) and almost exclusively associated with transseptal puncture. Three-dimensional EAM of all cardiac chambers, including mapping-guided biopsy and transseptal puncture is feasible in small dogs. Complications are similar to those reported in human patients. This suggests a potential added value of 3D EAM to conventional electrophysiology in dogs with arrhythmias.

Association Between Peripheral Versus Central Access for Alternative Access Transcatheter Aortic Valve Replacement and Mortality and Stroke: A Report From the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry.

In some patients, the alternative access route for transcatheter aortic valve replacement (TAVR) is utilized because the conventional transfemoral approach is not felt to be either feasible or optimal. However, accurate prognostication of patient risks is not well established. This study examines the associations between peripheral (transsubclavian/transaxillary, and transcarotid) versus central access (transapical and transaortic) in alternative access TAVR and 30-day and 1-year end points of mortality and stroke for all valve platforms. Using data from The Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry with linkage to Medicare claims, patients who underwent alternative access TAVR from June 1, 2015 to June 30, 2018 were identified. Adjusted and unadjusted Cox proportional hazards modeling were performed to determine the association between alternate access TAVR site and 30-day and 1-year end points of mortality and stroke. Of 7187 alternative access TAVR patients, 3725 (52%) had peripheral access and 3462 (48%) had central access. All-cause mortality was significantly lower in peripheral access versus central access group at in-hospital and 1 year (2.9% versus 6.3% and 20.3% versus 26.6%, respectively), but stroke rates were higher (5.0% versus 2.8% and 7.3% versus 5.5%, respectively; all P<0.001). These results persisted after 1-year adjustment (death adjusted hazard ratio, 0.72 [95% CI, 0.62-0.85] and stroke adjusted hazard ratio, 2.92 [95% CI, 2.21-3.85]). When broken down by individual subtypes, compared with transaxillary/subclavian access patients, transapical, and transaortic access patients had higher all-cause mortality but less stroke (P<0.05). In this real-world, contemporary, nationally representative benchmarking study of alternate access TAVR sites, peripheral access was associated with favorable mortality and morbidity outcomes compared with central access, at the expense of higher stroke. These findings may allow for accurate prognostication of risk for patient counseling and decision-making for the heart team with regard to alternative access TAVR.

Analysis of electrocardiographic signs in hypertrophic cardiomyopathy before and after septal myectomy. New criterion for proximal left bundle branch block

Aim. To analyze 20 electrocardiographic (ECG) signs of left bundle branch block (LBBB) before and after septal myectomy in patients with hypertrophic cardio myopathy (HCM) and develop a criterion for proximal LBBB based on the selected signs.Material and methods. This retrospective non-randomized study included 50 patients with obstructive HCM who underwent septal myectomy. There were following inclusion criteria: QRS width &lt;120 ms before surgery, transaortic access during septal myectomy, and QRS width ≥120 ms in the early postoperative period. For each patient, ECGs were analyzed before septal myectomy and in the first week after surgery. At the same time, 20 ECG signs proposed earlier in the LBBB criteria were independently assessed.Results. Exsection of a small myocardial area of the basal interventricular septal parts, weighing an average of 4,9±2 grams, led to a significant increase in the QRS width (by 61±14,6 ms) and the prevalence of almost all ECG signs of LBBB. In 100% of cases (n=50), the following signs demonstrated significant dynamics after surgery: (1) midQRS notching or slurring in ≥2 contiguous leads (I, aVL, V1-V2, V5-V6); (2) absence of q wave in V5-V6 and (3) discordant T wave in at least two leads (I, aVL, V5, V6). Based on the design of the study, (4) QRS width ≥120 ms was additionally included. These ECG characteristics were combined into a new criterion for proximal LBBBConclusion. A new criterion for proximal LBBB was developed using the pathophysiological model of iatrogenic conduction block of left bundle branch. Further estimation of this criterion on a set of candidates for CRT with heterogeneous level of LBBB is necessary.

Transcatheter aortic valve implantation via transaortic surgical access

We report a case of an 80-years&amp;ndash;old patient with a severe, symptomatic aortic valve stenosis and history of ischemic heart disease, previously treated by coronary artery bypass graft surgery. The patient was contraindicated for conventional surgical aortic valve replacement (SAVR) due to advanced age and underlying comorbidity, therefore transcatheter aortic valve implantation (TAVI) has been offered. The access options for the procedure were restricted by the underlying generalized atherosclerosis process causing peripheral vessel disease. We have chosen transaortic access for the patient which in that case was the only possible option. The transaortic valve implantation was successful with satisfactory hemodynamic results, improvement in functional class heart failure of the patient and preserving the function and anatomy of the coronary artery bypass graft. This case report demonstrates that the lack of favorable transfemoral access for TAVI should not be a limitation by itself for the procedure, rather than be stimulus for searching and using new and alternative access for it.

Minireview: Transaortic Transcatheter Aortic Valve Implantation: Is There Still an Indication?

Transaortic (TAo) transcatheter aortic valve implantation has become a valid alternative access route in patients with unsuitable femoral arteries. The current literature does not allow to clearly favor one of the alternative access routes. Every approach has its specific advantages. Transaortic (TAo) access is of particular importance in the case of calcifications of the supra-aortic branches and the aortic arch, as under these circumstances other alternative access routes, such as transaxillary or transcarotid, are not feasible. The purpose of this minireview is to give an overview and update on TAo transcatheter aortic valve implantation focusing on indication, technical aspects, and recent clinical data.

Surgery after Failed Transcatheter Aortic Valve Implantation: Indications and Outcomes of a Concerning Condition.

Objectives: The number of transcatheter aortic valve implantations (TAVI) has increased enormously in recent decades. Transcatheter valve prosthesis failure and the requirement of conventional surgical replacement are expected to attract more focus in the near future. Indeed, given the scarcity of research in this field, the next decade will likely represent the beginning of a period of meaningful exploration of the degenerative changes that occur with transcatheter valves. The current study represents—through a series of consecutive cases—one of the first analyses of the underlying causes of TAVI failure, i.e., degenerative, functional and infective, followed by surgical aortic valve replacement (SAVR) and postoperative outcome. Methods: Between October 2008 and March 2021, 2098 TAVI procedures, including 1423 with transfemoral, 309 with transapical, and 366 with transaortic access, were performed in our institution. Among these, 0.5% (number(n) = 11) required acute SAVR (n = 6) within 7 days (n = 3) or later (n = 2), and were included in the study. Results: Valve stent dislocation was the most common cause of replacement (83%). Causes of replacement within 7 days after TAVI were multifactorial. In the later course, endocarditis was the sole indication for SAVR after TAVI. TAVI with transapical or transaortal approach had a higher EuroSCORE II (10.9 (7.2–35.3) vs. 3.5 (1.8–7.8)). Their 30-day mortality after surgical conversion was higher (67% vs. 20%), when compared to those who underwent a transfemoral procedure. The longest documented survival beyond 30 days was 58 months. Conclusions: The causes of SAVR after TAVI failure are multifactorial, and include biological, physical and infectious factors. An acceptable midterm prognosis may be expected in patients with physical causes when dislocation of the catheter prosthesis is observed; in such cases, emergency conversion is required. Conversion due to infection, as in cases of endocarditis, had the worst outcome. Prognosis after conversion due to degeneration is still problematic, due to a lack of autopsies and the recent history of prosthetic implantations.

Feasibility of the Transseptal Approach for Mapping and Ablation in Patients with Ventricular Aneurysm-Related Ventricular Tachycardia with a Steerable Sheath

Background: A retrograde transaortic access might be limited in mapping and ablation for some left ventricular (LV) arrhythmias. We examined the feasibility and safety of a transseptal approach for catheter ablation of LV aneurysm (LVA)-related ischemic ventricular tachycardia (VT). Subjects and Methods: Five consecutive patients with postinfarction LVA-related VT were selected for catheter ablation at Fuwai Hospital from April 2011 to October 2015 in this retrospective study. After a routine transaortic LV-mapping approach was failed, a transseptal approach with a steerable sheath was performed in all these cases. The study was approved by the Ethics Committee of Fuwai Cardiovascular Hospital (approval No. 2016-768) on May 24, 2016. Results: In these five patients, four had LVAs located in the LV apical area, and one in the septum. Acute ablation successes were all failed to achieve through the transaortic route. Two were due to aortic stenosis and tortuous peripheral arteries and the others were due to failure to target the effective sites. While all ablation procedures succeeded through the sequent transseptal approach with a steerable sheath, and no major complications related to the transseptal approach were reported. During the 12-month (10–12 months) follow-up, no electrical storm or episode of VT was documented. One VT recurrence occurred, yet acute success was obtained again through the transseptal approach. Conclusions: Transseptal approach appears a feasible, safe, and effective method in catheter ablation for VT with LVA and could be considered as an elective approach.

New Intercostal Transcatheter Aortic Valve Replacement Access: No Touch.

Transcatheter aortic valve replacement (TAVR) is routinely performed via the transfemoral or transapical route. Subclavian, transcarotid, and transaortic access are described as alternative routes for TAVR. The small intercostal approach can be used for a safe TAVR without touching the ribs and sternum.

Five-Meter Walk Test as a Predictor of Prolonged Index Hospitalization After Transcatheter Aortic Valve Implantation

There are no studies evaluating comprehensive predictors of transcatheter aortic valve implantation (TAVI) outcomes encompassing frailty assessments in a South-East Asian cohort. In this longitudinal single-center cohort, all patients who underwent TAVI in a tertiary cardiac center and comprehensively assessed for frailty at baseline were included in a registry. The primary outcome was to investigate frailty indices predictive of prolonged index hospitalization after TAVI. Seventy-six patients with a mean age of 77.6 ± 8.5 years were included. Mean Society of Thoracic Society Predicted Risk of Mortality score was 5.2 ± 3.0, with 11 (14.5%) patients classified as high-risk (Society of Thoracic Society Predicted Risk of Mortality >8). Mean and median index hospitalization duration were 9.2 ± 5.6 and 7 [4.5 to 9.5] days, respectively. Univariate analysis demonstrated that lower hemoglobin (Hb) (p <0.01), longer 5-meter walk test (5MWT) (p <0.01), lower dominant hand grip strength (p <0.01), the use of transaortic access (p = 0.01), new atrial fibrillation post-TAVI (p <0.01), and lower postprocedural Hb (p <0.01) were associated with longer index hospitalization duration. Multivariate linear regression demonstrated preoperative Hb, preoperative atrial fibrillation and 5MWT were independent baseline predictors of index hospitalization duration (p <0.05). Additionally, a 5MWT cutoff of 11 seconds (0.45 m/s) had a high specificity (88.6%) in predicting prolonged index hospitalization duration. In conclusion, this is the first comprehensive frailty assessment in a South-East Asian cohort demonstrating 5MWT to be a significant predictor of prolonged index hospitalization. This simple and effective frailty assessment index may be considered to optimize patient selection for TAVI.

Outcomes Following Subclavian and Axillary Artery Access for Transcatheter Aortic Valve Replacement: Society of the Thoracic Surgeons/American College of Cardiology TVT Registry Report

ObjectivesThe aim of this study was to analyze the frequency and outcomes of patients who underwent transsubclavian or transaxillary (TAx) transcatheter aortic valve replacement (TAVR) using the balloon-expandable SAPIEN 3 prosthesis compared with traditional alternative access, transapical (TA) and transaortic (TAo). BackgroundThe transsubclavian and TAx approaches for TAVR are rapidly growing alternatives in the setting of hostile iliofemoral arteries, yet few data exist. MethodsThe Society of Thoracic Surgeons/American College of Cardiology TVT (Transcatheter Valve Therapy) Registry was queried for all patients undergoing TAx TAVR with the SAPIEN 3 prosthesis from June 2015 to February 2018. Secular trends over time were evaluated. Logistic regression analyses used to assess risk-adjusted outcomes. Propensity score matching was used to compare TAx access with TA and TAo access. ResultsIn total, 3,628 patients (5.7%) underwent nontransfemoral access with the SAPIEN 3. Overall, TAx TAVR accounted for 1,249 of these patients (34.4%). There has been rapid recent growth in TAx TAVR (from 20.2% in the third quarter of 2015 to 49.0% in the fourth quarter of 2017; p < 0.001 for trend) and a concomitant decrease in TA and TAo access (from 61.9% in the third quarter of 2015 to 35.3% in the fourth quarter of 2017; p < 0.001 for trend). The median number of TAx TAVR cases per hospital during the study period was 2, and 78.2% of centers performed ≤5 TAx TAVR procedures. The device success rate was 97.3%, and the major vascular complication rate was 2.5%. After propensity matching, TAx access had lower 30-day mortality (5.3% vs. 8.4%; p < 0.01), shorter lengths of intensive care unit and hospital stay, but a higher stroke rate (6.3% vs. 3.1%; p < 0.05) compared with TA and TAo access. ConclusionsTAx access has become the most frequent alternative access route for balloon-expandable TAVR procedures. Outcomes following TAx TAVR appear positive despite the relatively early experience of most centers performing these cases.

Transcarotid Versus Transapical and Transaortic Access for Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) using transcarotid access may improve outcomes compared with transapical or transaortic access. This study retrospectively evaluated 165 patients who were undergoing alternate access TAVR using transcarotid (n= 84), transapical (n= 48), and transaortic (n= 33) access. The 30-day outcomes and 2-year Kaplan-Meier survival were analyzed using a multivariable Cox proportional hazards model. The median Society of Thoracic Surgeons predicted risk of mortality was similar among patients treated by transcarotid, transapical, and transaortic access (9.0% [interquartile range (IQR), 6.6, 12.0] vs 9.1% [IQR, 7.0, 11.7] vs 10.0% [IQR, 8.5, 13.0]; p= 0.14), respectively. Patients treated with transcarotid TAVR had a trend toward lower 30-day mortality (3.6% [3 of 84] vs 6.3% [3 of 48] vs 15.2% [5 of 33]; p= 0.09) and significantly better 2-year survival (88.4% vs 79.2% vs 63.6%; p= 0.004) compared with patients treated by transapical and transaortic access, respectively. In addition, transcarotid access was associated with a shorter median length of stay (3.0 days [IQR, 2.0, 5.0] vs 6.5 days [IQR. 5.0, 9.5] vs 7.0 days [IQR, 5.0, 9.0]; p < 0.001), lower transfusion rate (4.8% [4 of 84] vs 12.0% [12 of 48] vs 24.2% [8 of 33]; p < 0.001), higher likelihood of discharge to home without home health care (89.3% [75 of 84] vs 54.2% [26 of 48] vs 42.4% [14 of 33]; p < 0.001), and similar 30-day stroke rates (2.4% [2 of 84] vs 2.1% [1 of 48] vs 3.0% [1 of 33];p= 0.9). Transcarotid compared with transapical and transaortic access for TAVR is associated with shorter length of stay, fewer transfusions, more frequent discharge to home, and better 2-year survival.

The use of a high-resolution mapping system may facilitate standard clinical practice in VE and VT ablation.

First experiences using a 64-electrode mini-basket catheter (BC) paired with an automatic mapping system (Rhythmia™) for catheter ablation (CA) of ventricular ectopy (VE) and ventricular tachycardia (VT) have been reported. We aimed to evaluate (1) differences in ventricular access for the BC and (2) benefit of this technology in the setting of standard clinical practice. Patients (pts) undergoing CA for VE or VT using the Intellamap Orion™ paired with the Rhythmia™ automated-mapping system were included in this study. For LV access, transseptal and retrograde access were compared. All 32 pts (29 men, age 63 ± 15years) underwent CA for VE (17 pts) or VT (15 pts). For mapping of VE originating from the left ventricle (LV) in 10 out of 13 pts, a transaortic access was feasible. The predominant access for CA of VT was transaortic (5/7). Feasibility and safety seem to be equal. The total procedure time was 179.1 ± 21.2min for VE ablation and 212.0 ± 71.7min for VT ablation (p = 0.177). For VE, an acquisition of 1602 ± 1672 map points and annotation of 140 ± 98 automated mapping points sufficed to abolish VE in all pts. During a 6-month follow-up (FU) after CA for VE, a VE burden reduction from 18.5 ± 2.1% to 2.8 ± 2.2% (p = 0.019) was achieved. In VT pts, one patient showed recurrence of sustained VT episodes during FU. Use of a high-resolution mapping system for VE/VT CA potentially facilitates revelation of VE origin and VT circuits in the setting of standard clinical practice. Feasibility and safety of a venous, transaortic, transseptal, or a combined approach seem to be equal.

Open chest epicardial and transapical endocardial substrate ablation for ventricular tachycardia with left ventricular aneurysm in a porcine model.

Endo-epicardial radiofrequency catheter ablation (RFCA) of ventricular tachycardia (VT) as a first-line strategy has been shown to improve outcomes. This study sought to evaluate the feasibility and validity of open-chest epicardial and transapical endocardial substrate ablation for VT with left ventricular aneurysm (LVA) applying to routine cardiac surgery. Porcine models of LVA with VT were developed and were divided into a study group (RFCA from the epicardium via direct-view and endocardium via transapical access) and a control group (endocardial RFCA via retrograde transaortic access). Substrate-based mapping and ablation targeting abnormal potentials were performed under thoracotomy. Outcomes, including procedural success and acute freedom from VT, were analysed. Twenty-four of 35 (68.57%) acute myocardial infarction (AMI) pigs developed LVA with VT in a 6-week survival period and were randomly divided into a study group (n=12) and a control group (n=12). All animals in the study group successfully underwent endocardial mapping and ablation by transapical access. The scar size of the endocardium and the left ventricular chamber volume were similar in the two groups. Acute freedom from VT in the study group was remarkably superior to that in the control group (88.33% vs. 58.33%, p=0.04). Combined, direct epicardial and transapical endocardial substrate mapping and ablation appeared to be feasible and effective for treating VT with LVA under thoracotomy.

Comparison of Transaortic and Subclavian Approaches for Transcatheter Aortic Valve Replacement in Patients with No Transfemoral Access Options

ABSTRACT Background: To compare outcomes among transcatheter aortic valve replacement (TAVR) performed via transaortic (TAo) and subclavian (SCL) approaches. Many patients are not amenable for TAVR via the transfemoral route due to peripheral vascular disease. Limited data exist regarding safety and procedural feasibility of TAVR via TAo and SCL routes. Methods: Single-center study comparing patients treated with CoreValve® and Sapien XT® from May 2013 to August 2015 via subclavian (SCL) or transaortic (TAo) approach. All patients were deemed inappropriate for transfemoral access. Baseline characteristics, procedural feasibility, and outcomes were compared. Results: A total of 27 (53%) patients underwent TAVR via the TAo approach and 24 (47%) via the SCL approach. Society of Thoracic Surgeons (STS) risk scores and patient age were similar: 11.33 versus 8.66; p = 0.13 and 84.7 years versus 82.6 years; p = 0.3, respectively. All patients in the SCL group received self-expandable valves. Overall vascular complications were low in both groups (SCL = 4.2% vs. TAo = 3.7%). Length of hospital stay was marginally longer in the TAo group (mean 7.25 vs. 6.2 days, p = 0.119). There was a trend towards increased mortality associated with TA access (11.1% vs. 4%, p = 0.36) at 30 days that was significant after 12 months (33.3% vs. 8.3%, p = 0.03). Conclusion: Our data shows a relatively low incidence of complications and comparable outcomes in these two groups. SCL or TAo access can be utilized as alternatives in patients with prohibitive ileofemoral anatomy, however, based on our limited data, subclavian access with self-expanding valves offers better outcomes.

Propensity-matched comparison of clinical outcomes after transaortic versus transfemoral aortic valve replacement

We aimed to compare the long-term outcomes of transaortic (TAo-AVR) and transfemoral (TF-AVR) transcatheter aortic valve replacement. Between January 2012 and December 2015, consecutive TAo-AVR and TF-AVR cases were compared using a propensity score-matching analysis. Primary endpoints were 30-day and one-year mortality; 644 TAVR patients were included (163 TAo-AVR and 481 TF-AVR). Peripheral artery disease (31.9% vs. 5%, p<0.001) and coronary artery disease (50.0% vs. 39.3%, p=0.009) were more frequent in TAo-AVR patients. The Society of Thoracic Surgeons scores were not different (6.9% vs. 6.5%, p=0.243). Propensity matching identified 124 well-matched patient pairs. Thirty-day and one-year mortality rates were similar in the overall population of TAo-AVR and TF-AVR patients (7.3% vs 7.6%, p=0.8 and 18.4% vs. 15.8%, p=0.6, respectively), and in the matched cohort (7.3% vs. 6.5%, p=0.8 and 15.3% vs. 16.1%, p=0.8, respectively). Transaortic access was associated with higher risk of new onset of atrial fibrillation (NOAF) (24.4% vs. 9.6%, p=0.012), life-threatening bleedings (6.5% vs. 0.8%, p=0.036) and transfusion (41% vs. 16.7%, p<0.001). No significant differences were observed between the respective 30-day and one-year mortality rates of TAo-AVR and TF-AVR patients. The transaortic approach thus constitutes a valid alternative to TF-AVR, but is associated with higher rates of NOAF, bleedings, and transfusion.

Случай успешного устранения эпикардиально расположенной монофокусной правопредсердной тахикардии из трансаортального доступа.

Случай успешного устранения эпикардиально расположенной монофокусной правопредсердной тахикардии из трансаортального доступа.

Случай успешной радиочастотной аблации фибрилляции предсердий из области муфты верхней полой вены

Случай успешной радиочастотной аблации фибрилляции предсердий из области муфты верхней полой вены