Transaortic Transcatheter Aortic Valve Replacement Research Articles

Ten-Year Experience with Transapical and Direct Transaortic Transcatheter Aortic Valve Replacement to Address Patients with Aortic Stenosis and Peripheral Vascular Disease.

Objective: Transcatheter aortic valve replacement (TAVR) through alternative access routes is indicated in patients with severe aortic valve stenosis and diseased peripheral arteries. We analysed and compared the outcome of patients undergoing transapical (TA) and direct transaortic (TAO) TAVR procedures. Methods: Preoperative characteristics, procedural details, and thirty-day outcome of patients undergoing transapical (TA-TAVR group) and direct transaortic (TAO-TAVR group) TAVR procedures were prospectively collected and retrospectively analysed. Results: From March 2012 to March 2022, 81 TA and 82 TAO-TAVR (total: 163 cases) were performed with balloon-expanding (n = 120; 73.6%) and self-expandable (n = 43; 26.4%) valves. The mean age was 79.7 ± 6.2 and 81.9 ± 6.7 years for the TA- and TAO-TAVR groups, respectively (p = 0.032). Females were more represented in the TAO-TAVR group (56% vs. 32%; p = 0.003) while TA-TAVR patients showed a higher prevalence of previous vascular surgery (20% vs. 6%; p = 0.01), previous cardiac surgery (51% vs. 3.6%; p < 0.001), and porcelain aorta (22% vs. 5%; p = 0.001). The mean ejection fraction was 49.0 ± 14.6% (TA) and 53.5 ± 12.2% (TAO) (p = 0.035) while mean gradients were 35.6 ± 13.2 mmHg (TA) and 40.4 ± 16.1 mmHg (TAO) (p = 0.045). The median EuroSCORE-II was 5.0% (IQR: 3.0−11.0) and 3.9% (IQR: 2.5−5.4) for the TA- and TAO-TAVR groups, respectively (p = 0.005). The procedural time was shorter for TA procedures (97 min (IQR: 882−118) vs. 102 min (IQR: 88−129); p = 0.133). Mortality at day 30 was 6% in both groups (p = 1.000); the permanent pacemaker implantation rate was similar (8.6% vs. 9.7%; p = 1.000), and hospital stay was shorter for the TAO group (8 days (IQR: 6−11) vs. 10 days (IQR: 7−13); p = 0.025). Conclusions: Our results show that transapical and direct transaortic TAVR in high-risk patients with diseased peripheral arteries provide satisfactory clinical results with similar thirty-day outcomes.

Transaxillary Versus Transaortic Transcatheter Aortic Valve Implantation in the Treatment of Aortic Stenosis: An Updated Systematic Review and Meta-Analysis.

Transcatheter aortic valve replacement (TAVR) is a technique that can be performed through multiple approaches, and the benefits of one approach over another are still being evaluated to make sure patients receive the best possible care. Our meta-analysis aims to compare clinical and procedural outcomes of the transaxillary (TAx) and transaortic (TAo) approaches to validate the more optimal procedure.The systematic literature search was done via PubMed/MEDLINE, Embase, and the Cochrane Central databases from inception to December 2021, to identify articles reporting data on both TAx TAVR and TAo TAVR. In addition, we checked ClinicalTrials.gov for more published or unpublished trials. Baseline patient characteristics, procedure results, and clinical results were extracted from the article and pooled for analysis. A quantitative meta-analysis was conducted using Review Manager (RevMan) version 5.3 (Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark). The outcomes extracted included blood transfusion, conversion to sternotomy, tamponade, contrast amount, procedure time, bleeding incidents (minor, major, or life-threatening), length of stay (LOS), vascular complications (minor or major), acute kidney injury (AKI), paravalvular leak (PVL), permanent pacemaker (PPM) implantation, 30-day mortality, one-year mortality, 30-day stroke, and device success.The final analysis included 11 articles, consisting of 10 observational studies and a pivotal trial. Cumulative results revealed that the TAo approach had a significantly lower incidence of vascular complications (RR = 2.30; 95% CI = 1.22 to 4.35), and the need for implantation of a permanent pacemaker (RR = 1.82; 95% CI = 1.30 to 2.54) along with a lower amount of contrast (mean difference (MD) = 27.40; 95% CI = 3.73 to 51.08) needed to be used. The TAx group was associated with a significantly lower 30-day mortality (RR = 0.46; 95% CI = 0.31 to 0.69), AKI (RR = 0.47; 95% CI = 0.33 to 0.67), and length of hospital stay (MD = −1.95; 95% CI = −2.51 to −1.38). No significant difference was observed between the outcomes of 30-day stroke (RR = 1.38; 95% CI = 0.81 to 2.33), PVL (RR = 1.05; 95% CI = 0.50 to 2.18), tamponade (RR = 0.71; 95% CI = 0.12 to 4.03), conversion to sternotomy (RR = 0.51; 95% CI = 0.06 to 4.30), device success (RR = 0.97; 95% CI = 0.88 to 1.07), the incidence of bleeding (RR = 0.75; 95% CI = 0.51 to 1.10), and procedure time (MD = 4.44; 95% CI = −96.30 to 105.17).Both the procedures were associated with their benefits and risks. Although most of the outcomes favored TAx transcatheter aortic valve implantation (TAVI), it is too early to say if it would be better than TAo TAVI. To authenticate the findings concluded in this meta-analysis and further improve our understanding of the efficacy, safety, and risk profile between TAx and TAo approaches for TAVI, large sample randomized clinical trials are required on a wide scale.

Transaortic Transcatheter Aortic Valve Replacement in Patients From a Single Institution - Feasibility, Safety, and Midterm Outcomes.

Transaortic transcatheter aortic valve replacement (TAo-TAVR) is an alternative to peripheral or transapical TAVR. The procedural feasibility, safety, and midterm outcomes of TAo-TAVR were investigated in this study.Methods and Results:Eighty-four consecutive patients underwent TAo-TAVR from 2011 to 2021. Their median age was 83 years (interquartile range, 80-87 years). The Edwards SAPIEN and Medtronic CoreValve devices were used in 45 (53.6%) and 38 (45.2%) patients, respectively. The surgical approach was a right mini-thoracotomy in 43 patients (51.2%) and partial sternotomy in 4 patients (4.8%). The remaining 37 patients (44.0%) underwent full sternotomy because of concomitant off-pump coronary artery bypass grafting. VARC-3 device success was achieved in 77 patients (91.7%). Valve migration occurred in 3 patients (3.6%) using a first-generation CoreValve device, necessitating implantation of a second valve. No aortic annulus rupture, aortic dissection, or coronary orifice occlusion occurred. Conversion to surgery was required for 1 patient because of uncontrollable bleeding. Only 1 in-hospital death occurred. New pacemaker implantation was required in 6 patients (7.1%). Echocardiography at discharge showed no or trivial paravalvular leak (PVL) in 58 patients (69.0%), mild PVL in 23 (27.4%), and mild to moderate PVL in 2 (2.4%) patients. The 1- and 3-year incidence of cardiovascular death was 1.6% and 4.8%, respectively, with no structural valve deterioration. TAo-TAVR is feasible and safe with satisfactory midterm outcomes using both currently available devices.

Alternative access in high-risk patients in the era of transfemoral aortic valve replacement

Background We aimed to evaluate the outcomes of transapical and transaortic transcatheter aortic valve replacement (TAVR) in high-risk patients who were not suitable for transfemoral access and had a logistic EuroSCORE-I ≥ 25% and Society of Thoracic Surgeons (STS) score >6%. ‘STS/ACC TAVR In-Hospital Mortality Risk App’ was evaluated. Material and methods Between January 2016 and May 2020, 126 patients at very high risk for aortic valve replacement underwent transapical (n = 121) or transaortic (n = 5) transcatheter aortic valve replacement. TAVR was performed using SAPIEN 3™ or ACURATE TA™ prosthesis. Results The logistic EuroSCORE-I was 40.6 ± 14.0%, the STS-score 7.9 ± 4.6%, and STS/ACC-score 8.4 ± 3.4%. Valve implantation was successful in all patients. Operative, in-hospital and 30-days mortality, were 0, 7.9, and 13.5%, respectively. Survival was 72% at one year and 48% at four years. Expected/observed in-hospital mortality was 1.0 for the STS-score and 1.06 for the STS/ACC-score. Renal failure, low ejection fraction, and postoperative acute kidney injury, hemorrhage, and vascular complications were identified as independent predictors for 30-day mortality. Conclusions Transapical and transaortic TAVR in high-risk patients unsuitable for transfemoral access is still a reasonable alternative in these patients. STS and STS/ACC-score appear to be highly accurate in predicting in-hospital mortality in high-risk patients undergoing TAVR.

General Anesthesia Increased the Risk of Atrial Fibrillation and Acute Kidney Injury in Transcatheter Aortic Valve Replacement.

To examine key impacts of anesthesia on new-onset atrial fibrillation (AF) and acute kidney injury (AKI) in transcatheter aortic valve replacement (TAVR). All consecutive patients who underwent transfemoral, transapical, and transaortic TAVR in Fuwai Hospital from 2012 to 2018 were retrospectively analyzed and dichotomized into 2 groups: TAVR under conscious sedation (CS) and under general anesthesia (GA). The primary endpoint was a composite of all-cause mortality, stroke, AF, permanent pacemaker implantation, myocardial infarction, heart failure, high-grade atrioventricular block, and AKI at 1 year. Binary logistic regression and adjusted multilevel logistic regression were performed to analyze the predictors of AF and AKI. A total of 107 patients were under CS and 66 patients under GA. No significant difference was observed in the composite endpoint (51.5% vs. 41.2%, GA vs. CS, P = .182) and ≥ mild paravalvular leakage (36.4% vs. 31.4%, GA vs. CS, P = .589) at 1 year. However, the GA group had a significantly higher rate of intensive care unit (ICU) admission (84.8% vs. 6.5%, P < .001), AKI (28.8% vs. 14.0%, P = .018), new-onset AF (15.2% vs. 5.5% at 1 year, P = .036). Multivariable analysis revealed GA to be the significant predictor of new-onset AF (odds ratio 3.237, 95% confidence interval 1.059 to 9.894, P = .039) and AKI (odds ratio 2.517, 95% confidence interval 1.013 to 6.250, P = .047). GA was associated with higher rates of ICU admission, postoperative AKI, and new-onset AF. The results may provide new evidence that CS challenges universal GA.

Transcarotid versus transthoracic access for transcatheter aortic valve replacement: A propensity-matched analysis.

Transcarotid access for transcatheter aortic valve replacement is emerging as an alternative to more traditional nonfemoral access options such as transapical or transaortic; however, comparative data are limited. The purpose of the study was to analyze outcomes after transcatheter aortic valve replacement using transcatheter compared with transthoracic (transapical/transaortic) access. The Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry was queried for patients who underwent transcarotid, transapical, or transaortic transcatheter aortic valve replacement with the SAPIEN 3 (Edwards Lifesciences, Irvine, Calif) transcatheter heart valve between June 2015 and July 2019. Thirty-day unadjusted outcomes were evaluated, and propensity score matching and logistic regression were used to compare transcatheter access with transthoracic access. In the propensity-matched analysis, 667 transcarotid transcatheter aortic valve replacement procedures were compared with 1334 transthoracic procedures. Transcarotid transcatheter aortic valve replacement was associated with lower mortality (4.2% vs 7.7%, P=.004), less new-onset atrial fibrillation (2.2% vs 12.1%, P<.0001), fewer readmissions at 30days (9.8% vs 16.1%, P=.0006), shorter median length of stay (3.0 vs 6.0days, P<.0001), shorter median intensive care unit stay (25 vs 47.2hours, P<.0001), and greater 30-day Kansas City Cardiomyopathy Questionnaire score improvement from baseline (25.1 vs 20.8, P=.007). Stroke (4.3% vs 3.7%, P=.44) and major vascular complications (1.4% vs 1.9%, P=.40) were similar. Transcatheter aortic valve replacement using transcarotid access is associated with lower 30-day mortality, less atrial fibrillation, shorter intensive care unit and overall length of stay, fewer readmissions, greater improvement in Kansas City Cardiomyopathy Questionnaire scores, and no significant difference in stroke or major vascular complications compared with transthoracic access.

A meta-analysis comparing transaxillary and transaortic transcatheter aortic valve replacement.

The alternative access route of choice for transcatheter aortic valve replacement (TAVR) remains to be elucidated due to lack of evidences. We performed a meta-analysis comparing the outcomes of two common alternative access routes, transaxillary (TAx) and transaortic (TAo) approaches. The PubMed/MEDLINE, Embase, and Cochrane library from inception to December 2018 were searched to identify the articles reporting data on both TAx-TAVR and TAo-TAVR. Patients' baseline characteristics, procedural outcomes, and clinical outcomes were extracted from the articles and pooled for analysis. Four studies, a total of 750 (374 TAo and 376 TAx) patients were included in the study. The two groups were similar in patients' baseline characteristics, although the TAx group comprised few female patients. The two groups differ in outcomes including 30-day mortality, rates of pacemaker implant and acute kidney injury, and length of hospital stay. There were no differences between the two groups with regard to device success, paravalvular leak, stroke, vascular complications, and 1-year mortality. Compared with the TAo approach, the TAx approach is associated with favorable short-term mortality, lower incidence of acute kidney injury, and shorter length of hospital stay, but increased pacemaker requirement. TAx could be considered over TAo as the preferred alternative access for TAVR.

Alternative access for transcatheter aortic valve replacement in older adults: A collaborative study from France and United States.

We examined the outcomes of older adults undergoing nontrans-femoral (non-TF) transcatheter aortic valve replacement (TAVR) procedures including trans-apical (TA), trans-aortic (TAo), trans-subclavian (TSub), and trans-carotid (TCa) techniques. This is an observational study of all consecutive older patients who underwent non-TF TAVR for symptomatic severe AS with Edwards Sapien (ES), Medtronic CoreValve, ES3 or Lotus Valve at three centers in France and the United States from 04/2008 to 02/2017. Baseline characteristics and clinical outcomes were defined according to VARC-2 criteria. Of 857 patients who received TAVR, 172 (20%) had an alternative access procedure. Of these, 45 (26%) were TA, 67 (39%) TAo, 17 (10%) TSub, and 43 (25%) TCa procedures. The preference for non-TF access site was different between the two countries (US: TA 39%, TAo 52%, TSub 9%; TCa 0% vs. France: TA 9%, TAo 23%, TSub 11%, and TCa 57%, P-value < .001). Most patients who underwent TAo TAVR were older women (median age: TA 82, TAo 84, TSub 81, TCa 81, P-value = 0.043; female gender: TA 32 (27%), TAo 30 (55%), TSub 10 (41%), TCa 27 (37%), P-value = .021). The predicted Society of Thoracic Surgery risk of mortality was similar among groups (TA 7%, TAo 7%, TSub 6%, TCa 7%, P-value= .738). No differences were observed in the frequency of para-valvular leak, intra-procedural bleeding, vascular complications, conversion to open-heart surgery, or development of acute kidney injury. The highest in-hospital mortality was observed in the TAo group (TA 2%, TAo 15%, TSub 0%, TCa 2%, P-value = .014). However, hospital length of stay, one-month, and one-year mortality were similar among non-TF techniques. Although regional differences exist in the choice of alternative access techniques, centers with high technical expertise can provide a safe alternative to traditional TF TAVR. TAo TAVR was associated with higher in-hospital mortality than other non-TF approaches, and this may have reflected patient rather than procedural factors. All alternative access techniques had similar mortality rates and clinical outcomes at one-year follow-up. Trans-carotid access is safe and feasible compared to other non-TF access techniques.

Outcomes, readmissions, and costs in transfemoral and alterative access transcatheter aortic valve replacement in the US Medicare population

ObjectiveTo comprehensively evaluate and compare utilization, outcomes, and especially costs of transfemoral (TF), transapical (TA), and transaortic (TAO) transcatheter aortic valve replacement (TAVR). MethodsAll Medicare fee-for-service patients undergoing TF (n = 4065), TA (n = 691), or TAO (n = 274) TAVR between January 1, 2011, and November 30, 2012, were identified using Health Care Procedure Classification Codes present on Medicare claims. Hospital charges from Medicare claims were converted to costs using hospital-specific Medicare cost-to-charge ratios. ResultsTA and TAO patients were similar in age, race, and common comorbidities. Compared with TF patients, TA and TAO patients were more likely to be female and to have peripheral vascular disease, chronic lung disease, and renal failure. Thirty-day mortality rates were higher among TA and TAO patients than among TF patients (TA, 9.6%; TAO, 8.0%; TF, 5.0%; P < .001). Adjusted mortality beyond 1 year did not differ by access. TA patients were more likely to require cardiopulmonary bypass (CPB). Increased adjusted mortality was associated with CPB (hazard ratio, 2.13; P < .01) and increased 30-day cost ($62,000 [interquartile range (IQR)], $45,100-$86,400 versus $48,800 [IQR, $38,100-$62,900]; P < .01). Cost at 30 days was lowest for TF ($48,600) compared with TA ($49,800; P < .01) and TAO ($53,200; P = .03). ConclusionsFor patients ineligible to receive TF TAVR, TAO and TA approaches offer similar clinical outcomes at similar cost with acceptable operative and 1-year survival, except for higher rates of CPB use in TA patients. CPB was associated with worse survival and increased costs.

Embolic protection in patients undergoing transaortic transcatheter aortic valve replacement: initial experience with the TriGuard HDH embolic deflection device.

Stroke remains one of the most worrisome complications following transcatheter aortic valve replacement (TAVR). This pilot study evaluates the safety, feasibility, and exploratory efficacy of the TriGuard HDH embolic deflection device (Keystone Heart Ltd., Caesarea, Israel) in patients undergoing transaortic TAVR. A total of 10 patients (median age: 81 years, STS score: 9.6 ± 5.6%) undergoing transaortic TAVR were included. All 30-day events were recorded and defined according to Valve Academic Research Consortium-2 criteria. Cerebral diffusion-weighted magnetic resonance imaging exams were planned preprocedure and within 10 days post-TAVR. The results of the magnetic resonances were analyzed in an independent core laboratory blinded to clinical data. Neurocognitive evaluation tests (Montreal Cognitive Assessment, Cogstate, Digit Symbol Substitution Test, Word Fluency Test, and Trailmaking tests) were performed at baseline, and within 10 and 30 days post-TAVR. The TriGuard HDH device was successfully deployed in all patients without complications. There was one procedural major vascular complication unrelated to the study device, and no clinically apparent stroke events were observed at 30-day follow-up. Cerebral diffusion weighted magnetic resonance imaging exams were performed in six patients at 7.5 ± 1.9 days post-TAVR showing the presence of new ischemic lesions in five patients (83.3%), which were single lesions in 60% of these individuals. Paired neurocognitive evaluation tests demonstrated no significant changes in neurocognitive parameters over time. This study shows the safety and feasibility of using the TriGuard HDH embolic protection device in transaortic TAVR. Further studies are warranted to determine the efficacy of embolic protection in this population.

Fungal Obstruction of Transcatheter Aortic Valve Replacement Valve.

An aged pensioner with a history of exertional dyspnea and severe aortic stenosis underwent uneventful J-type upper hemisternotomy with direct trans-aortic transcatheter aortic valve replacement (TAVR) of a 23-mm Edwards valve. Planned for review at 3 months, she returned 4 weeks early complaining of lethargy with no features of cardiac failure. Echocardiography revealed …

Transaortic approach for transcatheter aortic valve replacement with other concomitant cardiac procedures in high-risk patients.

The transaortic (TAo) approach has been proposed as an alternative to the transapical approach and can be used in concomitant procedures. We use the TAo transcatheter aortic valve replacement (TAVR) with other simultaneous cardiac procedures in high-risk patients who needed surgical management. Between September 2013 and September 2015, nine consecutive high-risk patients with severe aortic valve stenosis (AR) and combined tricuspid valve disease or coronary artery disease were treated with TAo TAVR and simultaneous tricuspid valve repair or coronary artery bypass grafting. Mean postoperative pressure gradient at discharge was 13.4 ± 3.2 mmHg and AR grade >2/4 was observed in one case (11.1%). New pacemaker implantation was required in one case (11.1%). Device success was achieved in 88.9% (n = 8), 30-day mortality was in 11.1% (n = 1), and intermediate mortality was in 33.3% (n = 3). TAo-TAVR approach offers definitive treatment to high-risk patients with coexisting complex cardiac lesions. Despite the relatively high 30-day and intermediate mortality, it is an option for selected high-risk patients.

Anaesthesia for trans-aortic Transcatheter Aortic Valve Replacement (TAVI-ta – does single-lung ventilation have an impact?

IntroductionTAVI-ta has become an alternative for selected patients and can be done by partial sternotomy or right-anterior mini thoracotomy (RAMT). Single-lung ventilation (SLV) may be necessary for RAMT. Isolation of the right lung may induce a shunt of about 50% and further lead to hypoxemia. We hypothesized that patients with SLV had a lower perioperative arterial partial pressure (PaO2). Furthermore we hypothetized that SLV-patients had a higher need of catecholaminergic therapy.MethodData for this pilot trial was retrieved from our prospective registry. We compared patients undergoing TAVI-ta in RAMT with and without SLV usage. Initiation and duration of SLV was at the discretion of the interventionalist. Arterial blood gas analysis (ABG) was analyzed before induction (room air), after induction (FiO2 1.0), 20 minute after initiation of SLV (or corresponding if SLV was not used) and on admission to ICU.ResultsBetween June 2008 and December 2014 62 patients underwent TAVI-ta. In 44/62 RAMT was chosen. SLV was used in 30/44 patients. Patient characteristics, ABG and catecholamine use are shown in the table. Median [IQR] ELV duration was 65 [30/85] min.DiscussionTabled 1no SLVSLVp-valuen= 14n=30Age (yrs)81 (78-86)82 (79-84)0.484EuroSCORE log (%)33.29 (20.07-42.53 )19.64 (15.76-35.30)0.300Euroscore II (%)10.14 (5.55-12.57)8.66 (3.46-12.95)0.441STS Mortality (%)10.16 (8.62-10.84)8.30 (3.79-18.00)0.447Ejection Fraction (%)35 (31-55)45 (30-60)0.320Aortic Valve Area (cm2)0.70 (0.60-0.86)0.60 (0.60-0.85)0.390Use of Caecholamines (n=)13 (92%)27 (90%)1.000Dosage Norepinephrine (mcg/kg)3.7 (2.2-7.0)7.1 (3.2-10.7)0.187Duration Anaesthesia (Min)215 (200-240)240 (208-278)0.046PaO2 before induction (mmHg)79 (69.9-88.5)74.5 (70.9-88.9)0.885PaCO2 before induction (mmHg)38 (37-40)36.6 (30.0-41.8)0.469PaO2 after induction (mmHg)337.6 (222.3-395.2)363.4 (340.9-413.1)0.422PaCO2 after induction (mmHg)45 (37.3-50.0)41 (36.6-46.9)0.454PaO2 during SLV (mmHg)219.3 (81.1-317.9)150.7 (111.6-301.9)0.865PaCO2 during SLV (mmHg)47.4 (42.3-55.4)45.6 (42.8-54.1)0.654PaO2 Admission ICU (mmHg)152.7 (115.8-202.2)118.9 (93.4-140.9)0.291PaCO2 Admission ICU (mmHg)41.5 (38.8-43.9)41.6 (35.8-46.8)0.928In-hospital mortality (n=)01 (3%)0.333Length of hospital stay (d)9 (8-17)11 (8-14)0.796 Open table in a new tab IntroductionTAVI-ta has become an alternative for selected patients and can be done by partial sternotomy or right-anterior mini thoracotomy (RAMT). Single-lung ventilation (SLV) may be necessary for RAMT. Isolation of the right lung may induce a shunt of about 50% and further lead to hypoxemia. We hypothesized that patients with SLV had a lower perioperative arterial partial pressure (PaO2). Furthermore we hypothetized that SLV-patients had a higher need of catecholaminergic therapy. TAVI-ta has become an alternative for selected patients and can be done by partial sternotomy or right-anterior mini thoracotomy (RAMT). Single-lung ventilation (SLV) may be necessary for RAMT. Isolation of the right lung may induce a shunt of about 50% and further lead to hypoxemia. We hypothesized that patients with SLV had a lower perioperative arterial partial pressure (PaO2). Furthermore we hypothetized that SLV-patients had a higher need of catecholaminergic therapy. MethodData for this pilot trial was retrieved from our prospective registry. We compared patients undergoing TAVI-ta in RAMT with and without SLV usage. Initiation and duration of SLV was at the discretion of the interventionalist. Arterial blood gas analysis (ABG) was analyzed before induction (room air), after induction (FiO2 1.0), 20 minute after initiation of SLV (or corresponding if SLV was not used) and on admission to ICU. Data for this pilot trial was retrieved from our prospective registry. We compared patients undergoing TAVI-ta in RAMT with and without SLV usage. Initiation and duration of SLV was at the discretion of the interventionalist. Arterial blood gas analysis (ABG) was analyzed before induction (room air), after induction (FiO2 1.0), 20 minute after initiation of SLV (or corresponding if SLV was not used) and on admission to ICU. ResultsBetween June 2008 and December 2014 62 patients underwent TAVI-ta. In 44/62 RAMT was chosen. SLV was used in 30/44 patients. Patient characteristics, ABG and catecholamine use are shown in the table. Median [IQR] ELV duration was 65 [30/85] min. Between June 2008 and December 2014 62 patients underwent TAVI-ta. In 44/62 RAMT was chosen. SLV was used in 30/44 patients. Patient characteristics, ABG and catecholamine use are shown in the table. Median [IQR] ELV duration was 65 [30/85] min. DiscussionTabled 1no SLVSLVp-valuen= 14n=30Age (yrs)81 (78-86)82 (79-84)0.484EuroSCORE log (%)33.29 (20.07-42.53 )19.64 (15.76-35.30)0.300Euroscore II (%)10.14 (5.55-12.57)8.66 (3.46-12.95)0.441STS Mortality (%)10.16 (8.62-10.84)8.30 (3.79-18.00)0.447Ejection Fraction (%)35 (31-55)45 (30-60)0.320Aortic Valve Area (cm2)0.70 (0.60-0.86)0.60 (0.60-0.85)0.390Use of Caecholamines (n=)13 (92%)27 (90%)1.000Dosage Norepinephrine (mcg/kg)3.7 (2.2-7.0)7.1 (3.2-10.7)0.187Duration Anaesthesia (Min)215 (200-240)240 (208-278)0.046PaO2 before induction (mmHg)79 (69.9-88.5)74.5 (70.9-88.9)0.885PaCO2 before induction (mmHg)38 (37-40)36.6 (30.0-41.8)0.469PaO2 after induction (mmHg)337.6 (222.3-395.2)363.4 (340.9-413.1)0.422PaCO2 after induction (mmHg)45 (37.3-50.0)41 (36.6-46.9)0.454PaO2 during SLV (mmHg)219.3 (81.1-317.9)150.7 (111.6-301.9)0.865PaCO2 during SLV (mmHg)47.4 (42.3-55.4)45.6 (42.8-54.1)0.654PaO2 Admission ICU (mmHg)152.7 (115.8-202.2)118.9 (93.4-140.9)0.291PaCO2 Admission ICU (mmHg)41.5 (38.8-43.9)41.6 (35.8-46.8)0.928In-hospital mortality (n=)01 (3%)0.333Length of hospital stay (d)9 (8-17)11 (8-14)0.796 Open table in a new tab

Transaortic transcatheter aortic valve replacement through a right minithoracotomy with the balloon-expandable Sapien 3 valve.

Transaortic transcatheter aortic valve replacement performed through a right anterolateral minithoracotomy at the second intercostal space is a safe and standardized minimally invasive procedure carrying important clinical advantages for the patient, in particular, no damage to the ventricular apex, preservation of the diseased peripheral arteries and no cross of the aortic arch with the delivery system, meaning a lower risk of calcium dislodgement and neurological complications. Using the third-generation, balloon-expandable Edwards Sapien™ 3 transcatheter heart valve and the Certitude™ delivery system, the transaortic procedure is easily performed under fluoroscopic and echocardiographic guidance. Compared with the transapical procedure, the transaortic technique requires an inversely mounted stent valve and follows the standard guidelines for valve positioning and deployment under rapid pacing. The transaortic approach through a right anterolateral minithoracotomy at the second intercostal space combines the positive aspects of both transfemoral and transapical valve replacements without the risks of either procedure (left ventricular, coronary and peripheral vascular injuries).

Transapical and Transaortic Transcatheter Aortic Valve Replacement in the United States

When transcatheter aortic valve replacement (TAVR) cannot be carried out through transfemoral access, alternative access TAVR is indicated. The purpose of this study was to explore inhospital and 1-year outcomes of patients undergoing alternative access TAVR through the transapical (TA) or transaortic (TAo) techniques in the United States. Clinical records of 4,953 patients undergoing TA (n = 4,085) or TAo (n = 868) TAVR from 2011 to 2014 in The Society of Thoracic Surgeons (STS)/American College of Cardiology Transcatheter Valve Therapy Registry were linked to Centers for Medicare and Medicaid Services hospital claims. Inhospital and 1-year clinical outcomes were stratified by operative risk; and the risk-adjusted association between access route and mortality, stroke, and heart failure repeat hospitalization was explored. Mean age for all patients was 82.8 ± 6.8 years. The median STS predicted risk of mortality was significantly higher among patients undergoing TAo (8.8 versus 7.4, p < 0.001). When compared with TA, TAo was associated with an increased risk of unadjusted 30-day mortality (10.3% versus 8.8%) and 1-year mortality (30.3% versus 25.6%, p = 0.006). There were no significant differences between TAo and TA for inhospital stroke rate (2.2%), major vascular complications (0.3%), and 1-year heart failure rehospitalizations (15.7%). Examination of high-risk and inoperable subgroups showed that 1-year mortality was significantly higher for TAo patients classified as inoperable (p = 0.012). Patients undergoing TAo TAVR are older, more likely female, and have significantly higher STS predicted risk of mortality scores than patients operated on by TA access. There were no risk-adjusted differences between TA and TAo access in mortality, stroke, or readmission rates as long as 1 year after TAVR.

Invited Commentary

Imagination is more important than knowledge. For knowledge is limited, whereas imagination embraces the entire world.–Albert Einstein, 1929 While Einstein wanted to describe imagination as the driving force behind the search for knowledge, the widespread use of a transcatheter aortic valve replacement (TAVR) is an example for the replacement of knowledge by imagination. It is quite astonishing that a novel technique like TAVR with at first a non-inferiority status [1Smith C.R. Leon M.B. Mack M.J. et al.Transcatheter versus Surgical Aortic-Valve Replacement in High-Risk Patients.N Engl J Med. 2011; 364: 2187-2198Crossref PubMed Scopus (4768) Google Scholar] over the established methods, shown in only 1 prospective randomized trial (by the way, sponsored by the same company selling the novel devices) with a very limited number of participants, could gain such relevance in patient treatment as well as in the scientific discussion. The superiority [2Adams D.H. Popma J.J. Reardon M.J. et al.Transcatheter aortic-valve replacement with a self-expanding prosthesis.N Engl J Med. 2014; 370: 1790-1798Crossref PubMed Scopus (2023) Google Scholar] of TAVR over conventional AVR could only later be shown in an, again, company-sponsored trial. The paper of Ribeiro and colleagues [3Ribeiro H. Dahou A. Urena M. et al.Myocardial injury after transaortic versus transapical transcatheter aortic valve replacement.Ann Thorac Surg. 2015; 99: 2001-2009Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar] deals with 2 different TAVR techniques (transaortic versus transapical approach) regarding myocardial injury and ventricular function after the procedure. A clear message can be read between the lines, although very cautiously phrased: transaortic (TAO) TAVR is superior to transapical (TA) TAVR because TAO TAVR leads to less myocardial injury and to a better left ventricular recovery. Interestingly, this does not lead to better clinical outcomes after 30 days or 12 months in the TAO TAVR group, as one would expect knowing the influence of high cardiac biomarkers on long-term outcomes after valve surgery [4Paparella D. Guida P. Caparrotti S. et al.Myocardial damage influences short- and mid-term survival after valve surgery: a prospective multicenter study.J Thorac Cardiovasc Surg. 2014; 148: 2373-2379Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar]. One important detail to be found in Supplemental Table 3 is not mentioned by the authors. Moderate or severe aortic valve regurgitation occurs nearly 4 times more often (nearly significantly more often) in the TAO TAVR group. Although there are data available on how high-degree aortic regurgitation worsens long-term survival [5Abdel-Wahab M. Zahn R. Horack M. et al.Aortic regurgitation after transcatheter aortic valve implantation: incidence and early outcome. Results from the German transcatheter aortic valve interventions registry.Heart. 2011; 97: 899-906Crossref PubMed Scopus (440) Google Scholar], the clinical outcomes of the 2 patient groups in this study are similar. Is it possible that higher biomarkers in the TA TAVR group and more aortic regurgitation in the TAO TAVR group balance each other? Clearly, the hypotheses of Ribeiro and colleagues [3Ribeiro H. Dahou A. Urena M. et al.Myocardial injury after transaortic versus transapical transcatheter aortic valve replacement.Ann Thorac Surg. 2015; 99: 2001-2009Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar] have to be proven “by future studies with larger sample size … to determine whether or not differences in myocardial injury … translate into significant differences in mortality…”, as the authors state themselves. Ribeiro and colleagues are to be congratulated on an excellent study inspired by their imagination, but they still have to contribute to the “limited knowledge.” Einstein again: “It’s important to go on asking questions.” Myocardial Injury After Transaortic Versus Transapical Transcatheter Aortic Valve ReplacementThe Annals of Thoracic SurgeryVol. 99Issue 6PreviewThe release of cardiac biomarkers of myocardial injury after transcatheter aortic valve replacement (TAVR) is common, but no data exist on patients undergoing TAVR through a transaortic approach. We aimed to evaluate the incidence and prognostic significance of the increase in cardiac biomarkers in nontransfemoral TAVR candidates, comparing transaortic and transapical approaches. Full-Text PDF

Long-term outcomes associated with the transaortic approach to transcatheter Aortic valve replacement.

We investigated the long-term safety, efficacy and clinical outcomes associated with transaortic (TAO) transcatheter aortic valve replacement (TAVR) in the United States. We previously reported the technical feasibility and short-term safety of TAO TAVR. Compared to transapical (TAP) access, the TAO approach was associated with shorter median intensive care unit (ICU) length of stay (LOS) and more favorable technical learning curve. However, outcomes data beyond 30 days were lacking and the longer-term clinical consequences of this strategy were unknown. Mortality outcomes at 1 year (and longer) of 44 consecutive patients who underwent TAO TAVR in our institution were compared with that of 76 consecutive patients who underwent TAP TAVR at our site. Risk-adjusted analysis was performed in propensity-matched patients (25 from each group) to account for baseline differences. TAO TAVR was associated with a trend towards lower all-cause mortality at 1 year compared to TAP TAVR (18% vs. 34%, P=0.09 in the overall sample; 12% vs. 40%, P=0.05 in the matched cohort). The higher probability of survival with TAO TAVR persisted after a median follow-up period of 23 months (hazard ratio [HR]=1.96, P=0.06 in the overall sample; HR=3.4, P=0.01 in the matched cohort). Cardiovascular mortality at 1 year was lower with TAO TAVR (2% vs. 22%, P=0.01 in the overall sample; 4% vs. 28%, P=0.05 in the matched cohort). ICU LOS (shorter in the TAO group) and implantation of second prosthetic valve (higher incidence in the TAP group) were independent predictors of long-term mortality. The outcomes associated with TAO TAVR compare favorably with TAP TAVR. Our results appear to corroborate the long-term safety and efficacy of the TAO approach in TAVR patients with inadequate iliofemoral access.

High-Risk Patients With Inoperative Aortic Stenosis: Use of Transapical, Transaortic, and Transcarotid Techniques

Patient characteristics and procedural outcomes from nontransfemoral (non-TF) transcatheter aortic valve replacement (TAVR) in high-risk or inoperable patients with aortic stenosis have been incompletely reported. The purpose of this study was to compare outcomes with non-TF TAVR access techniques including transapical (TA), transaortic (TAo), and transcarotid (TC) TAVR with a balloon-expandable valve. A retrospective review was performed of all patients undergoing TA, TAo, and TC TAVR from 2007 to 2013 at Emory University. Preoperative risk factors and postoperative outcomes were evaluated using Valve Academic Research Consortium-2 definitions. Of 469 patients undergoing TAVR during that period at our institution, 139 underwent TA TAVR, 35 had Tao TAVR, and 11 had TC TAVR. Patients undergoing TC TAVR were younger than those undergoing TA TAVR and TAo TAVR (mean ages: TC, 68.9 ± 23.6 years; TA, 81.3 ± 7.7 years; Tao, 83.8 ± 8.3 years; p= 0.017). Most patients undergoing TAo TAVR were women (82.9%), whereas patients undergoing TA TAVR were more likely to be men (62.6%). Slightly more than half of patients undergoing TA TAVR (54.7%) and TC (54.6%) TAVR hadundergone previous coronary artery bypass grafting (CABG), whereas no patients underwent TAo TAVR (0%). There was no preoperative difference in ejection fraction, New York Heart Association classification, significant chronic obstructive pulmonary disease, and The Society of Thoracic Surgeons predicted risk of mortality between TA TAVR, Tao TAVR, and TC TAVR, respectively. Average postoperative length of stay was 9 to 11 days and was similar among groups (p= 0.22). There were 13 (9.4%) TA TAVR operative deaths and 4 (11.4%) operative deaths in the TAo TAVR group. There were no deaths in the TC TAVR group. In high-risk and inoperable patients who are not candidates for TF TAVR, careful selection of alternative access options can lead to excellent and comparable postoperative outcomes.

Transcatheter aortic valve replacement: A novel abdominal transaortic approach

Transcatheter aortic valve replacement (TAVR) via the transfemoral (TF), transapical (TA), or even the transaortic (TAO) approach in high-risk or inoperable patients is quickly becoming a safe and effective modality for the treatment of symptomatic severe aortic stenosis (AS). However, in this selected group of patients, those with anatomical or physiologic constraints preventing TF, TA, and conventional TAO TAVR, alternative sites of access must be explored. Here, we report a successful TAVR in an inoperable patient with severe AS using a distal abdominal TAO approach via a synthetic graft-conduit.

Abstract 9908: Transcatheter Aortic Valve Replacement for High-risk Severe Aortic Stenosis: An Analysis of Incidence, Predictors and Prognostic Impact of New-onset Postprocedural Atrial Fibrillation- Mayo Clinic Experience

Introduction: Atrial fibrillation (AF) is a serious complication, which occurs in 30% to 40% of patients after surgical aortic valve replacement (SAVR) and contributes to adverse outcomes. Advanced technology has enabled transcatheter aortic valve replacement (TAVR) in patients with High-risk Severe Aortic Stenosis (HRSAS). In these patients, the compliance of the systemic vasculature is an independent predictor of diastolic dysfunction, a known predictor of postoperative AF (POAF). We hypothesize that patients with HRSAS undergoing TAVR represent a population at increased risk for POAF. METHODS: The medical records of 195 TAVR patients at the Mayo Clinic from November 2008 to January 2013 were analyzed. All patient demographic, clinical, pre- and post-procedural outcomes were collected from the patients’ medical records, and reviewed to ascertain all cases of POAF (AF ≤30 days of surgery). Patients with a prior history of AF (n= 75 (38.5%)) were excluded. Logistic regression analysis was used to identify clinical predictors of POAF after TAVR. Results: The mean age of the study population was 80.8±7.8 years and 60.8% (n=73) were men. The mean STS risk score was 8.9±5.1. Of the 120 patients without prior AF, 20.8% (n=25) developed new-onset POAF after TAVR. Patients who developed POAF were more likely to have undergone a transapical or transaortic TAVR approach (OR 3.20; 95% CI (1.3-8.0), had a higher incidence of renal complications (52.0% vs 21.5%; p= 0.003), greater hospital length of stay (7.4±2.58 vs 5.0±2.6 days; p= 0.0003, and a trend toward higher 30-day mortality (28.0% vs 13.7%; p= 0.09) and pulmonary complications (16.0% vs 5.4%; p= 0.08) compared with those who did not develop POAF, respectively. Neurologic complications were not different between the 2 group (4.0% vs 3.2%; p= 0.85). Conclusions: Patients with High-risk Severe Aortic Stenosis undergoing TAVR have increased risk of POAF, primarily associated with a transapical or aortic surgical approach. Patients who develop POAF had higher incidence of post-procedural complications and longer hospitalizations. Therefore, perioperative strategies aimed at prevention of POAF are as important in TAVR patients as in those undergoing SAVR.