Case Of Transcatheter Aortic Valve Implantation Research Articles

Transcatheter Aortic Valve Implantation in Rheumatic Aortic Valve Stenosis Using a Top-down Deployment Supra-annular Leaflets Transcatheter Aortic Valve: Technical Considerations

Aortic valve stenosis due to chronic rheumatic heart disease remains prevalent in the Asia-Pacific region. Because of the lack of substantial calcification that can anchor a transcatheter aortic valve, there are several technical considerations during transcatheter aortic valve implantation (TAVI) when treating this subset of patients. We report a case of successful TAVI using a novel top-down deployment supra-annular leaflets valve in a patient with rheumatic aortic valve stenosis and mechanical mitral valve prosthesis.

TAV-in-TAV in patients with prosthesis embolization: Impact of commissural alignment and global outcomes

BackgroundOptimal strategies to manage embolization of transcatheter aortic valve implantation (TAVI) devices are unclear; valve-in-valve (ViV) is often used. We aimed to describe through one-single center experience its rate, causes, consequences, and management as well as the rate and relevance of commissural alignment (CA) in this context. MethodsWe identified across 1038 TAVI cases, those cases requiring ViV for the management of first device embolization. CA (absence or mild misalignment) after first and second device was assessed by CT or fluoroscopy. ResultsA total of 23 cases (2.2%) were identified, 52.3% embolized towards the aorta and 47.7% towards the ventricle. Suboptimal implant height (38%) and embolization at the time of post-dilation (23%) were the most frequent mechanisms together with greater rate of bicuspid valve (p < 0.001) and a trend to greater annular eccentricity. Procedural and 1-year death occurred in 13% and 34%, respectively (vs. 1.1% and 7.8% in the global cohort, p < 0.001). CA was present in 76.9% of the prostheses initially implanted but was only spontaneously achieved in 30.8% of the second ViV device. Adequate CA of both prostheses was identified in only two cases (8.7%). There were no cases of coronary obstruction. ConclusionsTAVI device embolization mechanisms can often be predicted and prevented. Mortality following bail-out ViV is higher than in regular TAVI procedures but 2/3 of these patients survived beyond 1-year follow-up. In them, valve degeneration or coronary re-access might be particularly challenging since CA was rarely achieved with both devices suggesting that greater efforts should be made in this regard.

Optimising the Transcatheter Aortic Valve Implantation Patient Pathway

Cardiologists at four hospitals in Europe were interviewed on their experience with optimising the transcatheter aortic valve implantation (TAVI) patient pathway through implementing the Edwards Benchmark Program (Edwards Lifesciences, Irvine, California, USA) in their centres. Insights were received from José Díaz, Head of the Cardiology and Cardiovascular Surgery Department, Hospital Universitario Virgen Del Rocío, Seville, Spain; Franco De Remigis, Medical Director of the Haemodynamic Laboratory, Department of Cardiology, Hospital Giuseppe Mazzini, Teramo, Italy; Rajiv Das, Consultant Interventional Cardiologist, Freeman Hospital, Newcastle upon Tyne, UK; and Christophe Saint Etienne, Interventional Cardiologist, Centre Hospitalier Régional Universitaire (CHRU) de Tours, France. Feedback from four European countries illustrates how a patient-focused approach to optimising the TAVI pathway has the potential to improve the quality of care across different healthcare systems, and in hospitals with varying sizes of multidisciplinary heart team. A number of themes emerged. All hospitals reported improvements in patient pathways, including an increase in the number of TAVI cases (e.g., by 25–100%) after implementing the programme; reported reduced length of hospital stay (e.g., 80–90% of patients discharged within 3 days, compared with 5–10 days before the programme), with improved patient satisfaction; and recommended the implementation of a patient pathway optimisation programme, like the Edwards Benchmark Program, in order to address increasing capacity issues, and improve the quality of care. The interviews were conducted between April 2022–April 2023.

Healthcare provision of transcatheter aortic valve implantation in Germany.

Transcatheter aortic valve implantation (TAVI) for aortic stenosis in older patients is the standard of care with awell-established supply density in Germany. In the near future, healthcare reform is planned that may affect TAVI capacities. Therefore, it is important to know how political regulations may interfere with access to services and what the need for TAVI will be in the future, based on demographic trends. The number of TAVI procedures (DRG F98A +F98) and the in-hospital main diagnoses of aortic stenosis (ICD I35) in 2021 were analyzed at the level of county or federal state based on anonymized data from hospital reports, according to §21 of the German hospital reimbursement law. The number of TAVI and aortic stenosis cases was projected for 2035 based on data from the German Federal Statistical Office on demographic developments. With quality assurance data from hospitals in 2019 and aroute planner, the travel time to the next hospital performing TAVI (OPS 5‑35a.0) was calculated, and the consequence of apolitically suggested minimum volume cut-off was analyzed. In 2021, atotal of 26,506 TAVI procedures were reported with amean number of TAVI per 100,000 inhabitants of32 (range between federal states from25 to42). Among the 66,045 diagnoses of aortic stenosis, there was avariation per 100,000 inhabitants from64 to 108 (mean79) between federal states. Compared to 2021, an additional 8748 (+13%) diagnoses of aortic stenosis and an increase of 4673 (+18%) TAVI procedures is to be expected in 2035. In 2019, 57% of German citizens could reach aTAVI hospital within 30 min and 91% within 60 min of driving time by car (mean time to hospital 31 min). Applying aminimum number of 150 TAVI/hospital per year would increase the driving time to hospital from 33to 52 min in Saxony-Anhalt and instantly remove six out of eight hospitals from service in Hesse. Regulation of TAVI services by minimum volume numbers would arbitrarily interfere with access to services, in contradiction to the medical service assurance tasks of federal state governments. These issues should be considered in the upcoming healthcare system reform.

Contemporary European practice in transcatheter aortic valve implantation: results from the 2022 European TAVI Pathway Registry.

A steep rise in the use of transcatheter aortic valve implantation (TAVI) for the management of symptomatic severe aortic stenosis occurred. Minimalist TAVI procedures and streamlined patient pathways within experienced Heart Valve Centres are designed to overcome the challenges of ever-increasing procedural volume. The 2022 European TAVI Pathway Survey aims to describe contemporary TAVI practice across Europe. Between October and December 2022, TAVI operators from 32 European countries were invited to complete an online questionnaire regarding their current practice. Responses were available from 147 TAVI centres in 26 countries. In 2021, the participating centres performed a total number of 27,223 TAVI procedures, with a mean of 185 TAVI cases per centre (median 138; IQR 77-194). Treatment strategies are usually (87%) discussed at a dedicated Heart Team meeting. Transfemoral TAVI is performed with local anaesthesia only (33%), with associated conscious sedation (60%), or under general anaesthesia (7%). Primary vascular access is percutaneous transfemoral (99%) with secondary radial access (52%). After uncomplicated TAVI, patients are transferred to a high-, medium-, or low-care unit in 28%, 52%, and 20% of cases, respectively. Time to discharge is day 1 (12%), day 2 (31%), day 3 (29%), or day 4 or more (28%). Reported adoption of minimalist TAVI techniques is common among European TAVI centres, but rates of next-day discharge remain low. This survey highlights the significant progress made in refining TAVI treatment and pathways in recent years and identifies possible areas for further improvement.

Transcatheter Aortic Valve Implantation in Two High-Risk Patients with Low Coronary Ostial Heights Using the Novel Balloon-Expandable Myval Valve

The treatment of severe aortic stenosis by transcatheter aortic valve implantation (TAVI) is challenging in patients with high-risk coronary anatomy that is predisposed to iatrogenic or delayed coronary obstruction. Hence, the evidence on performing TAVI with adequate coronary protection with or without deploying a stent needs to be accumulated. We report two cases of TAVI performed in patients with low coronary heights, wherein a “wire only” strategy was used to provide coronary protection along with the implantation of a novel balloon-expandable Myval THV. The first patient underwent a valve-in-valve TAVI, while the second patient underwent the replacement of a native bicuspid Type 1A valve. This case series presents two high-risk TAVI cases wherein a guide extension catheter and a supportive coronary guidewire provided sufficient coronary protection. None of the cases required any rescue revascularization and no incidences of a new pacemaker implantation were reported.

Incidence and predictors of hemodynamic compromise due to high-grade AV block after TAVI.

High-grade AV block (HAVB) is the most frequent adverse event after transcatheter aortic valve implantation (TAVI). In rare cases, HAVB is associated with hemodynamic compromise (HC) followed by syncope or application of cardiopulmonary resuscitation (CPR), but data on this severe complication are scarce. The aim of the present study was to investigate the incidence and predictors of HC due to HAVB in patients undergoing TAVI. In this retrospective analysis of 4,602 TAVI cases between 2010 and 2022, 466 developed HAVB. Baseline characteristics and procedural and postprocedural findings were compared for patients with HC versus those without. Univariate and multivariable regression analyses were used to investigate independent predictors of HC. Forty-nine of 466 patients (10.5%) had HC due to HAVB after TAVI. Patients with HC had a longer hospital stay [10 (8-13) vs. 13 (9-18) days; p < 0.001], more frequent peripheral artery disease (PAD) (28.6% vs. 15.1%; p = 0.016), and lower hemoglobin levels [11.8 (±) vs. 12.5 (±) g/dl; p = 0.006]. In the HC group, HAVB onset post-TAVI was delayed compared with the non-HC group [2 (1-4) vs. 1 (0-3) days; p < 0.001]. Before HAVB onset, patients in the HC group more frequently developed post-TAVI delirium [18 (4.6%) vs. 11 (25.0%); p < 0.001]. In univariate regression analysis, PAD, hemoglobin, procedural time, contrast agent volume, and post-TAVI delirium were significant predictors of HC. After adjustment, only post-TAVI delirium and contrast agent volume remained independent predictors [OR 3.22 (95% CI: 1.05-9.89); p = 0.042 and OR: 1.01 (95% CI: 1.0-1.01); p = 0.04, respectively]. HC due to HAVB after TAVI occurred in over 10% of cases. Development of post-TAVI delirium and contrast agent volume are independent predictors of this severe complication.

REGIONAL NERVE BLOCK FOR SUBCLAVIAN ACCESS TAVI

Transcatheter aortic valve implantation (TAVI) program has started in the UK in 2007 performing 66 cases a year, the number of cases of TAVI done every year has been exponentially increasing since then to reach 6076 cases in the year 2020. (Ludman) The UK TAVI registry has shown a nationwide shift in practice from general anaesthesia to conscious sedation for trans-femoral access TAVI, analysis has shown a fall of In-hospital mortality from 4.7 in 2012 to 1.8% in 2016 (Ludman). This shift, however, has not occurred in the same way for other arterial access like trans-subclavian or trans-axillary, which is still widely practiced in the UK under general anaesthesia. The vast majority of cases in the UK are done through the femoral access, however, finding an alternative approach is sometimes needed due to contraindication to the standard femoral approach, mostly vasculopathy, which usually indicates higher risk patient and higher likelihood of associated co-morbidities. Performing the alternative access TAVI under general anaesthesia adds more risk to the patient and in some cases could be life threatening, some of these patients could be deemed unfit for the procedure. Finding an alternative anaesthetic technique will allow these patients to have their procedures done with lower risk and have the optimum chance for quicker recovery. The technique of combining Superficial cervical plexus block, interscalene block with Pectoral block type II was first described in 2018 by Alexander et al and reproduced by Block et al in the United States in the same year to allow for performing subclavian access TAVI without general anaesthesia. The same technique was partially adopted with some modification by Vivian et al in Canada and Toscano et al in Italy in 2020 and 2021 respectively. In this manuscript we share our experience doing a series of subclavian access TAVI under regional nerve block and conscious sedation at the Freeman hospital in Newcastle upon Tyne, to our knowledge, and from literature search, this is the first time this is performed successfully in the UK as we didn't see any published reports on this technique within the country.

Valve embolization during transcatheter aortic valve implantation: Incidence, risk factors and follow-up by computed tomography.

BackgroundIn most cases of transcatheter valve embolization and migration (TVEM), the embolized valve remains in the aorta after implantation of a second valve into the aortic root. There is little data on potential late complications such as valve thrombosis or aortic wall alterations by embolized valves.AimsThe aim of this study was to analyze the incidence of TVEM in a large cohort of patients undergoing transcatheter aortic valve implantation (TAVI) and to examine embolized valves by computed tomography (CT) late after TAVI.MethodsThe patient database of our center was screened for cases of TVEM between July 2009 and July 2021. To identify risk factors, TVEM cases were compared to a cohort of 200 consecutive TAVI cases. Out of 35 surviving TVEM patients, ten patients underwent follow-up by echocardiography and CT.Results54 TVEM occurred in 3757 TAVI procedures, 46 cases were managed percutaneously. Horizontal aorta (odds ratio [OR] 7.51, 95% confidence interval [CI] 3.4–16.6, p < 0.001), implantation of a self-expanding valve (OR 4.63, 95% CI 2.2–9.7, p < 0.01) and a left ventricular ejection fraction < 40% (OR 2.94, 95% CI 1.1–7.3, p = 0.016) were identified as risk factors for TVEM. CT scans were performed on average 26.3 months after TAVI (range 2–84 months) and detected hypoattenuated leaflet thickening (HALT) in two patients as well as parts of the stent frame protruding into the aortic wall in three patients.ConclusionTVEM represents a rare complication of TAVI. Follow up-CT detected no pathological findings requiring intervention.

Micro-dislodgement of a self-expanding transcatheter heart valve: Incidence, predictors, and outcomes

ObjectivesMalpositioning of transcatheter heart valves increases the risk of procedural failure. For the ACURATE system, inadvertent movement of the prosthesis to a varying extent is sometimes observed upon full release, but the incidence, mechanisms, and clinical impact of such valve micro-dislodgement (VMD) are poorly understood.The aim of the present study was to assess the incidence, predictors, and clinical outcomes of VMD in an all-comers population that underwent transcatheter aortic valve implantation (TAVI) with the ACURATE neo2 prosthesis (NEO2). MethodsThis was a retrospective analysis of 448 consecutive patients who underwent transfemoral TAVI with NEO2 at our institution. VMD was defined as displacement ≥2 mm between the initial position and immediately after valve release as measured on fluoroscopy at the non-coronary cusp. The initial valve position prior to step 2 was categorized using the radiopaque marker band (RMB) relative to the annular plane. In addition, further anatomical and procedural characteristics were assessed. ResultsA total of 68 (15.2%) cases with VMD were identified. A larger cover index, higher RMB position, partial detachment of the lower crown, and severe parallax prior to deployment were independent predictors of VMD, whereas a position of the delivery system in the outer curvature was protective against VMD. Among patients with VMD, the rates of valvular malpositioning and thus technical failure (VARC-3) were higher, but mean transprosthetic gradients were lower. ConclusionsVMD occurs in a notable proportion of transfemoral TAVI cases with NEO2 and is associated with more frequent technical failure of the procedure.

Long-term survival benefit of SAVR over TAVR in low-risk elective patients

Abstract Background Aortic valve (AV) stenosis can be treated either by surgical AV replacement (SAVR) or since 2002 by transcatheter aortic valve implantation (TAVI). Due to lower invasiveness, TAVI is a preferred approach in high- and prohibitive risk surgical candidates, yet outcome data is conflicting when lower risk patients are considered and in particular at long-term. Purpose Our study evaluates long-term survival in elective low-risk patients after AV replacement with severe AV stenosis. Methods We conducted a registry data analyses of patients scheduled for elective isolated AV with AV stenosis between 2015 and 2019 and underwent TAVI or SAVR. Urgent, emergent and salvage procedures were excluded. In TAVI group only transfemoral access was considered. Propensity score matching to determine SAVR controls for TAVI group in 1:3 ratio with caliper 0.2 of standardized deviation (figure 1). Results Study group included 2393 elective AVR patients 1765 was in SAVR group and 628 in TAVI group. Median follow-up was 2.72 years ([IQR: 1.32–4.08], max 6.0). Propensity matching with replacement returned 329 TAVI cases and 593 SAVR controls with median age 76 (Interquartile range [IQR:71–73]) and EuroScore II 1.81 [IQR:1.36–2.53]). 30-day mortality was 11/329 (3.32%) vs 18/593 (3.03%) in the TAVI vs SAVR respectively (RR 1.10 [0.52–2.37]; p=0.801). At two years, there was no difference between SAVR and TAVI in terms of mortality (HR 1.23 [0.83–1.83] P=0.309). At 6 years, overall survival analysis favored SAVR which was associated with 30% lower mortality (HR 0.70 [0.496–0.997]; p=0.048, see figure 2). Conclusions TAVI as compared to SAVR is equally safe in elective low-risk patients up to 2 years post-op. After that time survival is better in surgically managed patients. Extended observations from randomized trials in low-risk patients are warranted to draw definite conclusions regarding long-term safety of TAVI in this population. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The work was supported by the research non-commercial grant from Medical University of Silesia Figure 1Figure 2

Elective versus urgent in-hospital transcatheter aortic valve implantation.

Transcatheter aortic valve implantation (TAVI) is maturing as a treatment option and is now often undertaken during an unscheduled index hospital admission. The aim of this study was to look at procedural and mid-term outcomes of patients undergoing elective versus urgent in-hospital transcatheter aortic valve implantation. We identified a total of 1,157 patients who underwent TAVI between November 2007 and November 2019 at the Sussex Cardiac Centre in the UK. We compared the demographics, procedural outcomes, 30-day and 1-year mortality between elective and urgent patients. Emergency and salvage TAVI cases were excluded. Of the 1,157 patients who underwent the procedure, 975 (84.3%) had elective while 182 (15.7%) had urgent TAVI. Predominant aortic stenosis was more frequent in elective patients (91.7% vs. 77.4%); p <.01), while predominant aortic regurgitation was seen more commonly in the urgent group (11.5% vs. 4.2%; p < .01). Implantation success was similar between the elective (99.1%) and urgent group (99.4%). In-hospital (1.65% vs. 1.3%: p .11), 30 day (3.5% vs. 3.3%: p .81) and 1 year (10.9% vs. 11%; p .81) mortality rates were similar in the elective and urgent groups, respectively. In contemporary practice, urgent TAVI undertaken on the index admission can be performed at similar risk to elective outpatient TAVI.

Computational Analysis of Self-Expanding and Balloon-Expandable Transcatheter Heart Valves

Bicuspid aortic valve (BAV) patients are usually excluded from transcatheter aortic valve implantation (TAVI) as this valve anatomy likely leads to oval expansion. This study presents a numerical study of TAVI using both self-expanding and balloon expandable transcatheter heart valve (THV) in bicuspid patients with severe stenosis. The simulation framework included a patient-specific anatomy of the aortic root, calcifications and BAV leaflets extracted from medical imaging analysis as well as a realistic crimping and deployment of the THV. Tissue stress analysis highlighted local maxima in the contact area between the inner aortic lumen and the THV stent frame. Flow analysis based on the smoothed particle hydrodynamics (SPH) technique displayed the area at risk of paravalvular leakage (PVL). These findings provide insights on the TAVI in BAV and thus represents a further step towards the use of in-silico for the virtual planning of TAVI, aiming at improving not only the efficacy of the implantation but also the exploration of borderline anatomy as the case of TAVI in BAVs.

Evaluation of the Factors Affecting the Length of Stay in Hospital of Transcatheter Aortic Valve Implantation (TAVI) Cases

Introduction: In the treatment of inoperable patients with severe aortic stenosis or at high surgical risk, transcatheter aortic valve implantation (TAVI) is applied as an alternative to surgical aortic valve replacement. In our study, it was aimed to evaluate the factors affecting the length of stay in hospital of TAVI cases. Method: After obtaining the approval of the ethics committee, the patients who received TAVI between 09.06.2012-19.01.2018 in the Interventional Cardiology unit of Dokuz Eylül University were retrospectively screened. A total of 243 patients were included in the study. Demographic data, preoperative accompanying diseases and echocardiographic results of the cases, the type of anesthesia applied, the duration of postoperative coronary intensive care, and a hospital stay were recorded. The analysis of the data was carried out in the SPSS 22.0 statistical package program, Results: 53.5% of the patients who underwent transcatheter aortic valve implantation received general anesthesia, 46.5% received local anesthesia and sedation. 93.8% of the patients were discharged upon recovery. There was a significant difference between the postoperative length of stay in the hospital and the type of anesthesia (p=0.008). It was shown that patients who underwent general anesthesia were discharged later than patients who underwent sedation. Discussion and Conclusion: Due to the high risks of surgery, it is of vital importance to shorten the length of stay in hospital in high-risk patients over 65 years of age who undergo TAVI.

Decision Trees for Predicting Mortality in Transcatheter Aortic Valve Implantation.

Current prognostic risk scores in cardiac surgery do not benefit yet from machine learning (ML). This research aims to create a machine learning model to predict one-year mortality of a patient after transcatheter aortic valve implantation (TAVI). We adopt a modern gradient boosting on decision trees classifier (GBDTs), specifically designed for categorical features. In combination with a recent technique for model interpretations, we developed a feature analysis and selection stage, enabling the identification of the most important features for the prediction. We base our prediction model on the most relevant features, after interpreting and discussing the feature analysis results with clinical experts. We validated our model on 270 consecutive TAVI cases, reaching a C-statistic of 0.83 with CI [0.82, 0.84]. The model has achieved a positive predictive value ranging from 57% to 64%, suggesting that the patient selection made by the heart team of professionals can be further improved by taking into consideration the clinical data we identified as important and by exploiting ML approaches in the development of clinical risk scores. Our approach has shown promising predictive potential also with respect to widespread prognostic risk scores, such as logistic European system for cardiac operative risk evaluation (EuroSCORE II) and the society of thoracic surgeons (STS) risk score, which are broadly adopted by cardiologists worldwide.

Comparing Outcomes of Transcatheter Aortic Valve Implantation (TAVI) and Surgical Aortic Valve Implantation (SAVI) for Severe Aortic Stenosis Within the Southern District Health Board

Transcatheter aortic valve implantation (TAVI) provides a promising advancement in the management of aortic stenosis. Previous studies have identified the benefit of this technology, particularly in those at high risk for surgical intervention. Because of this well-documented success, TAVI was introduced to Dunedin Hospital in 2015. This study provides a retrospective observational audit of TAVI cases between 2015 and 2019 (n=71). TAVI cases were also compared against patients that had surgical aortic valve implantation (SAVI) between 2011 and 2016 (n=134) at Dunedin Hospital. Data were collected using the Heath Connect South (HCS) database, and the Society of Thoracic Surgeons (STS) and EuroSCORE surgical risk predictors calculated. It was found that TAVI patients were older, with higher surgical risk scores and greater comorbidities. Even so, rates of cardiovascular events and hospital readmissions were similar between the two groups over two years, and stroke more common in SAVI. These trends were most evident in the 80–89-year-olds. Thirty-day mortality was 4.2% for TAVI and 2.2% for SAVI. TAVI patients also spent significantly less time in hospital (2.4 days vs 9.3 days). These Results suggest the effective implementation of TAVI within Dunedin Hospital, with thirty-day mortality comparable to previous international studies. The 80-89-year-old cohort also received the greatest benefit from TAVI, which is precisely the group that has the most to gain from this procedure.

Trends and Predictors of Transcatheter Aortic Valve Implantation Related In-Hospital Mortality (From the National Inpatient Sample Database)

Existing surgical aortic valve replacement risk models accurately predict the post- surgical aortic valve replacement morbidity and mortality, but factors associated with post transcatheter aortic valve Implantation (TAVI) mortality are not well known. The National Inpatient Sample was queried to identify all cases of TAVI. The association of baseline comorbidities with in-hospital mortality was determined using a binary logistic regression model to obtain adjusted odds ratios (aOR). A total of 161,049 patients underwent TAVI between 2010 and 2017. Of these, 157,151 (97.6%) survived while 3,898 (2.4%) died during hospitalization. The baseline characteristics of TAVI-survivors and non-survivors showed a significant amount of variation, including age (80 vs 82 years, p ≤ 0.0001) and female sex (46% vs 52%, p ≤ 0.0001), respectively. The non-survivors had significantly higher adjusted odds of renal failure requiring hemodialysis (aOR 2.59, 95% CI 2.24 to 2.99, p ≤ 0.0001), history of mediastinal radiation (aOR 2.71, 95% CI 1.02 to 7.20, p = 0.05), liver disease (aOR 3.04, 95% CI 2.63 to 3.51, p ≤ 0.0001), pneumonia (aOR 2.47, 95% CI 2.15 to 2.83, p ≤ 0.0001), cardiogenic shock (aOR 9.83, 95% CI 8.93 to 10.82, p ≤ 0.0001), ventricular tachycardia (aOR 2.12, 95% CI 1.88 to 2.40, p ≤ 0.0001), acute ST-elevation myocardial infarction (aOR 7.38, 95% CI 5.53 to 9.84, p ≤ 0.0001), stroke (aOR 2.25, 95% CI 1.99 to 2.54, p ≤ 0.0001), and acute infective endocarditis (aOR 5.74, 95% CI 3.65 to 9.02, p ≤ 0.0001) compared to TAVI-survivors. The yearly trend of mortality showed an increase in the absolute number of TAVI procedures and mortality but the yearly rate showed a decline in mortality after an initial peak during 2012.Patients with renal failure on dialysis, ST-elevation myocardial infarction, cardiogenic shock, infective endocarditis, liver disease and pneumonia have a higher rate of in-hospital mortality post TAVI.

Transcatheter Aortic Valve Implantation for Failed Surgical Aortic Bioprostheses Using a Self-Expanding Device (from the Prospective VIVA Post Market Study)

Patients with symptomatic aortic stenosis are often treated with a surgical valve replacement. Surgical bioprosthetic valves degenerate over time and therefore may necessitate a redo surgery. This analysis reports the 2-year clinical outcomes of the Valve-in-Valve study, which evaluated transcatheter aortic valve implantation using the CoreValve and Evolut R devices in patients with degenerated surgical aortic bioprostheses at high risk for surgery. The prospective Valve-in-Valve study enrolled 202 eligible patients with failing surgical aortic bioprostheses due to stenosis, regurgitation, or a combination of both. The Evolut R bioprosthesis was used in 90.5% of valve-in-valve transcatheter aortic valve implantation cases. Two-year all-cause and cardiovascular mortality rates were 16.5% and 11.1%, respectively. Other clinical events included stroke (7.9%), disabling stroke (1.7%), and new pacemaker implantation (10.1%). The 2-year all-cause mortality rate was significantly higher in patients with discharge mean gradients ≥20 mmHg vs. those with lower mean gradients (21.0% vs 7.6%, p = 0.025). Discharge mean gradients ≥20 mm Hg were associated with smaller surgical bioprostheses (OR, 7.2 [95% CI 2.3 to 22.1]. In patients with failing surgical aortic bioprostheses, valve-in-valve treatment using a supra-annular self-expanding bioprosthesis provides significant functional improvements with acceptable rates of complications, especially if a postprocedural mean gradient of <20 mmHg can be achieved.

Transcatheter aortic valve implantation with a novel pre-packaged self-expandable dry-tissue transcatheter aortic valve: a case report.

BackgroundCurrent commercially available transcatheter aortic valves are stored separately in a glutaraldehyde solution and mounted onto the delivery system by a technical expert during the transcatheter aortic valve implantation (TAVI) procedure. A pre-mounted dry-tissue valve that is crimped on a ready-to-use delivery system could simplify the procedure. The Vienna self-expanding transcatheter valve (P&F, GmbH, Wessling, Germany) is a novel ready-to-use pre-mounted dry-tissue transcatheter aortic valve. There are no prior reports on the efficacy of this valve system.Case summaryHere, we report our experience of an implantation of a novel ready-to-use dry-tissue Vienna transcatheter aortic valve in a 72-year-old male with symptomatic severe aortic stenosis and severe left ventricular systolic dysfunction. He had presented with heart failure [N-terminal pro-brain natriuretic peptide (NT-proBNP) level at the admission of 10 600 pg/mL], New York Heart Association Class-3, and recurrent syncope. A 26 mm Vienna valve was successfully implanted via the transfemoral route under conscious sedation. There were no complications. The patient was discharged in a stable condition on the third post-procedure day. At 1-year follow-up, the valve is functioning well with no evidence of structural degeneration (mean gradient 9 mmHg, no valvular regurgitation). Currently, he is asymptomatic with normal left ventricular systolic function on echocardiography (NT-proBNP 57 pg/mL).DiscussionTo our knowledge, this is the first case of TAVI performed with the dry-tissue pre-mounted VIENNA valve. Our case highlights the feasibility and short-term efficacy of the VIENNA valve. Further safety and durability need to be addressed by a multicentre trial.

A case report of a transcarotid transcatheter aortic valve implantation with concomitant carotid endarterectomy.

BackgroundTranscarotid transcatheter aortic valve implantation (TAVI) is a worthwhile substitute in patients who might otherwise be inoperable; however, it is applied in <10% of TAVI cases. In patients with established carotid artery stenosis, the risk of complications is increased with the transcarotid access route.Case summaryWe report a case of concomitant transcarotid TAVI and carotid endarterectomy (CEA) in a patient with bovine aortic arch and previous complex infrarenal EndoVascular Aortic Repair (EVAR). The integrity and positioning of the previous EVAR endograft was risked by transfemoral access. The right subclavian artery was only 4.5 mm and the left subclavian was totally occluded so transcarotid access was chosen. The patient recovered well, with no neurological deficit and was discharged home after 72 h. He was last seen and was doing well 6 months post-procedure.DiscussionIn patients with severe aortoiliac disease, or previous aortic endografting, transfemoral access for TAVI can be challenging or even prohibitive. Alternative access sites such as transapical or transaortic are associated with added risk because they carry increased risk of major adverse cardiovascular events, longer intensive care unit and hospital stay, and increased cost. A transcaval approach for TAVI has also been reported but was not suitable for our patient due to prior EVAR. Concomitant TAVI via transcarotid access and CEA can be successful in experienced hands. This case highlights the importance of a team-based approach to complex TAVI cases in high-risk patients with complex vascular access.