Outcomes Of Transcatheter Aortic Valve Implantation Research Articles

Surgical Aortic Valve Replacement in Very Elderly Patients Aged 80 Years and Over: Evaluation of Early Clinical Outcomes

An increasing number of very elderly patients aged ≥80 years will require aortic valve replacement (AVR) for severe aortic stenosis (AS). Many are classified as high-risk surgical candidates. Transcatheter aortic valve implantation (TAVI) has been proposed as an alternative to surgical AVR (SAVR) for high-risk patients. We evaluated early clinical outcomes of very elderly patients undergoing SAVR to optimise TAVI candidate selection. We conducted a retrospective case review of 132 consecutive patients aged ≥80 years undergoing isolated SAVR (49 patients) or combined SAVR/CABG (83 patients) during February 2002-January 2010 at a single tertiary referral hospital. Risk for cardiac surgery was calculated using the logistic EuroSCORE (ES(log)). Mortality and morbidity data were collected for the 30-day postoperative period. Thirty-day mortality rate was 8.3% for patients undergoing SAVR (6.1% for isolated SAVR and 9.6% for SAVR/CABG). Permanent stroke occurred in 3.8% and renal insufficiency in 7.6% of the cohort. Thirty-five percent of patients had left ventricular ejection fraction <50%, 67% had advanced symptoms (NYHA class III or IV), and 42% of patients were stratified as high-risk (ES(log)≥20%). SAVR can be performed in very elderly patients with acceptable operative morbidity and mortality. The outcomes at our institution are comparable to contemporary SAVR and TAVI outcomes.

Transcatheter aortic valve implantation in nonagenarians: Effective and safe

BackgroundThe number of nonagenarians is rising dramatically. These patients often develop severe aortic stenosis for which transcatheter aortic valve implantation (TAVI) is an attractive option. The aim of this study was to analyze the outcome of TAVI performed in a cohort of nonagenarian patients. MethodsBetween August 2008 and November 2012, 23 consecutive patients in their 90th year of age or older underwent TAVI in our institution after having been assessed by the local heart team. Data concerning baseline characteristics, procedural details and outcome were prospectively entered into a dedicated database. Transthoracic echocardiography and clinical follow-up were performed pre-procedure, at discharge, at 6 and 12months and then annually post TAVI. ResultsPatients were male in 52% with a mean age of 90.3±2.3years. Mean logistic EuroSCORE and STS score were 26.6±14.5% and 8.7±2.9%, respectively. Transcatheter heart valve (THV) could be implanted in all but one patient. Mortality at 30days was 8.7% overall and 4.8% for transfemoral approach. At 30days the rate of stroke was 4.3%, paravalvular leak grade ≥2 was 8.7%, life-threatening bleeding was 13.0% and pacemaker implantation was 13%. Device success was 73.9%. The rate of all-cause mortality increased to 27.3% at one-year follow-up and 42.8% at a median follow-up of 417days. ConclusionsTAVI is safe and effective even in a selected population of nonagenarians. Consequently, these patients should not be refused such a procedure based only on their age. Multi-disciplinary assessment is essential in order to properly select candidates.

Outcome of Patients Treated with Engager Transapical Aortic Valve Implantation

The aim of this study was to investigate the short-term and midterm outcome of the Engager transcatheter aortic valve implantation (TAVI) system, a transapical self-expanding valve device with anatomic orientation. Transapical aortic valve implantation with the Engager valve prosthesis was performed in 10 patients. Endpoints were defined according to the Valve Academic Research Consortium recommendations for reporting outcomes of TAVI in clinical trials. Follow-up has been completed after 30 days and 1 year. All patients underwent the implantation procedure successfully. No device-related or delivery system-related complications were observed. One patient died of non-device-related reasons at postoperative day 23 in multiorgan failure. At 30-day follow-up, no more than mild transvalvular and paravalvular aortic regurgitation were seen. After 1 year, no transvalvular regurgitation was observed as assessed by transthoracic echocardiography. None of the patients had more than mild paravalvular leakage. The mean ± SD gradient was 15.3 ± 4.2 mm Hg. New York Heart Association class decreased one degree in mean and sustained until 1-year follow-up. No more patients died until 1-year follow-up. Application of the Engager TAVI system is safe and reliable. Prosthesis deployment in an anatomically correct position was facilitated by the design of the valve prosthesis and successful in all patients. No device-related or delivery system-related complications occurred. Procedural, short-term, and midterm results up to 1 year concerning the aortic valve performance are promising, with stable mean gradients and low rates of even mild regurgitation.

A 3-Center Comparison of 1-Year Mortality Outcomes Between Transcatheter Aortic Valve Implantation and Surgical Aortic Valve Replacement on the Basis of Propensity Score Matching Among Intermediate-Risk Surgical Patients

This study sought to compare all-cause mortality in patients at intermediate surgical risk undergoing transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR). Physicians are selecting "lower" surgical risk patients to undergo TAVI. No clinical data exist about the clinical outcomes of TAVI versus SAVR among intermediate-surgical-risk patients. We prospectively enrolled symptomatic patients with severe aortic stenosis who underwent TAVI or SAVR. Propensity-score matched pairs of TAVI and SAVR patients with Society of Thoracic Surgeons (STS) scores between 3% and 8% made up the study population. Primary endpoint was all-cause mortality at 1 year. Between November 2006 and January 2010, 3,666 consecutive patients underwent either TAVI (n = 782) or SAVR (n = 2,884). Four hundred five TAVI patients were matched to 405 SAVR patients. Of matched TAVI patients, 99 (24%) patients had STS scores <3%, 255 (63%) had scores between 3% and 8%, and 51 (13%) had scores >8%. Among patients with STS scores between 3% and 8%, 20 (7.8%) versus 18 (7.1%) patients had died up to 30 days (hazard ratio: 1.12, 95% confidence interval: 0.58 to 2.15, p = 0.74) and 42 (16.5%) versus 43 (16.9%) patients had died up to 1 year (hazard ratio: 0.90, 95% confidence interval: 0.57 to 1.42, p = 0.64) after TAVI and SAVR, respectively. Effects of treatment on 1-year mortality were similar across all subgroups except for sex, with some evidence for a beneficial effect of TAVI in women but not in men (test for interaction p = 0.024). Cumulative all-cause mortality at 30 days and 1 year was similar among propensity-score matched TAVI and SAVR patients at intermediate surgical risk. (Surgical Replacement and Transcatheter Aortic Valve Implantation [SURTAVI]; NCT01586910).

Two-Year Outcomes for Patients With Severe Symptomatic Aortic Stenosis Treated With Transcatheter Aortic Valve Implantation

Transcatheter aortic valve implantation (TAVI) is an emerging technique for the treatment of severe symptomatic aortic stenosis. Little has been reported about the use of different devices and multiple catheter-based options and anesthetic techniques in the same institution. We report the long-term clinical experience in treating patients with severe symptomatic aortic stenosis using TAVI. We analyzed the outcomes of 153 TAVI-treated patients who were followed for ≤2 years. All patients were at very high risk of surgical valve replacement. The Medtronic-CoreValve device was used in 59.5% and the Edwards-SAPIEN device in 40.5% of the patients. The primary end point was death from any cause during follow-up. The mean ± SD patient age was 81.1 ± 6 years, and 62% of the patients were women. The procedural success rate was 97.4%. At 30 days of follow-up, the all-cause mortality was 3.9%. Two-year follow-up data were obtained for 108 patients, with 85.5% survival of treated patients. The 30-day stroke rate was 3.9%. No significant differences in mortality were found when angioplasty was performed before or during TAVI compared with TAVI alone. Multivariate analysis showed that increased baseline creatinine (hazard ratio 1.55, 95% confidence interval 1.01 to 2.42, p = 0.049) and increased logistic European System for Cardiac Operative Risk Evaluation score (hazard ratio 1.03, 95% confidence interval 1.01 to 1.06, p = 0.048) predicted all-cause mortality. In conclusion, the clinical outcome of TAVI is favorable. The use of both procedural devices and multiple techniques in the same institution is feasible and potentially desirable.

Systematic review and meta-analysis of transcatheter aortic valve implantation versus surgical aortic valve replacement for severe aortic stenosis.

Transcatheter aortic valve implantation (TAVI) has emerged as an acceptable treatment modality for patients with severe aortic stenosis who are deemed inoperable by conventional surgical aortic valve replacement (AVR). However, the role of TAVI in patients who are potential surgical candidates remains controversial. A systematic review was conducted using five electronic databases, identifying all relevant studies with comparative data on TAVI versus AVR. The primary endpoint was all-cause mortality. A number of periprocedural outcomes were also assessed according to the Valve Academic Research Consortium endpoint definitions. Fourteen studies were quantitatively assessed and included for meta-analysis, including two randomized controlled trials and eleven observational studies. Results indicated no significant differences between TAVI and AVR in terms of all-cause and cardiovascular related mortality, stroke, myocardial infarction or acute renal failure. A subgroup analysis of randomized controlled trials identified a higher combined incidence of stroke or transient ischemic attacks in the TAVI group compared to the AVR group. TAVI was also found to be associated with a significantly higher incidence of vascular complications, permanent pacemaker requirement and moderate or severe aortic regurgitation. However, patients who underwent AVR were more likely to experience major bleeding. Both treatment modalities appeared to effectively reduce the transvalvular mean pressure gradient. The available data on TAVI versus AVR for patients at a higher surgical risk showed that major adverse outcomes such as mortality and stroke appeared to be similar between the two treatment modalities. Evidence on the outcomes of TAVI compared with AVR in the current literature is limited by inconsistent patient selection criteria, heterogeneous definitions of clinical endpoints and relatively short follow-up periods. The indications for TAVI should therefore be limited to inoperable surgical candidates until long-term data become available.

Quality of life- an integral aspect of transcatheter aortic valve implantation outcome

Quality of life- an integral aspect of transcatheter aortic valve implantation outcome

168: Transcatheter aortic valve implantation in patients with small body size

The purpose of this study was to evaluate the efficacy and safety of transcatheter aortic valve implantation (TAVI) in patients with small body size (SB). Clinical outcome of TAVI in patients with SB remains unclear. Between October 2006 and November 2011, 424 patients with severe aortic stenosis undergoing TAVI were evaluated. The cohort with small body surface area of <1.75 m 2 was defined as the “SB group” (n=215) and the rest of the cohort with large body-size as the “LB group” (n=209). In the SB group, the aortic annulus and femoral artery diameter were significantly smaller (23.0±1.86 vs 24.3±1.94 mm, p <0.001; 7.59±1.06 vs 8.29±1.34 mm, p <0.001, respectively). The logistic EuroSCORE was similar between the groups (22.5±10.4 vs 23.4±12.0, p=0.433). Equivalent device success (91.2 vs 91.4%, p=0.935) and 30-day survival rates (85.1 vs 87.6%, p=0.464) were achieved in both groups. Vascular complications were significantly higher in the SB group (13.0% vs 4.3%, p=0.002). Similar post-procedural mean pressure gradient was achieved in both groups (10.2±4.3 vs 11.0±4.6 mmHg, p=0.119). Kaplain-Meier survival analysis revealed no significant difference in the mid-term survival between groups (log-rank p=0.642). TAVI in patients with SB resulted in similar clinical outcomes with effective post-procedural hemodynamics compared with LB. Care should be taken to avoid vascular complication in patients with SB.

Comparison of Early Clinical Outcomes Following Transcatheter Aortic Valve Implantation versus Surgical Aortic Valve Replacement versus Optimal Medical Therapy in Patients Older than 80 Years with Symptomatic Severe Aortic Stenosis

PurposeTranscatheter aortic valve implantation (TAVI) has become an attractive therapeutic strategy for severe aortic stenosis (AS) in elderly patients due to its minimally-invasive nature. Therefore, early results of its clinical outcomes in elderly Korean patients were evaluated.Materials and MethodsWe compared early clinical outcomes of TAVI, surgical aortic valve replacement (SAVR), and optimal medical therapy (OMT) in patients aged ≥80 years with symptomatic severe AS. Treatment groups were allocated as follows: TAVI (n=10), SAVR (n=14), and OMT (n=42).ResultsBaseline clinical characteristics including predicted operative mortality were similar among the three groups. However, patients with New York Heart Association functional class III or IV symptoms and smaller aortic valve area were treated with TAVI or SAVR rather than OMT. In-hospital combined safety endpoints (all-cause mortality, major stroke, peri-procedural myocardial infarction, life-threatening bleeding, major vascular complication, and acute kidney injury) after TAVI or SAVR were significantly lower in the TAVI group than in the SAVR group (10.0% vs. 71.4%, respectively, p=0.005), along with an acceptable rate of symptom improvement and device success. During the follow-up period, the TAVI group showed the lowest rate of 3-month major adverse cardiovascular and cerebrovascular events, a composite of all-cause mortality, myocardial infarction, major stroke, and re-hospitalization (TAVI 0.0% vs. SAVR 50.0% vs. OMT 42.9%, p=0.017).ConclusionTreatment with TAVI was associated with lower event rates compared to SAVR or OMT. Therefore, TAVI may be considered as the first therapeutic strategy in selected patients aged ≥80 years with symptomatic severe AS.

Blood Transfusion and the Risk of Acute Kidney Injury After Transcatheter Aortic Valve Implantation

Blood transfusion is associated with acute kidney injury (AKI) after transcatheter aortic valve implantation (TAVI). We sought to elucidate in more detail the relation between blood transfusion and AKI and its effects on short- and long-term mortality. Nine hundred ninety-five patients with aortic stenosis underwent TAVI with the Medtronic CoreValve or the Edwards Valve in 7 centers. AKI was defined by the Valve Academic Research Consortium (absolute increase in serum creatinine ≥0.3 mg/dL [≥26.4 μmol/L] or ≥50% increase ≤72 hours). Logistic and Cox regression was used for predictor and survival analysis. AKI occurred in 20.7% (n=206). The number of units of blood transfusion ≤24 hours was the strongest predictor of AKI (≥5 units, OR, 4.81 [1.45-15.95], 3-4 units, OR, 3.05 [1.24-7.53], 1-2 units, OR, 1.47 [0.98-2.22]) followed by peripheral vascular disease (OR, 1.48 [1.05-2.10]), history of heart failure (OR, 1.43 [1.01-2.03]), leucocyte count ≤72 hours after TAVI (OR, 1.05 [1.02-1.09]) and European System for Cardiac Operative Risk Evaluation (EuroSCORE; OR, 1.02 [1.00-1.03]). Potential triggers of blood transfusion such as baseline anemia, bleeding-vascular complications, and perioperative blood loss were not identified as predictors. AKI and life-threatening bleeding were independent predictors of 30-day mortality (OR, 3.15 [1.56-6.38], OR, 6.65 [2.28-19.44], respectively), whereas transfusion (≥3 units), baseline anemia, and AKI predicted mortality beyond 30 days. AKI occurred in 21% of the patients after TAVI. The number of blood transfusions but not the indication of transfusion predicted AKI. AKI was a predictor of both short- and long-term mortality, whereas blood transfusion predicted long-term mortality. These findings indicate that outcome of TAVI may be improved by more restrictive use of blood transfusions.

TCT-136 Impact of pre-operative chronic kidney disease on transcatheter aortic valve implantation outcome

Nicolas Dumonteil, Alaide Chieffo, Didier Tchetche, Nicolas Van Mieghem, Bertrand Marcheix, Robert M A Van Der Boon, Gill Buchanan, Olivier Vahdat, Patrick Serruys, Jean Fajadet, Peter De Jaegere, Antonio Colombo, Didier Carrie Cardiovascular and Metabolic Pole, Rangueil Hospital, Toulouse, Toulouse, France, San Raffael Scientific Institute, Milan, Italy, Milan, Italy, Clinique Pasteur, Toulouse, Toulouse, France, Erasmus MC, Rotterdam, Rotterdam, Netherlands, Thoraxcenter, Erasmus Medical Center, Rotterdam, Rotterdam, Netherlands, San Raffaele Scientific Institute, Milan, Italy, Milan, Italy, Thoraxcenter, Erasmus MC, Rotterdam, Rotterdam, EMO GVM Centro Cuore Columbus srl, Milan, Milan, Italy

Feasibility of the Engager aortic transcatheter valve system using a flexible over-the-wire design

The aim was to investigate the safety and feasibility of the redesigned Engager™ transcatheter aortic valve implantation (TAVI) system. Transapical aortic valve implantation with the Engager™ valve prosthesis was intended in 11 patients, and performed in 10. Endpoints were defined according to the valve academic research consortium recommendations for reporting outcomes of TAVI in clinical trials. All 10 patients were implanted successfully. No devicerelated or delivery system complications like coronary obstruction or aortic dissection emerged. One patient (10%) died from non-device-related reasons at post-operative day 23 of multi-organ failure. The invasively measured peak-to-peak gradient after valve implantation was 7.1 ± 3.5 mmHg. In 90%, there was no or only trivial (≤grad I) aortic regurgitation due to paravalvular leakage. In 10% of the patients, aortic regurgitation grade I-II was observed. At 30-day follow up, the mean gradient was 15.6 ± 4.9 mmHg, and no more than a mild transvalvular and paravalvular aortic regurgitation was seen as assessed by transthoracic echocardiography. Application of the Engager™ TAVI system is safe and feasible. Prosthesis deployment in an anatomically correct position was facilitated by the design of the valve prosthesis and was successful in all patients. No device or delivery-system-related complications emerged. Safety and feasibility endpoints were met. Good results concerning the aortic valve performance after implantation and at 30-day follow up were ascertained. These results encouraged the start of a European Pivotal trial including patients to date.

Transcatheter Aortic Valve Implantation Outcomes

Aortic stenosis is a common valvular pathological finding in older adults. Currently, aortic valve replacement is the gold-standard treatment for severe symptomatic aortic stenosis. However, patients with advanced age and multiple comorbidities carry a significant operative risk. Transcatheter aortic valve implantation (TAVI) was developed with the goal of offering a less invasive alternative to symptomatic high-risk patients with aortic stenosis. Since the first successful TAVI procedure in 2002, TAVI has been used as a treatment option for patients at very high or prohibitive surgical risk in clinical feasibility trials, registries, and in ongoing randomized controlled trials. There are 2 transcatheter valves in widespread clinical application, with several others in different stages of development. This article provides an overview of TAVI outcomes including insertion options, procedural outcomes, morbidity, valve durability, short- to medium-term survival, and quality of life to guide nursing care interventions. Enhancing nurses' knowledge of the risks, benefits, and potential complications of TAVI will empower nurses in their role as patient advocates and educators and improve patient outcomes. Gaps in the current TAVI research literature are identified.

Chronic kidney disease is not associated with a higher risk for mortality or acute kidney injury in transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) has emerged as a new therapeutic option for surgical high-risk patients with severe aortic stenosis (AS). Many of these patients suffer from chronic kidney disease (CKD), which substantially increases the risk for acute kidney injury (AKI), need for renal replacement therapy (RRT) and mortality after surgical aortic valve repair. The impact of pre-existing CKD for the outcome of TAVI is still unclear. We retrospectively evaluated 199 consecutive patients with symptomatic high-grade AS undergoing TAVI with the CoreValve prosthesis at our centre. We analysed incidence and predictive factors for AKI, RRT and mortality in patients with and without CKD (defined as an estimated glomerular filtration rate <60 mL/min). 26.8% of the patients suffered from AKI, 4.9% needed RRT and 5.5% died. All patients on chronic haemodialysis (n = 10) survived. There were no significant differences between patients with or without CKD concerning the incidence of AKI, RRT and mortality. Age, peripheral vascular disease and the need for blood transfusion were independently associated with AKI. AKI proved to be a predictive factor for mortality. Transcatheter aortic valve replacement with the CoreValve prosthesis does not seem to bear an increased risk for patients with CKD. For surgical high-risk patients with severe AS, a more liberal consideration for TAVI as an alternative to open surgery might be justified.

Transapical vs. transfemoral aortic valve implantation: Which approach for which patient, from a surgeon's standpoint.

Transcatheter aortic valve implantation (TAVI) has gained increasing acceptance for treating patients with severe aortic stenosis (AS), especially in the presence of a higher risk profile. The procedure is performed a number of ways, however, the two main routes of access are the transfemoral (TF) retrograde approach and the transapical (TA) antegrade approach. At the present time TAVI is indicated in the presence of high risk according to current position statements from the European Society Cardiology and European Association Cardiothoracic Surgery (1). TAVI outcomes in intermediate risk patients, presenting with a logistic EuroSCORE lower than 20% or a Society of Thoracic Surgeons (STS) Score between 4% and 8% are currently being evaluated in prospective randomized trials such as the SURTAVI trial (TF CoreValve™ versus conventional surgery) and PARTNER 2 trial (Edwards SAPIEN-XT™ versus conventional surgery). Despite these advancements in endovascular approaches, conventional surgery remains the standard for many patients and is associated with excellent outcomes. For example, in 2011 a German registry reported an overall mortality to be as low as 3% in 11,500 patients undergoing conventional surgery for aortic valve disease (2). Our common goal is to perform the optimal therapy for an individual patient. This is fundamentally based on a low procedural risk together with immediate functional improvement and good longer term durability. Simplicity and safety will usually lead to good acceptance by the heart team of physicians, mostly cardiologists and cardiac surgeons, to use these approaches. For the individual patient, the overall balance of risks, which cannot be determined by incision length only but rather should prioritize hard endpoints such as mortality and morbidity such as stroke are extremely important. Thus, an objective pre-procedural informative discussion individualized to each patient’s unique risks and potential outcomes is mandatory before choosing between open versus percutaneous options. In this perspective, we highlight the different aspects of choosing the TF versus the TA approach using the best available current literature and propose future prospects for the care of aortic valve disease.

Critical aortic stenosis in a patient with a large saccular abdominal aortic aneurysm

Elderly patients with aortic stenosis are often deemed too high risk, and consequently turned down for conventional surgery. Transcatheter aortic valve implantation (TAVI) is a safe and an increasingly attractive option in this group of patients. Although TAVI has been shown to be successful and safe, the cardiovascular assessment of other co-morbidities in this susceptible group of patients is critical to ensuring good clinical outcomes. The presence of a saccular abdominal aortic aneurysm (AAA) in our patient was an example of an important co-morbidity which could have a significant impact on the outcome of TAVI, if not managed appropriately. The increased systolic pressure post successful TAVI will result in an increased strain within the wall of the saccular AAA with an increased risk of rupture. Therefore, a timely management strategy for the AAA was necessary. We believe that we report the first case of simultaneous TAVI and endovascular aneurysm repair (EVAR). The patient underwent uncomplicated transfemoral TAVI immediately followed by successful drive-by percutaneous EVAR delivered over the same superstiff guidewire via the transfemoral route. Our case highlights the importance of a detailed assessment in all patients before consideration for TAVI, and the multi-disciplinary team and a management strategy for both pathologies tailored to the patient. The case demonstrates the versatility of trans-catheter techniques which has enabled the treatment of aortic stenosis and abdominal AAA in a single procedure.

Transcatheter Aortic Valve Implantation in Dialysis Patients

Background/Aims: Transcatheter aortic valve implantation (TAVI) has emerged as a new therapeutic option for high-risk patients. However, dialysis patients were excluded from all previous studies. The aim of this study is to compare the outcomes of TAVI for dialysis patients with those for patients with chronic kidney disease (CKD) stages 3 and 4 and to compare TAVI with open surgery in dialysis patients. Methods: Part I: comparison of 10 patients on chronic hemodialysis with 116 patients with non-dialysis-dependent CKD undergoing TAVI. Part II: comparison of transcatheter (n = 15) with open surgical (n = 24) aortic valve replacement in dialysis patients. Results: Part I: dialysis patients were significantly younger (72.3 vs. 82.0 years; p < 0.01). Hospital stay was significantly longer in dialysis patients (21.8 vs. 12.1 days; p = 0.01). Overall 30-day mortality was 3.17%, with no deaths among dialysis patients. Six-month survival rates were similar (log-rank p = 0.935). Part II: patient age was comparable (66.5 vs. 69.5 years; p = 0.42). Patients in the surgical group tended to stay longer in hospital than TAVI patients (29.5 vs. 22.5 days; p = 0.35). Conclusion: TAVI is a safe procedure in patients on chronic hemodialysis. Until new data become available, we find no compelling reason to refuse these patients TAVI.

Sequential trans‐catheter aortic valve implantation and abdominal aortic aneurysm repair

Aortic stenosis in the elderly population is an increasing problem, with many patients being considered too high risk for surgery, and therefore being denied treatment. A percutaneous method of treatment in the form of trans-catheter aortic valve implantation (TAVI) is becoming an increasingly attractive option in this group of patients. Although, TAVI has been shown to be successful and improve cardiovascular haemodynamics, assessment of other comorbidities in this susceptible group of patients is essential to ensure good clinical outcomes. The presence of an abdominal aortic aneurysm (AAA) in our patient was an example of an important comorbidity which could have a significant impact on the outcome of TAVI, if not managed appropriately. The increased systolic pressure post successful TAVI will result in an increased strain within the AAA with an increased risk of rupture. Therefore, a timely management strategy for the AAA was necessary. Our case is of sequential TAVI followed by Endovascular aneurysm repair (EVAR). The patient underwent uncomplicated TAVI. There was complete abolition of trans-aortic gradient. EVAR was successfully undertaken three weeks post TAVI. The patient made an excellent recovery and remained well at six months follow-up. Our case highlights the importance of a detailed assessment in all patients prior to consideration for TAVI and the importance of having a management strategy for both pathologies tailored to the patient. This case demonstrates the benefits of development of trans-catheter techniques for two different conditions. Future developments including reduction of sheath size reduction and EVAR and TAVI device evolution, may enable simultaneous treatment of aortic stenosis and abdominal aortic aneurysm as a combined percutaneous procedure under local anaesthetic.

The surgeon’s role in transcatheter aortic valve implantation (TAVI)

Transcatheter aortic valve implantation (TAVI) has evolved into a routine procedure for elderly high-risk patients with severe aortic stenosis in specialised centres. It can be performed via a transfemoral or a transapical approach. Both approaches are truly minimally invasive and avoid the use of cardio-pulmonary bypass and cardioplegic arrest. TAVI is associated with good outcome and acceptable complication rates. The outcome of TAVI has improved over the last few years as centres became more experienced in the procedure. Up to now there is no clear evidence-based benefit for one or the other approach. A careful patient selection for each approach is therefore crucial for good results. Both procedures should be performed by a heart team of cardiologists, cardiac surgeons and cardiac anaesthetists. The knowledge the cardiac surgeons gained over the last decades by treating aortic stenosis with conventional aortic valve replacement is very important in TAVI procedures: Not only in terms of the procedure itself, but also for preoperative patient screening. TAVI must be approached as a team effort where cardiologists and cardiac surgeons play an equal role and should not be performed without a cardiac surgeon.

Early‐ and mid‐term outcomes of transcatheter aortic valve implantation in patients with logistic EuroSCORE less than 20%: A comparative analysis between different risk strata

Transcatheter aortic valve implantation (TAVI) is an emerging alternative to medical therapy reserved to a limited population with severe aortic stenosis. The European consensus document recommended TAVI for prohibitive-risk patients not eligible for conventional surgery (prohibitive risk defined as expected mortality ≥ 20% calculated with the Logistic EuroScore (LES) in association with clinical judgment). To date, there is lack of clarity on data about outcomes of TAVI in lower risk patients. We sought to evaluate the outcomes of patients undergoing TAVI with LES ≥ 20% in comparison with patients with LES < 20%. Of 165 patients who underwent TAVI using the 18-French Medtronic CoreValve (N = 153) and the Sapien Edwards™ (N = 12) at our Institution between June 2007 and September 2010, we identified those with LES < 20%, with prosthesis implantation (n = 84), and reported on their clinical outcome compared with patients with LES ≥ 20% (n = 78). The primary endpoint was the incidence of overall death and major adverse cerebrovascular and cardiac events (MACCE) at 30-day and midterm follow-up stratifying patients by clinical characteristics. At 30-day, a significant higher incidence of MACCE (20.8% vs. 6.0%, odds ratio [OR] 4.08 95% confidence interval [CI] 1.42-11.74, P = 0.009) and death (15.6% vs. 2.4%, OR 7.45 95% CI 1.61-34.48, P = 0.010) was reported in the LES ≥ 20% group as compared with the LES < 20% group, respectively. The 12-month MACCE rates was (27.1% vs. 11.4%, hazard ratio [HR] 2.47 95% CI 0.93-6.63, P = 0. 071) for LES ≥ 20% and LES < 20% patients, respectively (mortality rates was 25.7% vs. 6.8% HR 4.21 95% CI 1.24-14.30, P = 0.021). This study tends to suggest that current mortality reported after TAVI could be significantly affected by the very-high risk profile of the population which currently undergoes this procedure, making comparison with surgical series rather unreliable.