Transcatheter Aortic Valve Implantation Procedure Research Articles

Cost-effectiveness of transcatheter aortic valve implantation in patients at low surgical risk in France: a model-based analysis of the Evolut LR trial

BackgroundIn the recent Evolut Low Risk randomized trial, transcatheter aortic valve implantation (TAVI) was shown to be non-inferior to surgery (SAVR) regarding the composite end point of all-cause mortality or disabling stroke at 24 months.AimsTo evaluate the cost-effectiveness of self-expandable TAVI in low-risk patients, using the French healthcare system as the basis for analysis.MethodsMortality, health-related quality of life, and clinical event rates through two-year follow-up were derived from trial data (N = 725 TAVI and N = 678 SAVR; mean age: 73.9 years; mean STS-PROM: 1.9%). Cost inputs were based on real-world data for TAVI and SAVR procedures in the French healthcare system. Costs and effectiveness as quality-adjusted life years (QALYs) were projected to lifetime via a decision-analytic model under assumption of no mortality difference beyond two years. The discounted incremental cost-effectiveness ratio (ICER) was evaluated against a willingness-to-pay threshold of €50,000 per QALY gained. Deterministic and probabilistic sensitivity analyses were conducted, including assumptions about differential long-term survival.ResultsFor the base case, mean survival was 13.69 vs 13.56 (+ 0.13) years for TAVI and SAVR, respectively. Discounted QALYs were 9.34 vs. 9.21 (+ 0.13) and discounted lifetime costs €52,267 vs. €51,433 (+ €833), resulting in a lifetime ICER of €6368 per QALY gained. In probabilistic sensitivity analysis, TAVI was found dominant or cost-effective in 74.4% of samples.ConclusionTAVI in patients at low surgical risk is a cost-effective alternative to SAVR in the French healthcare system. Longer follow-up data will help increase the accuracy of lifetime survival projections.Graphical

Fully Endoscopic Mitral Valve Repair with Percutaneous Cannulation of Groin Vessels.

Endoscopic mitral valve surgery (EMS) has become a standard of care at specialized heart centers, further reducing surgical trauma compared to a traditional minimally invasive, thoracotomy-based approach. Exposure of the groin vessels for the establishment of cardiopulmonary bypass (CPB) via surgical cutdown in minimally invasive surgery (MIS) may result in wound healing disorders or seroma formation. The avoidance of surgical exposure of the groin vessels by using fully percutaneous techniques for the insertion of a CPB cannula with the implementation of vascular pre-closure devices has the potential to reduce these complications and improve clinical results. Herein, we present the utilization of a novel plug based vacsular closure device with a resobable collagen plug and the absence of suture material for closure of the arterial access for CPB in MIS. While this device was initially predominantly used in transcatheter aortic valve implantation (TAVI) procedures, with its safety and feasibility shown, we herein show that it can be used in CPB cannulation, since it is capable of closing arterial access sites up to 25 French (Fr.) in size. This device may be suitable to significantly reduce groin complications in MIS and simplify the establishment of CPB. Here, we describe the fundamental steps of EMS, including percutaneous groin cannulation and decannulation using a vascular closure device.

Changes in muscle strength and muscle mass after transcatheter aortic valve implantation (TAVI)

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Amsterdam UMC. Background Maintenance of muscle strength and muscle mass is important for long-term health. Periods of physical inactivity and poor dietary intake (e.g. waiting for a medical procedure) can provoke loss of muscle strength and muscle mass. Purpose We aim to determine the course of muscle strength and muscle mass in patients with severe aortic stenosis from before until six months after an elective transcatheter aortic valve implantation (TAVI). Moreover, we aim to explore baseline characteristics associated with change. Methods All patients undergoing an elective TAVI in our high-volume tertiary center were asked to participate. Included patients received three home visits (pre-procedural and 30 days and 6 months post-procedural). During these home visits, handgrip strength was measured with a handheld dynamometer. Muscle mass was determined as skeletal muscle index with a bioelectrical impedance (BIA) measurement. Multivariate mixed linear models were used to determine changes over time. A linear model adjusted for age and sex was performed to explore baseline characteristics associated with changes in muscle strength or muscle mass. Results In total 112 patients were included, mean age of the participants was 81 ± 5 years and 58% were male. The preprocedural measurement took place on a median of 48 [IQR: 19 – 79] days before the TAVI. Preprocedural handgrip strength was on average 36 kg for male and 24 kg for female patients and decreased after the TAVI (-0.12 [95% CI: -0.21, -0.02] kg/month, p=0.02). Living alone and lower hemoglobin level were predictive for a higher decrease in strength (β -2.20 [95% CI: -3.98, -0.42], p=0.02 and β 0.14 [95% CI: 0.02, 0.27] per mmol/l, p=0.03, respectively). Appendicular skeletal muscle index was 7.2 kg/m2 for males and 6.1 kg/m2 for females and did not change after TAVI (0.00 [95%CI: -0.01, 0.01] kg/m2/month, p=0.95). No baseline characteristics were associated with a change in muscle mass. Conclusion Muscle strength significantly declines and muscle mass remains the same from before until six months after the TAVI procedure. Patients living alone or patients with low hemoglobin levels are at increased risk to lose muscle strength. Future studies should focus on the prevention of strength loss, for instance with interventions focusing on nutrition and exercise around the TAVI procedure.

Usefulness of parahisian pacing for risk prediction of pacemaker implantation after TAVI

Abstract Funding Acknowledgements Type of funding sources: None. Background Conduction disturbances determining pacemaker implantation are a significant concern in patients undergoing Transcatheter Aortic Valve Implantation (TAVI), a procedure that is nowadays spreading even in the low-risk population. OBJECTIVE The aim of the study was to evaluate the role of the parahisian pacing, a method to directly identify the conduction system anatomical variability, in predicting the iatrogenic damage risk conditioning pacemaker implantation after TAVI. Methods Between October 2021 and November 2022 we prospectively collected clinical features, ECG, procedural and imaging data (cardiac CT and echocardiography) of every patient who underwent electrophysiological study for pre-existing or worsening conduction disorders within 48 hours after TAVI procedures in our centre. After having recorded the HV interval, parahisian stimulation at decreasing energy output was performed (CL 600 ms, 25V to 0.5V x 2 ms) with definition of the loss of capture pattern related to the three anatomical variations of His bundle described by Kawashima (1). Fisher’s exact test was used for statistical analysis; p-value <0.05 was considered statistically significant. Results Out of 110 TAVI performed, a total of 31 patients with conduction disorders have been studied. Patients who developed permanent 3rd degree AV block after the procedure were excluded. Mean age was 82.6±4.4 years; 21 patients (67.7%) were males. 11 patients (35.5%) had a pre-existing conduction disorder worsened after TAVI, 13 patients (41.9%) developed newly-onset LBBB; 8 (25.8%) also developed 1st degree AV block. The total number of patients who underwent PM implantation was 16 (51.6%). The anatomical variables (membranous septum <3mm and/or septal cusps calcifications) and type of valve implanted were not significantly associated with PM implantation (p = NS). An HV interval <70 ms was registered in 20 (64.5%) patients (Fig. 1); 7 of them underwent PM implantation as they developed paroxysmal 3rd degree AV block. These 7 patients all had type 2 or type 3 pattern during parahisian stimulation. None of the patients undergoing PM implantation presented a type 1 pattern during parahisian stimulation. A significant protective value (p = 0.02) for PM implantation in patients with type 1 pattern was observed (Fig. 2). Conclusions Parahisian stimulation can be a useful tool to define the conduction system anatomical variability. It can also be helpful to predict the conduction system damage risk during TAVI, conditioning PM implantation. Our data need to be confirmed in a larger population.

Efficacy and Safety of Home-Based Cardiac Telemonitoring Rehabilitation in Patients After Transcatheter Aortic Valve Implantation: Single-Center Usability and Feasibility Study

No consensus exists on the efficacy of home-based cardiac rehabilitation (CR) in patients who have undergone transcatheter aortic valve implantation (TAVI). Additionally, there are no reports on home-based cardiac telemonitoring rehabilitation (HBTR) in patients after TAVI. We aimed to investigate the efficacy of HBTR in patients who have undergone TAVI. This single-center preliminary study introduced HBTR to patients after TAVI, and the efficacy outcomes of the rehabilitation method were compared to that of a historical control cohort. The historical control cohort (control group) consisted of 6 consecutive patients who underwent ordinary outpatient CR after TAVI from February 2016 to March 2020. Patients who participated in the HBTR program were only recruited after the TAVI procedure and before discharge between April 2021 and May 2022. In the first 2 weeks after TAVI, patients underwent outpatient CR and were trained using telemonitoring rehabilitation systems. Thereafter, patients underwent HBTR twice a week for 12 weeks. The control group performed standard outpatient CR at least once a week for 12 to 16 weeks. Efficacy was assessed using peak oxygen uptake (VO2) prior to and after CR. Eleven patients were included in the HBTR group. All patients underwent 24 HBTR sessions during the 12-week training period, and no adverse events were observed. The control group participants performed 19 (SD 7) sessions during the training period, and no adverse events were observed. Participants in the HBTR and control groups had a mean age of 80.4 (SD 6.0) years and 79.0 (SD 3.9) years, respectively. In the HBTR group, preintervention and postintervention peak VO2 values were 12.0 (SD 1.7) mL/min/kg and 14.3 (SD 2.7) mL/min/kg (P=.03), respectively. The peak VO2 changes in the HBTR and control groups were 2.4 (SD 1.4) mL/min/kg and 1.3 (SD 5.0) mL/min/kg (P=.64), respectively. Home-based CR using a telemonitoring system is a safe outpatient rehabilitation method. Its efficacy is not inferior to that of standard CR in patients who have undergone TAVI. Japan Registry of Clinical Trials jRCTs032200122; https://jrct.niph.go.jp/latest-detail/jRCTs032200122.

Results and insights after 413 TAVI procedures performed by cardiac surgeons on their own.

Current evidence on transcatheter aortic valve implantation (TAVI) has been generated exclusively by cardiology studies and no operative data from cardiac surgeons are available. Here, we describe the development of our TAVI programme and report the results of transfemoral (TF) TAVI done by cardiac surgeons on their own. This study included all the TAVI procedures on native valve performed at Cardiac Surgery Unit, Ospedali Riuniti di Ancona, during the period October 2018 to July 2022. Relevant prospectively collected preoperative, intraprocedural and postoperative data were retrieved from the Institutional database. A total of 413 patients were included in the study. Mean patients' age was 82 years and among them 44% (180/413) were male. STS score was 3.1% (2.2-4.4). Eighty patients underwent transapical TAVI and 333 patients had a TF approach. We progressively moved from transapical TAVI towards TF procedures that are now routinely performed on conscious sedation and using a fully percutaneous approach. After TF TAVI, 30-day mortality rate was 1%, cerebral stroke occurred in 2% of the cases, permanent pacemaker implantation was necessary in 23% of the patients and in 6% of the cases there was a moderate/severe degree of aortic regurgitation. There was no association between operators performing TAVI and 30-day mortality. The acquisition of catheter-based skills and an adequate training allowed cardiac surgeons to perform on their own awake and fully percutaneous TF TAVI with similar results when compared with major randomized clinical trials and registries' experiences.

Translation and Codons

Background: The trend in the use of fluoroscopic-guided transcatheter aortic valve implantation (TAVI) is increasing because the procedure is less invasive than surgical procedure. However, high radiation doses have been reported with the procedure. Moreover, the amount of radiation received by patients undergoing TAVI has never before been registered in Thailand. Objectives: This study aimed to investigate the radiation dose and the effects of sex and body mass index (BMI) on the radiation dose received by patients undergoing TAVI at Chulabhorn Hospital. Materials and methods: Data were collected on the radiation dose received by patients undergoing the TAVI procedure during the first 26 months after the operation at the Cardiology Center, Chulabhorn Hospital. We recorded patient demographic data including age, sex, and BMI and the following measures of radiation dose from the procedure: the number of exposure images, air kerma-area product (PKA), cumulative air kerma at the patient entrance reference point (Ka,r), and total fluoroscopy time. Results: In total, 68 patients (35 male and 33 female) underwent TAVI, with medi­an exposure images, PKA, Ka,r, and total fluoroscopy time of 1,067 images, 166.14 Gy/cm2, 1,171.50 mGy, and 31.90 minutes, respectively. The patient’s sex did not affect total fluoroscopy time or the radiation dose received. Patients with BMI ≥30.0 kg/m2 had the highest median values of PKA, Ka,r, and total fluoroscopy time. Moreover, patients with BMI ≥18.5-24.9 kg/m2 received higher doses of radiation than patients with BMI ≥25.0-29.9 kg/m2; the result corresponded with longer total fluoroscopy time in the lower BMI category. Conclusion: The amount of radiation that patients received during TAVI was appropriate for diagnosis and treatment. However, to ensure patient safety, operators should consider reducing the duration of radiation during the procedure. Data from this study are a starting point for the recording of radiation doses received by patients undergoing TAVI and can be used as a future dose reference.

Echocardiographic Evaluation after Transcatheter Aortic Valve Implantation: A Comprehensive Review.

Transcatheter aortic valve implantation (TAVI) is an increasingly popular treatment option for patients with severe aortic stenosis. Recent advancements in technology and imaging tools have significantly contributed to the success of TAVI procedures. Echocardiography plays a pivotal role in the evaluation of TAVI patients, both before and after the procedure. This review aims to provide an overview of the most recent technical advancements in echocardiography and their use in the follow-up of TAVI patients. In particular, the focus will be on the examination of the influence of TAVI on left and right ventricular function, which is frequently accompanied by other structural and functional alterations. Echocardiography has proven to be key also in detecting valve deterioration during extended follow-up. This review will provide valuable insights into the technical advancements in echocardiography and their role in the follow-up of TAVI patients.

The impact of transcatheter aortic valve implantation planning and procedure on acute and chronic renal failure.

Severe aortic valve stenosis inhibits renal perfusion, thereby potentially worsening renal function, in particular in elderly patients most often assigned to transcatheter aortic valve implantation (TAVI). Pre-TAVI diagnostics and the procedure itself may adversely impact renal function, however renal perfusion and function may also improve post-procedure. This study aimed to clarify the impact of TAVI planning and procedure on kidney function METHODS: In this retrospective study, kidney function of patients who underwent transfemoral TAVI at a tertiary university hospital between 2016 and 2019 was analyzed. The present study investigated kidney function at baseline, after computed tomography (CT) was performed for evaluation of TAVI, after TAVI, at discharge and at follow-up. Among 366 patients, the prevalence of acute kidney injury (AKI) was 14.5% after TAVI. Independent predictors of AKI were arterial hypertension, baseline creatinine, AKI post CT and coronary intervention during pre-procedural diagnostics. At discharge and follow-up, 2.1% and 3.4%, respectively had sustained relevant impairment of kidney function (defined as creatinine/baseline creatinine > 1.5 or renal replacement therapy). Patients with known chronic kidney disease showed no higher rates of short- and long-term impairment, but higher rates of improvement of renal function after TAVI. In most cases TAVI does not worsen renal function. A sustained impairment after TAVI was found in only a few cases. This was independent of reduced baseline kidney function. Transfemoral TAVI can thus be planned and performed even in patients with higher stages of chronic kidney disease.

Interatrial blocks in patients with tavi and their associations with clinic parameters

Aims: The present study attempted to evaluate the prevalence of basal interatrial blocks (IABs), their associations with clinical parameters, and the interatrial conduction in the follow-up after a successful transcatheter aortic valve implantation (TAVI) procedure among patients with severe aortic stenosis. Methods: We retrospectively evaluated the findings of 90 patients undergoing TAVI in our center. Overall, we considered the presence and grades of IABs and P-wave durations in electrocardiograms (ECG), preoperative echocardiography (ECHO) findings (maximum and mean gradients and left atrium (LA) diameter), valve size and type, and changes in these parameters at sixth month. Results: Forty-six patients were included in the study which are suitable for the pre-determined inclusion criteria. We found the mean age of the patients to be 74.78 ± 8.66 years. In preoperatively-evaluated ECGs, while we detected partial IABs in 37% of the patients, there were advanced IABs in 6.5%, but 56.5% yielded no interatrial conduction disorder. On the other hand, in postoperatively-evaluated ECGs, while we observed partial IABs in 30.4% of the patients, there were advanced IABs among 21.7% (p = 0.017). Nevertheless, we could not conclude any IABs among 47.8% of the patients. Besides, 54.3% of the patients received a self-expandable valve, and a balloon-expandable valve was inserted in 45.7%. In this regard, we detected partial (7 patients) and advanced (2 patients) IABs in the preoperatively-evaluated ECGs of the patients receiving a self-expandable valve. In the postoperative ECGs of these patients, while the partial IAB remained the same in 4 patients (57.1%), it progressed to an advanced IAB in 3 (42.9%). In addition, while the advanced IAB regressed to a partial IAB in one patient, it remained the same for the other patient. In this group, the mean P-wave durations were found to be 118.4±22.67 before the TAVI and 119.6±21.69 after the TAVI (p = 0.113). In the preoperative ECGs of 21 patients with a balloon-expandable valve, we detected partial IABs in 10 patients and an advanced IAB in one patient. While a partial IAB developed in five patients (p = 0.022), five patients with a partial IAB developed an advanced IAB following the procedure (p = 0.022). In this group, we noticed a significant difference between preoperative (127.62±19.4) and postoperative (138.71+ 32.03) P-wave durations (p = 0.038). Conclusion: In a nutshell, we concluded no significant change in interatrial conduction time of the patients with TAVI compared to the baseline in their sixth-month ECGs. When considered by valve type, we concluded that the development and progression of IABs were significant among those with a balloon-expandable valve. The higher postoperative mean gradient among those with a balloon-expandable valve compared to those with a self-expandable valve may be associated with significantly longer P-wave duration among those with a balloon-expandable valve.

One-Year Outcomes after Myval Implantation in Patients with Bicuspid Aortic Valve Stenosis-A Multicentre Real-World Experience.

Bicuspid aortic valve (BAV) affects approximately 1.5% of the general population and is seen in nearly 50% of candidates for aortic valve replacement (AVR). Despite increasingly utilised transcatheter aortic valve implantation (TAVI) in aortic stenosis (AS) patients, its use among patients with severe bicuspid AS is limited as BAV is a heterogeneous disease associated with multiple and complex anatomical challenges. To investigate the one-year outcomes of TAVI using the balloon-expandable Myval transcatheter heart valve (THV) (Meril Life Sciences Pvt. Ltd., Vapi, India) in patients with severe bicuspid AS. We collected data from consecutive patients with bicuspid AS who underwent TAVI with the Myval THV and had at least one-year follow-up. Baseline characteristics, procedural, and 30-day echocardiographic and clinical outcomes were collected. Sixty-two patients were included in the study. The median age was 72 [66.3, 77.0] years, 45 (72.6%) were males, and the mean STS PROM score was 3.2 ± 2.2%. All TAVI procedures were performed via the transfemoral route. The median follow-up duration was 13.5 [12.2, 18.3] months; all-cause mortality was reported in 7 (11.3%) patients and cardiovascular hospitalisation in 6 (10.6%) patients. All-stroke was reported in 2 (3.2%), permanent pacemaker implantation 5 (8.3%), and myocardial infarction 1 (1.6%) patients. The echocardiographic assessment revealed a mean pressure gradient of 10 [8, 16.5] mmHg, effective orifice area 1.7 [1.4, 1.9] cm2, moderate AR in 1 (2%), mild AR in 14 (27%), and none/trace AR in 37 (71%). In total, 1 patient was diagnosed with valve thrombosis (2.1%), Stage II (moderate) haemodynamic deterioration was seen in 3 (6.4%), and stage III (severe) haemodynamic deterioration in 1 (2.1%) patient. TAVI with the Myval THV in selected BAV anatomy is associated with favourable one-year hemodynamic and clinical outcomes.

Comparison of patients with bicuspid and tricuspid aortic valve in transcatheter aortic valve implantation

Background Transcatheter aortic valve implantation (TAVI) has emerged as a safe and effective alternative to surgery for aortic stenosis (AS). However, there are still differences in the procedural process and outcome of bicuspid aortic valve (BAV) treated with TAVI compared with tricuspid aortic valve. Areas covered This review paper aims to summarize the main characteristics and clinical evidence of TAVI in patients with bicuspid and tricuspid aortic valves and compare the outcomes of TAVI procedure. Expert opinion The use of TAVI in patients with BAV has shown similar clinical outcomes compared with tricuspid aortic valve. The efficacy of TAVI for challenging BAV anatomies remains a concern due to the lack of randomized trials. Detailed preprocedural planning is of great importance in low-surgical-risk BAV patients. A better understanding of which subtypes of BAV anatomy are at greater risk for adverse outcomes can potentially benefit the selection of TAVI or open-heart surgery in low surgical risk AS patients.

Early acute kidney injury after transcatheter aortic valve implantation: predictive value of currently available risk scores.

Acute kidney injury (AKI) after transcatheter aortic valve implantation (TAVI) is a frequent complication associated with adverse outcomes and mortality. Various scores have been developed to predict this complication in the coronary setting. However, none have ever been tested in a large TAVI population. This study aimed to evaluate the power of four different scores in predicting AKI after TAVI. Overall, 1535 consecutive TAVI patients from the observational multicentric "Magna Graecia" TAVI registry were included in the analysis. Of the study population, 235 (15.31%) developed AKI early. The Mehran, William Beaumont Hospital, CR4EATME3AD3, and ACEF scores were calculated retrospectively. The patients who developed TAVI-related AKI had significantly higher absolute values of all risk scores than those who did not. The receiver-operating characteristic analysis also showed a significant correlation between these four scores and AKI, but without a significant difference among all of them (p value=0.176). Nevertheless, based on their area under the curve values (≤0.604 for all), none had adequate diagnostic accuracy in predicting TAVI-related AKI. Importantly, multivariate analysis identified myocardial revascularization close to the TAVI procedure and implantation of self-expanding prostheses, as well as atrial fibrillation, low-osmolar contrast media administration, corrected contrast medium volume, and any transfusion (p value<0.05 for all) as independent risk factors for AKI. Although high values of current AKI risk scores are significantly associated with the development of this complication, these are not sufficiently accurate. Further studies are needed so that a TAVI-dedicated AKI risk score may be created.

Importance of Instant Thrombectomy to Treat Cerebral Vessel Occlusion During TAVI in Third World Country

Background: Transcatheter aortic valve implantation (TAVI) is considered to be one of the treatments for symptomatic severe aortic stenosis. This procedure has been associated with cerebrovascular events be it thromboembolic or hemorrhagic in nature that increase the periprocedural mortality and morbidity. Strokes post TAVI are mostly ischemic in origin; they can be either due to symptomatic or silent emboli. These thromboembolic events may occur during the procedure or up to 2 months after the procedure. In the acute setting, especially during the procedure, immediate intervention is crucial for better patient outcome. Mechanical thrombectomy is the best treatment modality for immediate revascularization and stroke prevention. Case description: We present a case of a patient who developed symptomatic signs of hypoperfusion during the procedure that required an urgent mechanical thrombectomy in a third world country. The patient didn’t undergo CT imaging and wasn’t transferred to the brain angiography suite; the procedure was done using the x-ray machine and in the cardiology catherization lab which lacks proper equipment to do cerebral DSA (Digital subtraction angiography). This case is the 8th to be reported in the literature where mechanical thrombectomy was done on the table during a TAVI procedure. Based on this case and the literature review, we will propose an algorithm for dealing with similar cases. Conclusion: We highlight the importance of instant thrombectomy that should be done in a patient suffering from a thromboembolic event while performing TAVI procedure. Using the same endovascular access, in the same setting in the cardiac catherization lab to assess thrombus location, even if done sub-optimally without DSA, in correlation with patient’s symptoms, without taking the patient to perform a CT scan, is life saving and guarantees quick reperfusion after clot aspiration with clinical improvement afterwards and better patient outcome.

Aortic valve and vascular calcium score in pre-TAVI CT: correlation with early post-procedural complications

PurposeThe aim of our study was to evaluate the prevalence of early complications after Transcatheter Aortic Valve Implantation (TAVI) and their correlation with the Calcium Score (CS) of the aortic valve, aorta and ilio-femoral arteries derived from pre-procedural computed tomography (CT).Materials and methodsWe retrospectively reviewed 226 patients (100 males, mean age 79.4 ± 6.7 years) undergoing 64-slice CT for pre-TAVI evaluation from January 2018 to April 2021. The population was divided into CS quartiles.ResultsOverall, 173 patients underwent TAVI procedure, of whom 61% presented paravalvular leak after the procedure, 28% presented bleeding or vascular complications, 25% presented atrioventricular block, and 8% developed acute kidney injury. The prevalence of paravalvular leak and vascular complications was higher in the upper CS quartiles for aortic valve and ilio-femoral arteries.ConclusionsAortic valve and vascular CS could help to predict post-TAVI early complications.

Safety and Feasibility of Staged Versus Concomitant Transcatheter Edge-to-Edge Mitral Valve Repair After Transcatheter Aortic Valve Implantation

The data on the safety and feasibility of performing concomitant or staged transcatheter edge-to-edge repair (TEER) of the mitral valve with transcatheter aortic valve implantation (TAVI) remains limited. The Nationwide Readmission Database was used to identify TEER and TAVI procedures from October 1, 2015 to December 31, 2019, using the International Classification of Diseases, Tenth Revision, Clinical Modification administrative data. A total of 627 weighted cases of TEER and TAVI procedures were included in the analysis. Of those cases, 453 underwent staged TEER after TAVI, whereas 174 had concomitant TAVI and TEER during the same admission. Patients who underwent staged procedures were mostly men (64.8%, p=0.02) and had a higher median age of 85years (interquartile range 79 to 88) versus 82years (interquartile range 72 to 86) in the concomitant procedure group. The adjusted propensity-matched mortality rate was similar for staged versus same-admission procedures (6.1% vs 7.0%, p=0.79). In-hospital complication rates, including acute kidney injury, vascular complications, need for percutaneous coronary intervention, mechanical support, and pacemaker implantation, were higher for the same-admission TEER and TAVI group than TEER performed as a staged procedure. Nonhome facility discharges and length of hospital stay (15 vs 4days) were also significantly higher for the concomitant same-admission TEER and TAVI groups. In conclusion, there was no difference in in-hospital mortality rate between patients who underwent concomitant or staged TEER and TAVI procedures, whereas complication rates were significantly higher in the concomitant group.

Spatial analysis and factors associated with transcatheter aortic valve implantation in Portugal: a retrospective analysis from 2015 to 2017

ObjectivesTo identify the factors associated with transcatheter aortic valve implantation (TAVI) use of TAVI in inpatients with aortic stenosis (AS) in Portugal and its geographical distribution.MethodsA quantitative, observational and retrospective...

Dedicated Next Day Discharge Post Minimalist TAVI: The Tasmanian Experience.

To assess the safety, feasibility and independent predictors of next day discharge (NDD) in patients undergoing minimalist transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS) in a real-world Australian population. This single centre study reviewed 135 consecutive patients who underwent minimalist transfemoral TAVI from June 2020 to February 2022. Baseline demographics, procedural characteristic and outcomes were obtained. All patients were assessed by the local protocol for NDD. Patients were then divided into two groups: those who achieved next day discharge (NDD) and those requiring >1 overnight hospital stay. Univariate, bivariate and stepwise multivariate logistic regression modelling was used to identify the predictors of successful next day discharge. The mean age of the cohort was 82.9±5.7 years with 62.3% patients male, the average STS score was 4.1±2.4. All 135 patients underwent a successful transfemoral TAVI procedure, with 131 (97%) receiving a balloon-expandable valve. Ninety-seven (97) (71.9%) patients achieved NDD. Thirty (30)-day outcomes were excellent with a 30-day mortality of 0.7%, transient ischaemic attack/cardiovascular accident (TIA/CVA) 1.5%, major vascular complication 1.5% and 11.4% need for permanent pacemaker (PPM). In patients not achieving NDD, the average length of stay (LOS) was 3.0 days. Baseline characteristics demonstrated pre-existing first degree atrioventricular (AV) block and right bundle branch block (RBBB) as statistically significant negative predictors of NDD on univariate analysis. Next day discharge was achievable in only 50% of patients who suffered any minor or major procedural complication (15/30). Stepwise multivariate logistic regression modelling demonstrated female gender (OR 3.094, 95% CI 1.141-8.391, p=0.026), smaller aortic valve area (AVA) (OR 48.265, 95% CI 2.269-102.6, p=0.013), the presence of diabetes mellitus (OR 0.594, 95% CI 0.356-0.991, p=0.046) and a longer procedure time (OR 0.960, 95% CI 0.935-0.986, p=0.002) as statistically significant negative predictors of NDD. In addition, there was no difference in 30-day readmission rates between the NDD and non-NDD cohort (7.2% vs 10.5%, p=0.386). Next day discharge is safe and feasible in almost three quarters of patients undergoing minimalist TAVI for severe AS in a predominantly balloon expandable valve cohort, with a very low rate of 30-day readmission. NDD provides advantages for hospital efficiency and improved cost-effectiveness. Female gender, smaller AVA, the presence of diabetes mellitus and a longer procedure time were independent negative predictors of successful NDD.

Redo-Transcatheter Aortic Valve Implantation Using the SAPIEN 3/Ultra Transcatheter Heart Valves—Expert Consensus on Procedural Planning and Techniques

Recent guidelines on valvular heart disease in Europe and the United States have expanded the indications for transcatheter aortic valve implantation (TAVI) to younger patients and those at lower surgical risk with severe symptomatic aortic stenosis. Consequently, the number of TAVI procedures will significantly increase worldwide. Patients with longer life expectancies will outlive their transcatheter heart valves (THVs) and require established treatment strategies for re-intervention. Current data have shown encouraging outcomes, including low mortality, with redo-TAVI; in contrast, surgical explantation of THVs is associated with high mortality. Redo-TAVI, therefore, is likely to be the treatment of choice for THV failure. The expected increase in the number of redo-TAVIs stands in contrast to the current lack of evidence on how this procedure should be planned and performed, including the risks and pitfalls operators need to consider. Preliminary reports stress the importance of preprocedural planning, understanding of THV skirt and leaflet characteristics, and implantation guidelines specific to different THVs. Currently, SAPIEN 3/Ultra is the only THV approved in Europe and the United States for redo-TAVI. Therefore, we gathered a panel of experts in TAVI procedures with the aim of providing operative guidance on redo-TAVI, using the SAPIEN 3/Ultra THV. This consensus article presents a step-by-step approach encompassing clinical, anatomical, and technical aspects in preprocedural planning, procedural techniques, and postprocedural care. In conclusion, the recommendations aim to improve the feasibility, safety, and long-term outcomes of redo-TAVI, including the durability of implanted THVs.

Endovascular Technique for Ascending Aorta Repair Based on TEVAR and TAVI Procedures

Purpose: Ascending aorta (AAo) acute pathology still has an open-surgery indication with a high mortality rate associated to cardiopulmonary bypass and circulatory arrest. In these cases, the endovascular aortic approach could be an excellent option. The aim of the present study is to detail an optimized technique for the endovascular treatment of AAo diseases, based on thoracic endovascular aortic repair (TEVAR) and transcatheter aortic valve implantation (TAVI) procedures. Technique: The procedure implies the usual preparation for TEVAR and TAVI implants. A transient pacemaker lead is necessary to deliver the prosthesis under “rapid pacing.” As in the TAVI technique, a final high-support guidewire is placed at the left ventricle. The proximal landing zone is the sinotubular junction (zone 0B). Transesophageal echocardiography is essential to ensure aortic valve function and patency in coronary arteries during the delivery. To assess a potential occlusion of the brachiocephalic artery, a guidewire is positioned in the descending aorta from the axillary artery. Finally, a noncovered stent is implanted to stabilize the AAo prosthesis. Conclusion: The technique presented here can standardize a safe and reproducible procedure to endovascular repair of AAo diseases. However, new devices specifically designed for the AAo could facilitate the transcatheter approach. Clinical Impact Ascending aorta acute pathology still has an open-surgery indication with high mortality rate associated to cardiopulmonary bypass and circulatory arrest. Moreover, near 30% of patients are not considered suitable for surgery because of age, critical situation or the presence of severe comorbidities. The present study provides a detailed and optimized technique for the endovascular treatment of ascending aorta disease, based on TEVAR and TAVI procedures.