Transfemoral Transcatheter Aortic Valve Replacement Research Articles

P4499Impact of new onset atrial fibrillation on outcome of patients undergoing transfemoral transcatheter aortic valve replacement

P4499Impact of new onset atrial fibrillation on outcome of patients undergoing transfemoral transcatheter aortic valve replacement

234Treatment of degenerated aortic bioprostheses: a comparison between conventional reoperation and valve-in-valve transfemoral transcatheter aortic valve replacement

234Treatment of degenerated aortic bioprostheses: a comparison between conventional reoperation and valve-in-valve transfemoral transcatheter aortic valve replacement

Hemodynamic monitoring by pulse contour analysis during trans-catheter aortic valve replacement: A fast and easy method to optimize procedure results.

Residual aortic regurgitation (AR) complicates a not negligible number of transcatheter aortic valve replacement (TAVR) procedures, and its entity is not always clear at intraprocedural angiographic and echocardiographic control. We applied a minimally invasive hemodynamic monitoring system (Pressure Recording Analytical Method, PRAM) in the setting of TAVR, with the aim of identifying parameters that may help in detection and quantification of residual AR. We performed hemodynamic monitoring with PRAM in 43 patients undergoing trans-femoral TAVR. Investigated parameters were systolic (Psys, mm Hg), diastolic (Pdia, mm Hg), mean (MAP, mm Hg) and dicrotic pressure (Pdic, mm Hg), cardiac output (CO, L/min), stroke volume (SV, mL), cardiac cycle efficiency (CCE, Units), dP/dtmax_rad (mm Hg/ms), MAP-Pdic (mm Hg). Procedural success was achieved in 86% of the patients; vascular complications occurred in 3 (6.9%), death in 2 (4.7%). Twenty (46.5%) patients had at least mild residual AR. CO, SV, CCE and dP/dtmax_rad changed significantly (p < 0.001) between baseline and end of procedure in the overall population, with more evident modifications in the subgroup without residual AR. MAP-Pdic variations were statistically significant only in the subgroup without AR (p = 0.05). TAVR determined an improvement in hemodynamic parameters such as CO, SV, CCE, dP/dtmax_rad. MAP-Pdic was able to discriminate patients with significant residual AR. Hemodynamic monitoring with PRAM system during TAVR is easy and fast to obtain and may help in clinical decision-making in controversial cases.

Prophylactic Ipsilateral Superficial Femoral Artery Access in Patients With Elevated Risk for Femoral Access Complications During Transfemoral Transcatheter Aortic Valve Replacement

We report 2 patients, both men, 87 and 82 years of age, with severe aortic stenosis scheduled for transcatheter aortic valve replacement (TAVR), both with histories of lower extremity peripheral artery disease and endovascular abdominal aortic aneurysm repair with presence of dense bilateral groin

Predicted magnitude of alternate access in the contemporary transcatheter aortic valve replacement era

We aimed to evaluate the true extent of alternate access in a contemporary cohort of transcatheter aortic valve replacement (TAVR) patients. Appropriate access selection for TAVR impacts clinical outcomes. Despite device miniaturization, some patients remain ineligible for transfemoral arterial access. Five hundred seventy-five consecutive TAVR patients were classified according to iliofemoral artery diameters measured by computed tomography (<5.0 mm, 5.0-5.4 mm, 5.5-5.9 mm, or ≥6 mm) and need for alternate access rate was estimated according to commercially available transcatheter heart valve Instructions For Use (IFU). Based on iliofemoral artery diameters alone, 11.5% of patients were predicted to require alternate access. After patient-level adjustment for the size of the planned THV and severe tortuosity or severe calcification, 14.9% and 20.8% of patients, respectively were predicted to require alternate access. Overall, 87.8% of patients underwent transfemoral TAVR and 12.3% underwent alternate access. There was no difference in the rate of major vascular complications and life threatening or major bleeding between groups, but transfusion rate was higher in smaller vessel groups. Despite device miniaturization, a substantial minority of contemporary TAVR patients still require alternate access. Most are eligible for newer extrathoracic approaches including transcaval, subclavian, and transcarotid that avoid the morbidity of transthoracic access.

Variation in post-TAVR antiplatelet therapy utilization and associated outcomes: Insights from the STS/ACC TVT Registry

Dual antiplatelet therapy (DAPT) is recommended following transcatheter aortic valve replacement (TAVR); however, the optimal antiplatelet strategy is undefined, and little is known about practice patterns. We aimed to describe contemporary practice patterns of antiplatelet therapy and their relationship to outcomes post-TAVR. The population was derived from the National Cardiovascular Data Registry, Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapies Registry with Center for Medical Services linkage for 1-year outcomes from October 1, 2011 to June 30,2016. The primary outcome measured was DAPT use in patients without anticoagulation. Secondary outcomes included death, major bleeding, myocardial infarction (MI), and stroke at 1 year. Overall, 16,694 patients underwent transfemoral TAVR at 444 hospitals and were discharged without anticoagulation. Among these, 13,546 (81.1%) patients were discharged on DAPT, whereas 3,148 patients (18.9%) were discharged on monotherapy. Patients discharged on DAPT versus monotherapy were similar in age, sex, and most comorbid illnesses but had higher rates of coronary artery disease (64.6% vs 52.3%; P < .01) and peripheral artery disease (25.2% vs 22.3%; P < .01). Hospital prescribing patterns varied significantly (median frequency of DAPT 85.7%, interquartile range 94.1%-74.2%). DAPT (vs monotherapy) patients had a similar mortality risk at 1 year (adjusted hazard ratio 0.92, 95% CI 0.81-1.05), significantly higher risk for major bleeding (1.48, 1.10-1.99), and similar hazard for stroke (1.04, 0.83-1.31) and MI (1.00, 0.72-1.39). In the United States, most patients were discharged on DAPT following TAVR. Practice patterns varied significantly among hospitals. Patients discharged with DAPT had a similar adjusted risk of mortality, stroke, and MI compared to antiplatelet monotherapy, although risk for bleeding was significantly higher. Future investigation is needed to define the optimal antiplatelet therapy for patients undergoing TAVR.

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

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

A Review of Alternative Access for Transcatheter Aortic Valve Replacement.

With the advent of transcatheter aortic valve replacement (TAVR), appropriately selected intermediate-, high-, and extreme-risk patients with severe aortic stenosis (AS) are now offered a less invasive option compared to conventional surgery. In contemporary practice, TAVR is performed predominantly via a transfemoral arterial approach, whereby a transcatheter heart valve (THV) is delivered in a retrograde fashion through the iliofemoral arterial system and thoraco-abdominal aorta, into the native aortic valve annulus. While the majority of patients possess suitable anatomy for transfemoral arterial access, there is a subset of patients with extensive peripheral vascular disease that precludes this traditional approach to TAVR. Fortunately, innovation in the field of structural heart disease has led to the refinement of alternative access options for THV delivery. Selection of the most appropriate route of therapy mandates a careful consideration of multiple factors, including patient anatomy, technical feasibility, and equipment specifications. Furthermore, understanding the risks conferred by each access site for valve delivery-notably stroke, vascular injury, and major bleeding-is of paramount importance when selecting the approach that will best optimize the outcome for an individual. In this review, we provide a comprehensive summary of alternative approaches to transfemoral arterial TAVR as well as the available outcome data supporting each of these various techniques.

Stent fractures after common femoral artery bail-out stenting due to suture device failure in TAVR

Vascular access site-related complications are frequent in the context of transfemoral transcatheter aortic valve replacement (TAVR). The implantation of a covered stent graft is an effective treatment option for bleeding control. However, the external iliac and common femoral arteries are exposed to flexion of the hip joint. Therefore, stent compression and stent/strut fractures may occur, facilitating stent occlusion. In all 389 patients who received transfemoral TAVR from 2013-2015 at the Düsseldorf Heart Centre, we monitored the management of vascular access site-related complications. Our analyses focused on immediate technical success and bleeding control, primary patency, and the occurrence of stent/strut fractures after six to 12 months of follow-up. Vascular access site-related complications occurred in 13 % (n = 51), whereof in 10 patients, the bleeding was successfully managed by prolonged compression. In 40 out of 51 patients, a covered stent graft was implanted in the common femoral artery, leading to 100 % immediate bleeding control. After a mean follow-up of 334 ± 188 days, 28 stents out of 29 patients with completed follow-up (excluding e. g. death) were without flow-limiting stenosis (primary patency 97 %) or relevant stent compression (diameter pre/post 8.6/8.1 mm, p = 0.048, late lumen loss 1.1 ± 0.2 mm, mean flow velocity 92 ± 34 cm/s). In four asymptomatic patients, stent/strut fractures were detected (14 %) without flow-limiting stenosis. The implantation of a covered stent graft is highly effective and safe to control vascular access site-related complications after TAVR. Stent/strut fractures in the flexible segment of the common femoral artery may occur, as consequently verified by X-ray visualization, but show no impairment on flow or clinical parameters after six to 12 months.

Gender-dependent association of diabetes mellitus with mortality in patients undergoing transcatheter aortic valve replacement.

Diabetes mellitus (DM) is a risk factor for cardiovascular disease. However, its effect on procedural and follow-up performance after transcatheter aortic valve replacement (TAVR) remains controversial. We performed an observational study of all consecutive patients treated with a transfemoral TAVR in a single-center cohort (n = 1818). All patients were stratified by diabetes status and gender. All-cause 3-year mortality was the primary endpoint. Male patients with DM were identified to have substantially increased 3-year mortality [125/314 (39.8%)] compared to males without DM [142/478 (29.7%), p < 0.01]. Male patients with DM had significantly higher 3-year mortality in comparison to female patients with (p < 0.01) or without DM (p < 0.01). There was no difference in 3-year mortality for female patients with [135/465 (29.0%)] and without DM [151/554 (27.3%); p = 0.70]. This increase in mortality in male DM patients was triggered by both cardiovascular and non-cardiovascular mortality. Furthermore, DM served as an independent predictor of 3-year mortality after TAVR selectively only in men. The interaction between male gender and diabetes mellitus was identified as an independent predictor of 3-year mortality [HR 1.88 (1.25; 2.82); p < 0.01]. DM did not affect 30-day mortality for the overall cohort and for males. Males with DM are a high-risk subgroup of patients after TAVR and require close medical attention including aggressive therapy of modifiable risk factors. Intensified diabetes management may improve long-term survival after TAVR.

Transcatheter aortic valve replacement with the 34 mm Medtronic Evolut valve : Early results of single institution experience.

ObjectivesTo report our experience with the recently introduced 34 mm Evolut transcatheter aortic valve replacement (TAVR) prosthesis.BackgroundA larger TAVR prosthesis has become available for the treatment of aortic stenosis (AVS) in larger native aortic annuli (up to 30 mm). Outcomes with this new device are still unreported.ResultsThe first 25 transfemoral TAVRs performed by our team with the self-expandable 34 mm Evolut are presented. The majority of patients were male (84%) with a mean age of 81.3 ± 5.6 years, a median logistic euro-SCORE of 14.7 (5.4-61.0), and a computed tomography measured mean perimeter-derived aortic annulus diameter of 27.1 ± 1.4 mm (min. 25.0–max. 31.2 mm). We implanted one 34 mm Evolut in all patients. Median operative time and radiation time were 68.5 and 12.4 min respectively. To optimise final valve position and haemodynamic performance, at least one complete re-sheathing and re-positioning of the same valve was reported in 33.2%. New permanent pacemaker implantation (PPMI) was necessary in 28.5%. At Receiver Operating Characteristic (ROC) analysis, a minimal diameter of the left ventricular outflow tract <21.9 mm was a significant predictor for PPMI (specificity 82%; sensitivity 83%; p = 0.005; Area Under the Curve (AUC) = 0.9). Length of stay in hospital was 9.2 ± 5.8 days and no in-hospital death was reported. At discharge, grade 1 + para-valvular regurgitation was present in 32%, and no regurgitation in the remaining patients. Device success and early safety were 100% and 92% respectively.ConclusionsTAVR with the 34 mm Evolut prosthesis has shown satisfactory acute outcomes. Although results are consistent with those observed with smaller Evolut prostheses, a trend for a higher PPMI rate has been noticed and could derive from a higher oversizing rate.

Transcatheter Aortic Valve Replacement: Comparing Transfemoral, Transcarotid, and Transcaval Access

Despite newer-generation valves using smaller-sized sheaths, 10% to 20% of patients undergoing transcatheter aortic valve replacement (TAVR) require nonfemoral artery access for valve delivery. To avoid a transthoracic procedure, we have used transcarotid (TC) and transcaval (TCav) approaches in these patients. This study compared the results of a contemporary experience with transfemoral (TF), TC, and TCav approaches. Between January 2015 and March 2017, 491 patients underwent TAVR at our institution, of which 463 were included in this analysis. Valve delivery was TF in 373 patients, TCav in 58, and TC in 32. Patient characteristics and outcomes, including 1-year survival, were compared. Preoperative demographics and postoperative outcomes were similar for the three groups with several exceptions. TCav patients had higher The Society of Thoracic Surgeons risk score than TF patients (8.0 ± 5.2 vs 6.1 ± 4.3, p= 0.004). Lung disease, cerebrovascular disease, and peripheral vascular disease were more common in TC and TCav patients. Median length of stay was 2 days for TF, 3 days for TC, and 4 days for TCav (TF vs TCav, p= 0.001). Procedural mortality, percentage discharged home, and the 30-day readmission rate were similar for all. Unadjusted Kaplan-Meier survival was also similar at 1 year (TF, 86%; TC, 83%; TCav, 80%). Patients unsuitable for TF TAVR treated with TC or TCav access had 30-day/in-hospital and 1-year survival similar to a contemporary cohort undergoing TF access. Avoiding surgical entry to the chest may offer procedural and intermediate-term outcomes equivalent to TF TAVR.

Real-Time Detection of an Acute Cerebral Thrombotic Occlusion During a Transcatheter Valve Intervention

A 77-year-old man with a history of severe chronic obstructive pulmonary disease and severe symptomatic aortic stenosis was admitted for transfemoral transcatheter aortic valve replacement with a 31-mm self-expandable valve (CoreValve Evolut R, Medtronic, Minneapolis, Minnesota). Real-time

Early changes in N-terminal pro-B-type natriuretic peptide levels after transcatheter aortic valve replacement and its impact on long-term mortality

BackgroundN-terminal pro-hormone B-type natriuretic peptide (NT-proBNP) levels correlate with higher peri-procedural mortality after transcatheter aortic valve replacement (TAVR). The long-term prognostic value of NT-proBNP within the first days after TAVR, however, remains unclear. This study examined early changes in NT-proBNP prior to and within 6 days after TAVR, the diagnostic value of this biomarker regarding aortic regurgitation (AR), and its prognostic value regarding one-year mortality. Methods and resultsNT-proBNP concentrations were measured in 504 consecutive patients undergoing transapical (TA) or transfemoral (TF) TAVR before and directly after TAVR as well as 4 h and 1, 2, 3, and 6 days after TAVR. The follow-up period was 1 year. NT-proBNP was elevated in all patients at baseline (median 2141 ng/L [IQR 1021–5319 ng/L]). NT-proBNP changes in the first 6 days after TAVR showed significant differences depending on the approach, with a greater and more prolonged rise evident in TA-TAVR patients. NT-proBNP was an independent predictor of mortality in TA patients with AR, with an AUC of 0.794 (95% CI 0.663–0.925; P = 0.003) when measured on day 3 after TAVR. For TF patients with AR and reduced left ventricular systolic function, the AUC for prediction of mortality was 0.897 (95% CI 0.778–1.0; P = 0.004) on day 2. ConclusionsThe prognostic information of early post-procedural NT-proBNP concentrations is superior to pre-procedural values regarding all-cause mortality within 1 year. Post-procedural NT-proBNP must be interpreted in relation to the TAVR approach. NT-proBNP predicts mortality in TF-TAVR patients with AR and reduced left ventricular function.

Open Surgical Access for Transfemoral TAVR Should Not Be a Contraindication for Conscious Sedation

The use of monitored anesthesia care (MAC) for transcatheter aortic valve replacement (TAVR) is gaining favor in the United States, although general anesthesia (GA) continues to be common for these procedures. Open surgical cutdown for transfemoral TAVR has been a relative contraindication for TAVR with MAC at most centers. The objective of this study was to review the authors' results of transfemoral TAVR performed in patients with open surgical cutdown with the use of MAC. Retrospective study design from a prospectively recorded database. Tertiary academic (teaching) hospital. Two hundred eighty-two patients undergoing transfemoral TAVR with open surgical cutdown under MAC from 2015 to 2017. Transfemoral TAVR under MAC with surgical cutdown for femoral vascular access. The study cohort consisted of 282 patients with severe aortic stenosis (mean area 0.65 [± 0.16] cm2, mean gradient of 48.9 [±13.3] mmHg, and mean age of 82.7 [± 7.31] years). Eleven (3.9%) patients required conversion to GA. First postoperative pain score (0-10) was 2.9 and highest postoperative pain score was 4.6. Major and minor vascular complications occurred in 2 (0.7%) and 6 (2.1%) patients, respectively. Twenty-nine (10.3%) patients were readmitted within 30 days, and 6 (2.1%) patients had in-hospital mortality. Open surgical cutdown for transfemoral TAVR can be performed safely using MAC and ilioinguinal block with low rates of conversion to general anesthesia and acceptable postoperative outcomes and pain scores.

Cardiorespiratory Stability of Patients Undergoing Transcatheter Aortic Valve Replacement Is Not Improved During General Anesthesia Compared to Sedation: A Retrospective, Observational Study

ABSTRACTPurpose: To evaluate whether general anesthesia (GA) provides improved cardiorespiratory stability compared to sedation during TAVR.Methods: A retrospective analysis at a single center, university hospital. Patients undergoing TAVR were given either routine GA or deep sedation with dexmedetomidine for TAVR.Results: The superiority of GA versus deep sedation was evaluated statistically by testing if any of the following were lower in the GA patient group; the incidence of cardiorespiratory perturbations (hypotension, bradycardia, or hypoxemia), the amount of volume resuscitation (crystalloid, colloid, or allogeneic blood administration), or the doses of drugs needed to control blood pressure (epinephrine, norepinephrine, calcium, and nitroglycerine). A total of 206 TAVR patients were studied. Of these, 150 patients underwent TAVR via the transfemoral approach and were included for comparative analysis. In total 58 (39%) received sedation. Sedation patients were older than those who received GA. There were not less cardiorespiratory perturbations in the GA group. No less vasocactive agents were administered in the GA patients. Volume resuscitation was also not less in the patients receiving GA. All broad indices of stability were not lower in GA patients. Patients in the GA group were also more likely to receive a packed red blood cell transfusion. In all, 8 (13.8%) of the patients required conversion of sedation to GA. Patients who received GA were almost twice as likely to be transferred to the ICU intubated.Conclusion: Transfemoral TAVR patients who received GA did not have more cardiorespiratory stability compared to those receiving sedation.

In-hospital outcomes after transcatheter or surgical aortic valve replacement in younger patients less than 75 years old: a propensity-matched comparison

Randomised trials comparing transcatheter aortic valve replacement (TAVR) with surgical aortic valve replacement (SAVR) have included mainly elderly patients >80 years. The authors investigated comparative in-hospital outcomes of younger patients <75 years undergoing transfemoral (TF) TAVR or isolated SAVR. A total of 6,972 patients aged 65-74 years undergoing TF-TAVR or SAVR between 2013 and 2014 were identified from the observational German Quality Assurance Registry on Aortic Valve Replacement (AQUA), which comprises all TAVR and SAVR procedures performed in Germany. Analyses were performed for the overall unmatched cohort as well as for 1,388 propensity-matched patients. Overall, 82.4% of patients <75 years needing treatment for aortic valve stenosis received SAVR. Patients undergoing TF-TAVR were older and had more comorbidities with higher predicted risk of death. After propensity-matching, in-hospital mortality (1.3% vs. 1.9%, p=0.39), neurologic complications (1.0% vs. 2.1%, p=0.09), and myocardial infarctions (0 vs. 0.3%, p=0.16) were not different after TF-TAVR or SAVR. Postoperative delirium was more frequent after SAVR (8.9% vs. 2.4%, p<0.001), whereas the need for new pacemaker was 4 times higher after TF-TAVR (13.3% vs. 3.5%, p<0.001). Younger patients <75 years undergoing TF-TAVR or SAVR had similar outcomes with the exception of more frequent need for new pacemaker implantation and less frequent incidence of post-operative dialysis and delirium in TF-TAVR patients. Whether these similar in-hospital outcomes are replicable in the longer-term events in TF-TAVR and SAVR remains to be proven in future studies.

Combined carotid endarterectomy and transcatheter aortic valve replacement: Technique and outcomes.

Stroke and transient ischemic attack after transcatheter aortic valve replacement results in significantly higher morbidity and mortality. Severe carotid artery disease may be a contributing factor to this increased risk. We report our technique and outcomes of combined carotid endarterectomy (CEA) with transcatheter aortic valve replacement (TAVR). From March 2013 to November 2017 a total of 753 TAVRs were performed at our institution for symptomatic severe aortic stenosis. Of this group, 16 patients underwent concomitant TAVR and CEA. A retrospective review was performed to assess risk, outcomes, and short-term survival. Sixteen patients underwent concomitant CEA/TAVR procedures for severe carotid and severe aortic stenosis. The mean Society of Thoracic Surgeons (STS) Risk Score was 7.0 ± 4.7. All patients had severe carotid artery stenosis and aortic stenosis. Nine patients had a transfemoral TAVR approach and eight patients had a transapical TAVR approach. The mean length of stay was 6.4 ± 3.7 days. At 30 days there were no cerebrovascular events and no mortalities. The use of concomitant CEA and TAVR in patients with severe aortic stenosis and severe carotid stenosis can be done safely without increased risk of complications. This approach may reduce the risk of stroke associated with TAVR in appropriately selected patients.

Risk factors and outcome of postoperative delirium after transcatheter aortic valve replacement.

POD is associated with a worse postoperative course in patients after cardiac surgery, but its incidence and effects after TAVR are not well-understood. The aim of the present study was to analyze incidence, risk factors, and in-hospital outcomes of postoperative delirium (POD) after transfemoral (TF-AVR) and transapical (TA-AVR) transcatheter aortic valve replacement (TAVR) in a nationwide cohort. Administrative data on all patients undergoing isolated TAVR in Germany in 2014 were analyzed. 9038 TF-AVR and 2522 TA-AVR procedures were performed. POD incidence was 7% after TF-AVR and 12% after TA-AVR. Atrial fibrillation (TF: OR 1.35, p < 0.001; TA: OR 1.53, p = 0.001) and NYHA III/IV (TF: OR 1.23, p = 0.017, TA: OR 1.51, p = 0.001) were independent risk factors for POD. Dementia was a risk factor only in TF-AVR (OR 3.04, p < 0.001). Female sex was protective (TF: OR 0.56, p < 0.001, TA: OR 0.51, p < 0.001). We found the occurrence of POD to be associated with more postoperative complications such as stroke and bleeding. Consequently, patients with POD were ventilated and hospitalized longer and suffered an increased risk of in-hospital mortality (unadjusted OR TF: 1.83, p = 0.001, TA: 1.82, p = 0.01). After adjusting for postoperative events and comorbidities, POD's effect on in-hospital mortality disappeared. In contrast, stroke and bleeding remained independent predictors for mortality irrespective of POD. Patients with POD after TAVR are at increased risk for in-hospital mortality. However, after adjusting for postoperative events and comorbidities, stroke and bleeding, but not POD, are independent mortality predictors.

Complications after Transfemoral Transcatheter Aortic Valve Replacement with a Balloon‐Expandable Prosthesis: The Importance of Preventative Measures and Contingency Planning

Transcatheter aortic valve replacement (TAVR) with balloon-expandable Edwards-SAPIEN valve was superior to standard therapy in inoperable patients and noninferior to surgical aortic valve replacement in high surgical-risk, but operable patients, with severe symptomatic aortic stenosis in the randomized controlled PARTNER trial. Since the first case of TAVR with a balloon-expandable valve in 2002, several groups have reported their experience with balloon-expandable valves with high-procedural success. In the United States, the balloon-expandable Edwards-SAPIEN valve is the only transcatheter heart valve approved by the FDA for commercial use. Moreover, this is only in high-risk inoperable patients. Despite increasing experience with the TAVR procedure, it can be associated with complications, which can be technically challenging, even for an experienced operator. Complications associated with TAVR include vascular complications, valve malpositioning, regurgitation, embolization, coronary compromise, conduction abnormalities, stroke/transient ischemic attack, acute kidney injury, cardiac tamponade, and hemodynamic collapse. A thorough understanding of the procedure is essential for pre-emptive planning for procedural complications and early identification and management of complications are necessary for procedural success. We hereby review our experience of transfemoral TAVR with balloon-expandable valves, offer practical tips to maximize the likelihood of procedural success, describe pre-emptive strategies to prevent peri-procedural complications and bailout measures to manage them, should they occur. © 2018 Wiley Periodicals, Inc.