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Kaneko T, Hirji SA, Yazdchi F, Sun YP, Nyman C, Shook D, Cohen DJ, Stebbins A, Zeitouni M, Vemulapalli S, Thourani VH, Shah PB, O'Gara P. Association Between Peripheral Versus Central Access for Alternative Access Transcatheter Aortic Valve Replacement and Mortality and Stroke: A Report From the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. Circ Cardiovasc Interv 2022; 15:e011756. [PMID: 36126131 DOI: 10.1161/circinterventions.121.011756] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In some patients, the alternative access route for transcatheter aortic valve replacement (TAVR) is utilized because the conventional transfemoral approach is not felt to be either feasible or optimal. However, accurate prognostication of patient risks is not well established. This study examines the associations between peripheral (transsubclavian/transaxillary, and transcarotid) versus central access (transapical and transaortic) in alternative access TAVR and 30-day and 1-year end points of mortality and stroke for all valve platforms. METHODS Using data from The Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry with linkage to Medicare claims, patients who underwent alternative access TAVR from June 1, 2015 to June 30, 2018 were identified. Adjusted and unadjusted Cox proportional hazards modeling were performed to determine the association between alternate access TAVR site and 30-day and 1-year end points of mortality and stroke. RESULTS Of 7187 alternative access TAVR patients, 3725 (52%) had peripheral access and 3462 (48%) had central access. All-cause mortality was significantly lower in peripheral access versus central access group at in-hospital and 1 year (2.9% versus 6.3% and 20.3% versus 26.6%, respectively), but stroke rates were higher (5.0% versus 2.8% and 7.3% versus 5.5%, respectively; all P<0.001). These results persisted after 1-year adjustment (death adjusted hazard ratio, 0.72 [95% CI, 0.62-0.85] and stroke adjusted hazard ratio, 2.92 [95% CI, 2.21-3.85]). When broken down by individual subtypes, compared with transaxillary/subclavian access patients, transapical, and transaortic access patients had higher all-cause mortality but less stroke (P<0.05). CONCLUSIONS In this real-world, contemporary, nationally representative benchmarking study of alternate access TAVR sites, peripheral access was associated with favorable mortality and morbidity outcomes compared with central access, at the expense of higher stroke. These findings may allow for accurate prognostication of risk for patient counseling and decision-making for the heart team with regard to alternative access TAVR.
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Affiliation(s)
- Tsuyoshi Kaneko
- Division of Thoracic and Cardiac Surgery (T.K., S.H., F.Y.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sameer A Hirji
- Division of Thoracic and Cardiac Surgery (T.K., S.H., F.Y.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Farhang Yazdchi
- Division of Thoracic and Cardiac Surgery (T.K., S.H., F.Y.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Yee-Ping Sun
- Division of Cardiovascular Medicine (Y.P.S., P.S., P.O.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Charles Nyman
- Division of Cardiac Anesthesia (C.N., D.S.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Douglas Shook
- Division of Cardiac Anesthesia (C.N., D.S.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - David J Cohen
- Cardiovascular Research Foundation, New York, NY (D.J.C.).,Duke Clinical Research Institute, Durham, NC (D.J.C.)
| | | | | | | | | | - Pinak B Shah
- Division of Cardiovascular Medicine (Y.P.S., P.S., P.O.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Patrick O'Gara
- Division of Cardiovascular Medicine (Y.P.S., P.S., P.O.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Anesthesia Considerations for Transcatheter Mitral and Aortic Valve Procedures. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00452-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Kindzelski B, Mick SL, Krishnaswamy A, Kapadia SR, Attia T, Hodges K, Siddiqi S, Lowry AM, Blackstone EH, Popovic Z, Svensson LG, Unai S, Yun JJ. Evolution of Alternative-access Transcatheter Aortic Valve Replacement. Ann Thorac Surg 2021; 112:1877-1885. [PMID: 33647251 DOI: 10.1016/j.athoracsur.2021.02.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 12/28/2020] [Accepted: 02/02/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Transfemoral access is the most common approach for transcatheter aortic valve replacement (TAVR). However, a subset of patients require alternative access. This study describes the evolution and outcomes of alternative-access TAVR at Cleveland Clinic. METHODS From January 2006 to January 2019, 2446 patients underwent TAVR, 414 (17%) through alternative access (247 transapical, 95 transaortic, 56 transaxillary, 2 transcarotid, 10 transiliac, 4 transcaval). Patients undergoing alternative-access TAVR had high preoperative risk. Propensity-matched comparisons were targeted at comparing transfemoral versus transaxillary approaches since 2012. RESULTS Over time, the favored alternative-access approach shifted from transapical and transaortic to transaxillary. Pacemaker requirement was similar for alternative-access and transfemoral approaches. Compared with transfemoral access, major vascular injuries were higher in the alternative-access group (12 [2.9%] vs 27 [1.3%], P = .02), but minor vascular injuries were lower (13 [3.1%] vs 198 [9.8%], P < .0001). Non-risk-adjusted 5-year survival was lower in the alternative-access group (45% vs 59%). Compared with intrathoracic approaches (transapical and transaortic), transaxillary access was associated with fewer blood transfusions (12 [21%] vs 176 [51%], P < .0001), less prolonged ventilation (1 [1.8%] vs 38 [11%], P = .03), and shorter length of stay (median, 5 vs 7.5 days, P < .0001). Survival and major morbidity were similar in matched comparisons of the transfemoral and transaxillary approaches. No brachial plexus injuries occurred with transaxillary access. CONCLUSIONS The transaxillary approach has emerged as our preferred alternative-access strategy for TAVR. It is associated with superior operative outcomes compared with transthoracic approaches, and results are comparable with those of the transfemoral approach.
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Affiliation(s)
- Bogdan Kindzelski
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Stephanie L Mick
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Amar Krishnaswamy
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Tamer Attia
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kevin Hodges
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shirin Siddiqi
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ashley M Lowry
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Zoran Popovic
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shinya Unai
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - James J Yun
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
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Gregory SH, Sodhi N, Zoller JK, Quader N, Ridley CH, Maniar HS, Lasala JM, Zajarias A. Anesthetic Considerations for the Transcatheter Management of Mitral Valve Disease. J Cardiothorac Vasc Anesth 2019; 33:796-807. [DOI: 10.1053/j.jvca.2018.05.054] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Indexed: 12/19/2022]
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Alatawi FO, Abuelatta RA, AlAhmedi AB, Alharbi IH, Alghamdi SS, Sakrana AA, Alamodi OA, Naeim HA. Clinical outcomes with transcatheter aortic valve implantation at a single cardiac center in Saudi Arabia. Ann Saudi Med 2018; 38:167-173. [PMID: 29848933 PMCID: PMC6074303 DOI: 10.5144/0256-4947.2018.167] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Transcatheter aortic valve implantation (TAVI) has been recognized as a valid alternative to surgery for severe aortic valve stenosis (AS) in high-risk surgical patients. OBJECTIVE Determine first-year clinical outcomes for TAVI at Madinah Cardiac Center (MMC) in Saudi Arabia. DESIGN Retrospective, analytical cross-sectional. SETTING Tertiary cardiac care center. PATIENTS AND METHODS All patients who underwent TAVI for severe AS between February 2013 and December 2016 were included. Clinical, imaging, and laboratory information at baseline and at one year follow-up were analyzed. MAIN OUTCOME MEASURES Clinical and echocardiography out.comes at discharge, at 1-month, and at end of follow-up; one-year mortality, complications and clinical response to TAVI procedure. SAMPLE SIZE AND CHARACTERISTICS N=80, mean (SD) age 79.5 (10.6) years, with severe AS and high-surgical risk. RESULTS Fifty-five (69.2%) patients received Core valves, and 25 (30.8%) received Edward valves. Peri-procedure mortality was 3.8% and 1-year post-operative mortality was 13.8%. Ten patients (12.5%) had life-threatening or major bleeding. Nineteen (23.8%) patients had vascular complications, which were mostly minor. Fourteen patients (17.5%) developed acute kidney injury and 86% of these patients recovered. Five patients (6.25%) had pericardial effusion. Two patients (2.5%) developed endocarditis and another 2 patients (2.5%) had cerebrovascular accidents. Five patients (6.25%) received pacemakers. Mean aortic valve gradient significantly reduced from a mean (SD) 47.6 (19) mm Hg to 10.7 (6.0) mm Hg (P less than .001). New York Heart Association functional class was significantly reduced (P less than .001). CONCLUSION The TAVI experience at MCC is encouraging and comparable to international outcomes in terms of success, morbidity, and mortality rate. LIMITATIONS Retrospective, relatively small sample size. Rate of minor bleeding was overestimated. CONFLICT OF INTEREST None.
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Affiliation(s)
- Faisal Owdah Alatawi
- Dr. Faisal Owdah Alatawi, Department of Medicine, Taibah University, PO Box 30001, Madinah, Saudi Arabia, T: + 966.562-579286, faisalawdahalatawi@ hotmail.com, ORCID: http://orcid. org/0000-0003-1022-9688
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Transcatheter Aortic Valve Replacement: Efficiency and Safety Improvements With Progressive Experience and Improved Technology. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2018; 13:120-124. [PMID: 29668502 DOI: 10.1097/imi.0000000000000480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Transcatheter aortic valve replacement is now commercially available for intermediate-risk, high-risk, or inoperable patients with severe aortic stenosis. In this study, we investigated change in the safety and efficiency of the transcatheter aortic valve replacement procedure at our institution and patient outcomes comparing our first 100, second 100, and last 100 patients. METHODS From March 2012 to June 2016, 544 patients underwent transcatheter aortic valve replacement at our center. Three hundred patients were selected for this study and were categorized in the following three groups: group A, first to 100th patient; group B, 101st to 200th patient; and group C, 444th to 544th patient. Preoperative, intraoperative, and postoperative data were collected. RESULTS Three hundred patients, 162 male (54%) male and 138 female (46%) with a mean ± SD age of 79.10 ± 8.93 years and mean ± SD society of thoracic surgeons' risk score of 7.47 ± 0.76 were included. Fluoroscopy time, operation time, and incision time significantly decreased form group A to group C (all P < 0.05). Mean of contrast volume was also the highest in group A and the lowest in group C (P < 0.001). Acute kidney injury rate was 26% (n = 26) in group A versus 23% (n = 23) in group B (P = 0.743), and only one patient in group C (group C vs. group B, P < 0.001). Strokes declined over time: five (5%) stroke in group A; two (2%) stroke in group B, and no patient in group C (group C vs. group B, P = 0.1, and group C vs. group A, P = 0.059). In-hospital mortality was 5% (n = 5) in group A, 4% (n = 4) in group B, and 1% in group C (P = 0.21). CONCLUSIONS Progressive experience and technology advances with transcatheter aortic valve replacement procedures improved operators' expertise, making the transcatheter aortic valve replacement more efficient and safer over time.
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Aalaei-Andabili SH, Anderson RD, Bavry AA, Lee TC, Wayangankar S, Arnaoutakis GJ, Beaver TM. Transcatheter Aortic Valve Replacement. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2018. [DOI: 10.1177/155698451801300208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Seyed Hossein Aalaei-Andabili
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, FL USA
- Division of Cardiology, Department of Medicine, University of Florida, Gainesville, FL USA
| | - R. David Anderson
- Division of Cardiology, Department of Medicine, University of Florida, Gainesville, FL USA
| | - Anthony A. Bavry
- Division of Cardiology, Department of Medicine, University of Florida, Gainesville, FL USA
- North Florida/South Georgia Veterans Health System, Gainesville, FL USA
| | - Teng C. Lee
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, FL USA
| | - Siddharth Wayangankar
- Division of Cardiology, Department of Medicine, University of Florida, Gainesville, FL USA
| | - George J. Arnaoutakis
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, FL USA
| | - Thomas M. Beaver
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, FL USA
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Zhu Y, Roselli EE, Idrees JJ, Kapadia S, Svensson LG. Combined Transapical Transcatheter Aortic Valve Replacement and Thoracic Endovascular Aortic Repair for Severe Aortic Stenosis and Arch Aneurysm. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2016; 4:175-177. [PMID: 28516094 DOI: 10.12945/j.aorta.2016.16.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 10/23/2016] [Indexed: 11/18/2022]
Abstract
An 83-year-old male with multiple comorbidities presented with critical aortic stenosis and a saccular aortic arch aneurysm. Through a mini thoracotomy, a balloon expandable transcatheter aortic valve was delivered transapically. A thoracic stent graft was then delivered through the prosthetic valve and deployed in the arch, while a covered stent was deployed in the left common carotid artery. Three-year postoperative computed tomography showed a thrombosed arch aneurysm with decreased size. This case demonstrates the feasibility of using combined transapical transcatheter technologies to treat multicomponent disease in a high-risk patient during a single operation.
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Affiliation(s)
- Yuanjia Zhu
- Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Eric E Roselli
- Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jay J Idrees
- Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Samir Kapadia
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Lars G Svensson
- Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Patel JS, Krishnaswamy A, Svensson LG, Tuzcu EM, Mick S, Kapadia SR. Access Options for Transcatheter Aortic Valve Replacement in Patients with Unfavorable Aortoiliofemoral Anatomy. Curr Cardiol Rep 2016; 18:110. [DOI: 10.1007/s11886-016-0788-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Does a Higher Society of Thoracic Surgeons Score Predict Outcomes in Transfemoral and Alternative Access Transcatheter Aortic Valve Replacement? Ann Thorac Surg 2016; 102:474-82. [PMID: 27209615 DOI: 10.1016/j.athoracsur.2016.02.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Revised: 02/01/2016] [Accepted: 02/08/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Nontransfemoral (non-TF) transcatheter aortic valve replacement (TAVR) is often associated with worse outcomes than TF TAVR. We investigated the relationship between increasing Society of Thoracic Surgeons (STS) predicted risk of mortality (PROM) score and observed mortality and morbidity in TF and non-TF TAVR groups. METHODS We reviewed 595 patients undergoing TAVR at Emory Healthcare between 2007 and 2014. Clinical outcomes were reported for 337 TF patients (57%) and 258 non-TF patients (43%). We created 3 STS PROM score subgroups: <8%, 8%-15%, and >15%. A composite outcome of postoperative events was defined as death, stroke, renal failure, vascular complications, or new pacemaker implantation. RESULTS TF patients were older (82.4 ± 8.0 vs 80.8 ± 8.7 years, p = 0.02), whereas the STS PROM was higher in non-TF patients (10.5% ± 5.3% vs 11.7% ± 5.7%, p = 0.01). Observed/expected mortality was less than 1.0 in all groups. The rate of the composite outcome did not differ between STS PROM subgroups in TF (p = 0.68) or non-TF TAVR (p = 0.27). One-year mortality was higher for patients with STS PROM >8% in the non-TF group; however, this difference was not observed in TF patients (p = 0.40). CONCLUSIONS As expected, non-TF patients were at a higher risk than TF patients for procedural morbidity and death. Although no differences were observed in 30-day deaths or morbidity in different STS PROM subgroups, those undergoing non-TF TAVR at a higher STS PROM (>8%) had higher 1-year mortality. When applicable, TF TAVR remains the procedure of choice in high- or extreme-risk patients undergoing TAVR.
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Condado JF, Block PC. Will Transcatheter Aortic Valve Replacement (TAVR) be the Primary Therapy for Aortic Stenosis? CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2016. [DOI: 10.15212/cvia.2016.0012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Suri RM, Minha S, Alli O, Waksman R, Rihal CS, Satler LP, Greason KL, Torguson R, Pichard AD, Mack M, Svensson LG, Rajeswaran J, Lowry AM, Ehrlinger J, Mick SL, Tuzcu EM, Thourani VH, Makkar R, Holmes D, Leon MB, Blackstone EH. Learning curves for transapical transcatheter aortic valve replacement in the PARTNER-I trial: Technical performance, success, and safety. J Thorac Cardiovasc Surg 2016; 152:773-780.e14. [PMID: 27215927 DOI: 10.1016/j.jtcvs.2016.04.028] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 03/30/2016] [Accepted: 04/07/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Introduction of hybrid techniques, such as transapical transcatheter aortic valve replacement (TA-TAVR), requires skills that a heart team must master to achieve technical efficiency: the technical performance learning curve. To date, the learning curve for TA-TAVR remains unknown. We therefore evaluated the rate at which technical performance improved, assessed change in occurrence of adverse events in relation to technical performance, and determined whether adverse events after TA-TAVR were linked to acquiring technical performance efficiency (the learning curve). METHODS From April 2007 to February 2012, 1100 patients, average age 85.0 ± 6.4 years, underwent TA-TAVR in the PARTNER-I trial. Learning curves were defined by institution-specific patient sequence number using nonlinear mixed modeling. RESULTS Mean procedure time decreased from 131 to 116 minutes within 30 cases (P = .06) and device success increased to 90% by case 45 (P = .0007). Within 30 days, 354 patients experienced a major adverse event (stroke in 29, death in 96), with possibly decreased complications over time (P ∼ .08). Although longer procedure time was associated with more adverse events (P < .0001), these events were associated with change in patient risk profile, not the technical performance learning curve (P = .8). CONCLUSIONS The learning curve for TA-TAVR was 30 to 45 procedures performed, and technical efficiency was achieved without compromising patient safety. Although fewer patients are now undergoing TAVR via nontransfemoral access, understanding TA-TAVR learning curves and their relationship with outcomes is important as the field moves toward next-generation devices, such as those to replace the mitral valve, delivered via the left ventricular apex.
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Affiliation(s)
| | - Sa'ar Minha
- Assaf-Harofeh Medical Center, Zerifin, Israel
| | | | - Ron Waksman
- MedStar Washington Hospital Center, Washington, DC
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Raj Makkar
- Cedars Sinai Medical Center, Los Angeles, Calif
| | | | - Martin B Leon
- Columbia University Medical Center/New York-Presbyterian Hospital, New York, NY
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Biancari F, Rosato S, D'Errigo P, Ranucci M, Onorati F, Barbanti M, Santini F, Tamburino C, Santoro G, Grossi C, Covello RD, Ventura M, Fusco D, Seccareccia F. Immediate and Intermediate Outcome After Transapical Versus Transfemoral Transcatheter Aortic Valve Replacement. Am J Cardiol 2016; 117:245-51. [PMID: 26639038 DOI: 10.1016/j.amjcard.2015.10.036] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 10/14/2015] [Accepted: 10/14/2015] [Indexed: 12/23/2022]
Abstract
A few studies recently reported controversial results with transfemoral transcatheter aortic valve replacement (TF-TAVR) versus transapical transcatheter aortic valve replacement (TA-TAVR), often without adequate adjusted analysis for baseline differences. Data on patients who underwent TF-TAVR and TA-TAVR from the Observational Study of Effectiveness of avR-tavI procedures for severe Aortic stenosis Treatment study were analyzed with propensity score 1-to-1 matching. From a cohort of 1,654 patients (1,419 patients underwent TF-TAVR and 235 patients underwent TA-TAVR), propensity score matching resulted in 199 pairs of patients with similar operative risk (EuroSCORE II: TF-TAVR 8.1 ± 7.1% vs TA-TAVR, 8.4 ± 7.3%, p = 0.713). Thirty-day mortality was 8.0% after TA-TAVR and 4.0% after TF-TAVR (p = 0.102). Postoperative rates of stroke (TA-TAVR, 2.0% vs TF-TAVR 1.0%, p = 0.414), cardiac tamponade (TA-TAVR, 4.1% vs TF-TAVR 1.5%, p = 0.131), permanent pacemaker implantation (TA-TAVR, 8.7% vs TF-TAVR 13.3%, p = 0.414), and infection (TA-TAVR, 6.7% vs TF-TAVR 3.6%, p = 0.180) were similar in the study groups but with an overall trend in favor of TF-TAVR. Higher rates of major vascular damage (7.2% vs 1.0%, p = 0.003) and moderate-to-severe paravalvular regurgitation (7.8% vs 5.2%, p = 0.008) were observed after TF-TAVR. On the contrary, TA-TAVR was associated with higher rates of red blood cell transfusion (50.0% vs 30.4%, p = 0.0002) and acute kidney injury (stages 1 to 3: 44.4% vs 21.9%, p <0.0001) compared with TF-TAVR. Three-year survival rate was 69.1% after TF-TAVR and 57.0% after TA-TAVR (p = 0.006), whereas freedom from major adverse cardiovascular and cerebrovascular events was 61.9% after TF-TAVR and 50.4% after TA-TAVR (p = 0.011). In conclusion, TF-TAVR seems to be associated with significantly higher early and intermediate survival compared with TA-TAVR. The transfemoral approach, whenever feasible, should be considered the route of choice for TAVR.
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Affiliation(s)
- Fausto Biancari
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Stefano Rosato
- National Centre for Epidemiology, Surveillance and Health Promotion, Istituto Superiore di Sanità, Rome, Italy.
| | - Paola D'Errigo
- National Centre for Epidemiology, Surveillance and Health Promotion, Istituto Superiore di Sanità, Rome, Italy
| | - Marco Ranucci
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, Milan, Italy
| | - Francesco Onorati
- Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy
| | - Marco Barbanti
- Division of Cardiology, Ferrarotto Hospital, University of Catania, Catania, Italy
| | - Francesco Santini
- Division of Cardiac Surgery, Institute for Treatment and Research University Hospital San Martino Scientific Institute for Tumours, Genova, Italy
| | - Corrado Tamburino
- Division of Cardiology, Ferrarotto Hospital, University of Catania, Catania, Italy
| | | | - Claudio Grossi
- Division of Cardiac Surgery, Azienda Sanitaria Ospedaliera Santa Croce e Carle, Cuneo, Italy
| | - Remo Daniel Covello
- Department of Anesthesia and Intensive Care, Ospedale di Busto Arsizio, Varese, Italy
| | - Martina Ventura
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Danilo Fusco
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Fulvia Seccareccia
- National Centre for Epidemiology, Surveillance and Health Promotion, Istituto Superiore di Sanità, Rome, Italy
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Murdock JE, Jensen HA, Thourani VH. Nontransfemoral Approaches to Transcatheter Aortic Valve Replacement. Interv Cardiol Clin 2015; 4:95-105. [PMID: 28582125 DOI: 10.1016/j.iccl.2014.09.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Transcatheter aortic valve replacement (TAVR) is noninferior to surgical aortic valve replacement in patients with high operative risk and superior to medical treatment in patients deemed unsuitable for surgical intervention. However, up to 30% to 50% of patients screened for this intervention are not candidates for TAVR via the preferred transfemoral route because of severe peripheral arterial disease. Alternative access routes must be considered and include the transapical, transaortic, transsubclavian, and transcarotid approaches. The use of alternative access is predicated on appropriate patient selection as determined by a dedicated multispecialty heart valve team and can lead to excellent outcomes.
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Affiliation(s)
- Jared E Murdock
- Division of Cardiothoracic Surgery, Joseph B. Whitehead Department of Surgery, Structural Heart and Valve Center, Emory University School of Medicine, 550 Peachtree Street Northeast, Atlanta, GA 30308, USA
| | - Hanna A Jensen
- Division of Cardiothoracic Surgery, Joseph B. Whitehead Department of Surgery, Structural Heart and Valve Center, Emory University School of Medicine, 550 Peachtree Street Northeast, Atlanta, GA 30308, USA
| | - Vinod H Thourani
- Division of Cardiothoracic Surgery, Joseph B. Whitehead Department of Surgery, Structural Heart and Valve Center, Emory University School of Medicine, 550 Peachtree Street Northeast, Atlanta, GA 30308, USA.
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Transapical sutureless aortic valve implantation under magnetic resonance imaging guidance: Acute and short-term results. J Thorac Cardiovasc Surg 2014; 149:1067-72. [PMID: 25466854 DOI: 10.1016/j.jtcvs.2014.10.101] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2014] [Revised: 10/16/2014] [Accepted: 10/26/2014] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Despite the increasing success and applicability of transcatheter aortic valve replacement, 2 critical issues remain: the durability of the valves, and the ideal imaging to aid implantation. This study was designed to investigate the transapical implantation of a device of known durability using real-time magnetic resonance imaging (MRI) guidance. METHODS A sutureless aortic valve was used that employs a self-expanding nitinol stent and is amenable to transapical delivery. MRI (1.5-T) was used to identify the anatomic landmarks in 60-kg Yucatan swine. Prostheses were loaded into an MRI-compatible delivery device with an active guidewire to enhance visualization. A series of acute feasibility experiments were conducted (n = 10). Additional animals (n = 6) were allowed to survive and had follow-up MRI scans and echocardiography at 90 days postoperatively. Postmortem gross examination was performed. RESULTS The valve was MRI compatible and created no significant MRI artifacts. The 3 commissural struts were visible on short-axis view; therefore, coronary ostia obstruction was easily avoided. The average implantation time was 65 seconds. Final results demonstrated stability of the implants with preservation of myocardial perfusion and function over 90 days: the ejection fraction was 48% ± 15%; the peak gradient was 17.3 ± 11.3 mm Hg; the mean gradient was 9.8 ± 7.2 mm Hg. Mild aortic regurgitation was seen in 4 cases, trace in 1 case, and a severe central jet in 1 case. Prosthesis positioning was evaluated during gross examination. CONCLUSIONS We demonstrated that a sutureless aortic valve can be safely and expeditiously implanted through a transapical approach under real-time MRI guidance. Postimplantation results showed a well-functioning prosthesis, with minimal regurgitation, and stability over time.
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