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Kirker E, Korngold E, Hodson RW, Jones BM, McKay R, Cheema M, Heimansohn D, Moainie S, Hermiller J, Chatriwalla A, Saxon J, Allen KB. Transcarotid Versus Subclavian/Axillary Access for Transcatheter Aortic Valve Replacement With SAPIEN 3. Ann Thorac Surg 2020; 110:1892-1897. [DOI: 10.1016/j.athoracsur.2020.05.141] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 05/04/2020] [Accepted: 05/14/2020] [Indexed: 11/25/2022]
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Bhardwaj B, Cohen DJ, Vemulapalli S, Kosinski AS, Xiang Q, Li Z, Allen KB, Kapadia S, Aggarwal K, Sorajja P, Chhatriwalla AK. Outcomes of transcatheter aortic valve replacement for patients with severe aortic stenosis and concomitant aortic insufficiency: Insights from the TVT Registry. Am Heart J 2020; 228:57-64. [PMID: 32828047 DOI: 10.1016/j.ahj.2020.07.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/14/2020] [Indexed: 11/25/2022]
Abstract
AIMS Data regarding outcomes for patients with severe aortic stenosis (AS) with concomitant aortic insufficiency (AI), undergoing transcatheter aortic valve replacement (TAVR) are limited. This study aimed to analyze the prevalence of severe AS with concomitant AI among patients undergoing TAVR and outcomes of TAVR in this patient group. METHODS AND RESULTS Using data from the STS/ACC-TVT Registry, we identified patients with severe AS with or without concomitant AI who underwent TAVR between 2011 and 2016. Patients were categorized based on the severity of pre-procedural AI. Multivariable proportional hazards regression models were used to examine all-cause mortality and heart failure (HF) hospitalization at 1-year. Among 54,535 patients undergoing TAVR, 42,568 (78.1%) had severe AS with concomitant AI. Device success was lower in patients with severe AS with concomitant AI as compared with isolated AS. The presence of baseline AI was associated with lower 1 year mortality (HR 0.94 per 1 grade increase in AI severity; 95% CI, 0.91-0.98, P < .001) and HF hospitalization (HR 0.87 per 1 grade increase in AI severity; 95% CI, 0.84-0.91, P < .001). CONCLUSIONS Severe AS with concomitant AI is common among patients undergoing TAVR, and is associated with lower 1 year mortality and HF hospitalization. Future studies are warranted to better understand the mechanisms underlying this benefit. SHORT ABSTRACT In this nationally representative analysis from the United States, 78.1% of patients undergoing TAVR had severe AS with concomitant AI. Device success was lower in patients with severe AS with concomitant AI as compared with isolated AS. The presence of baseline AI was associated with lower 1 year mortality (HR 0.94 per 1 grade increase in AI severity; 95% CI, 0.91-0.98, P < .001) and HF hospitalization (HR 0.87 per 1 grade increase in AI severity; 95% CI, 0.84-0.91, P < .001).
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Sathananthan J, Fraser R, Hatoum H, Barlow AM, Stanová V, Allen KB, Chhatriwalla AK, Rieu R, Pibarot P, Dasi LP, Søndergaard L, Wood DA, Webb JG. A bench test study of bioprosthetic valve fracture performed before versus after transcatheter valve-in-valve intervention. EUROINTERVENTION 2020; 15:1409-1416. [DOI: 10.4244/eij-d-19-00939] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Sathananthan J, Sellers S, Barlow AM, Stanová V, Fraser R, Toggweiler S, Allen KB, Chhatriwalla A, Murdoch DJ, Hensey M, Lau K, Alkhodair A, Dvir D, Asgar AW, Cheung A, Blanke P, Ye J, Rieu R, Pibarot P, Wood D, Leipsic J, Webb JG. Valve-in-Valve Transcatheter Aortic Valve Replacement and Bioprosthetic Valve Fracture Comparing Different Transcatheter Heart Valve Designs: An Ex Vivo Bench Study. JACC Cardiovasc Interv 2019; 12:65-75. [PMID: 30621980 DOI: 10.1016/j.jcin.2018.10.043] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 10/04/2018] [Accepted: 10/23/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The authors assessed the effect of valve-in-valve (VIV) transcatheter aortic valve replacement (TAVR) followed by bioprosthetic valve fracture (BVF), testing different transcatheter heart valve (THV) designs in an ex vivo bench study. BACKGROUND Bioprosthetic valve fracture can be performed to improve residual transvalvular gradients following VIV TAVR. METHODS The authors evaluated VIV TAVR and BVF with the SAPIEN 3 (S3) (Edwards Lifesciences, Irvine, California) and ACURATE neo (Boston Scientific Corporation, Natick, Massachusetts) THVs. A 20-mm and 23-mm S3 were deployed in a 19-mm and 21-mm Mitroflow (Sorin Group USA, Arvada, Colorado), respectively. A small ACURATE neo was deployed in both sizes of Mitroflow tested. VIV TAVR samples underwent multimodality imaging, and hydrodynamic evaluation before and after BVF. RESULTS A high implantation was required to enable full expansion of the upper crown of the ACURATE neo and allow optimal leaflet function. Marked underexpansion of the lower crown of the THV within the surgical valve was also observed. Before BVF, VIV TAVR in the 19-mm Mitroflow had high transvalvular gradients using either THV design (22.0 mm Hg S3, and 19.1 mm Hg ACURATE neo). After BVF, gradients improved and were similar for both THVs (14.2 mm Hg S3, and 13.8 mm Hg ACURATE neo). The effective orifice area increased with BVF from 1.2 to 1.6 cm2 with the S3 and from 1.4 to 1.6 cm2 with the ACURATE neo. Before BVF, VIV TAVR with the ACURATE neo in the 21-mm Mitroflow had lower gradients compared with S3 (11.3 mm Hg vs. 16 mm Hg). However, after BVF valve gradients were similar for both THVs (8.4 mm Hg ACURATE neo vs. 7.8 mm Hg S3). The effective orifice area increased from 1.5 to 2.1 cm2 with the S3 and from 1.8 to 2.2 cm2 with the ACURATE neo. CONCLUSIONS BVF performed after VIV TAVR results in improved residual gradients. Following BVF, residual gradients were similar irrespective of THV design. Use of a small ACURATE neo for VIV TAVR in small (≤21 mm) surgical valves may be associated with challenges in achieving optimum THV position and expansion. BVF could be considered in selected clinical cases.
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Allen KB, Brovman EY, Chhatriwalla AK, Greco KJ, Rao N, Kumar A, Urman RD. Opioid-Related Adverse Events: Incidence and Impact in Patients Undergoing Cardiac Surgery. Semin Cardiothorac Vasc Anesth 2019; 24:219-226. [DOI: 10.1177/1089253219888658] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Purpose. Opioid-related adverse drug events (ORADEs) increase patient length of stay (LOS) and health care costs. However, ORADE rates may be underreported. This study attempts to understand the degree to which ORADEs are underreported in Medicare patients undergoing cardiac surgery. Materials and Methods. The Center for Medicare and Medicaid Services administrative claims database was used to identify ORADEs in 110 158 Medicare beneficiaries who underwent cardiac valve (n = 50 525) or coronary bypass (n = 59 633) surgery between April 2016 and March 2017. The International Classification of Disease (ICD)-10 codes specifically linked to ORADEs were used to identify an actual ORADE rate, while additional ICD codes, clinically associated with butas not specific to adverse drug events were analyzed as potential ORADEs. Length of stay (LOS) and hospital daily revenue were analyzed among patients with or without a potential ORADE. Results. Among patients undergoing valve or bypass surgery, the documented ORADE rate was 0.7% (743/110 158). However, potential ORADEs may have occurred in up to 32.4% (35 658/110 158) of patients. In patients with a potential ORADE, mean LOS was longer (11.4 vs 8.2 days; P < .0001) and mean Medicare revenue/day was lower ($4016 vs $4412; P < .0001). The mean net difference in revenue/day between patients with and without an ORADE varied between $231 and $1145, depending on the Diagnosis-Related Group analyzed. Conclusions. ORADEs are likely underreported following cardiac surgery. ORADEs can be associated with increased LOS and decreased hospital revenue. Understanding the incidence and economic impact of ORADEs may expedite changes to postoperative pain management. Adopting multimodal pain management strategies that reduce exposure to opioids may improve outcomes by reducing complications, side effects, and health care costs.
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Allen KB, Chhatriwalla AK, Saxon JT, Cohen DJ, Nguyen TC, Webb J, Loyalka P, Bavry AA, Rovin JD, Whisenant B, Dvir D, Kennedy KF, Thourani V, Lee R, Aggarwal S, Baron S, Hart A, Davis JR, Borkon AM, Janarthanan S, Beaver T, Karimi A, Gory D, Lin L, Spriggs D, Ofenloch J, Dhoble A, Loyalka P, Hummel B, Russo M, Haik B, Lim M, Babaliaros V, Greenbaum A, O'Neill W, Karha J, Park D, Garrett E, Pak A, Hawa Z, Mitchell J, Unbehaun A, Tandar A, Yadav P, Ricci J, Yeung A. Bioprosthetic valve fracture: Technical insights from a multicenter study. J Thorac Cardiovasc Surg 2019; 158:1317-1328.e1. [DOI: 10.1016/j.jtcvs.2019.01.073] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 01/09/2019] [Accepted: 01/21/2019] [Indexed: 11/26/2022]
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Sathananthan J, Hensey M, Sellers S, Barlow AM, Chhatriwalla AK, Allen KB, Cheung A, Søndergaard L, Blanke P, Ye J, Leipsic J, Wood D, Webb J. Performance of the TRUE dilatation balloon valvuloplasty catheter beyond rated burst pressure: A bench study. Catheter Cardiovasc Interv 2019; 96:E187-E195. [PMID: 31566873 DOI: 10.1002/ccd.28503] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 09/05/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVES We undertook an independent bench test assessing the performance of the TRUE dilatation (TD) balloon valvuloplasty catheter (Bard Vascular Inc., Tempe, AZ) beyond its rated burst pressure (RBP). BACKGROUND The TD balloon has a RBP of six atmospheres (atm), and its performance beyond this RBP is poorly understood. Techniques such as bioprosthetic valve fracture require inflation pressures beyond manufacturer recommendations. METHODS A 20, 22, 24, 26, and 28 mm TD balloon were inflated to increasing pressures in increments of 3 atm until balloon failure. Measurements were performed at the proximal, middle, and distal balloon segments with scientific digital calipers. Z-MED balloons (Braun Interventional Systems Inc., Bethlehem, PA) were used as a comparator. RESULTS The mean diameter at the middle of the 20, 22, 24, 26, and 28 mm TD balloon at nominal pressure (3 atm) was 20.02 ± 0.09, 21.77 ± 0.07, 23.9 ± 0.06, 25.82 ± 0.08, and 27.62 ± 0.08 mm, respectively. The maximal mean diameter at the middle of the 20, 22, 24, 26, and 28 mm TD balloon was 20.39 ± 0.03 mm (15 atm), 22.35 ± 0.03 mm (15 atm), 24.55 ± 0.02 mm (15 atm), 26.48 ± 0.02 mm (12 atm), and 28.39 ± 0.03 mm (12 atm), respectively. The 20/22/24 and 26/28 mm balloon failed when inflated beyond 15 atm and 12 atm, respectively. Failure was due to either leakage or longitudinal balloon rupture. TD balloons were more likely to maintain dimensions similar to their labeled size and less likely to fail at higher pressures as compared to Z-MED balloons. CONCLUSION The TD balloon catheter maintains a similar diameter to its labeled size, when inflated beyond its RBP. When inflated beyond 12 atm, the TD balloon can fail due to either leakage or rupture. This has implications for percutaneous structural heart interventions.
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Allen KB, Chhatriwalla AK, Cohen D, Saxon J, Hawa Z, Kennedy KF, Aggarwal S, Davis R, Pak A, Borkon AM. Transcarotid Versus Transapical and Transaortic Access for Transcatheter Aortic Valve Replacement. Ann Thorac Surg 2019; 108:715-722. [DOI: 10.1016/j.athoracsur.2019.02.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 01/18/2019] [Accepted: 02/04/2019] [Indexed: 10/27/2022]
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Allen KB, Vamanan K, Alsop S, Chhatriwalla A, Saxon J, Aggarwal S, Davis JR, Borkon AM. PC012. Carotid Access to Deliver Large Endovascular Devices in Patients With Inadequate Iliofemoral Access. J Vasc Surg 2019. [DOI: 10.1016/j.jvs.2019.04.299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Saxon JT, Allen KB, Cohen DJ, Whisenant B, Ricci J, Barb I, Gafoor S, Harvey J, Dvir D, Chhatriwalla AK. Complications of Bioprosthetic Valve Fracture as an Adjunct to Valve-in-Valve TAVR. STRUCTURAL HEART-THE JOURNAL OF THE HEART TEAM 2019. [DOI: 10.1080/24748706.2019.1578446] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Allen KB, Mahoney A, Aggarwal S, Davis JR, Thompson E, Pak AF, Heimes J, Michael Borkon A. Transmyocardial revascularization (TMR): current status and future directions. Indian J Thorac Cardiovasc Surg 2018; 34:330-339. [PMID: 33060956 DOI: 10.1007/s12055-018-0702-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 06/07/2018] [Accepted: 07/13/2018] [Indexed: 01/22/2023] Open
Abstract
Purpose Cardiac surgeons are increasingly faced with a more complex patient who has developed a pattern of diffuse coronary artery disease (CAD), which is refractory to medical, percutaneous, and surgical interventions. This paper will review the clinical science surrounding transmyocardial revascularization (TMR) with an emphasis on the results from randomized controlled trials. Methods Randomized controlled trials which evaluated TMR used as sole therapy and when combined with coronary artery bypass grafting were reviewed. Pertinent basic science papers exploring TMR's possible mechanism of action along with future directions, including the synergism between TMR and cell-based therapies were reviewed. Results Two laser-based systems have been approved by the United States Food and Drug Administration (FDA) to deliver laser therapy to targeted areas of the left ventricle (LV) that cannot be revascularized using conventional methods: the holmium:yttrium-aluminum-garnet (Ho:YAG) laser system (CryoLife, Inc., Kennesaw, GA) and the carbon dioxide (CO2) Heart Laser System (Novadaq Technologies Inc., (Mississauga, Canada). TMR can be performed either as a stand-alone procedure (sole therapy) or in conjunction with coronary artery bypass graft (CABG) surgery in patients who would be incompletely revascularized by CABG alone. Societal practice guidelines have been established and are supportive of using TMR in the difficult population of patients with diffuse CAD. Conclusions Patients with diffuse CAD have increased operative and long-term cardiac risks predicted by incomplete revascularization. The documented operative and long-term benefits associated with sole therapy and adjunctive TMR in randomized trials supports TMR's increased use in this difficult patient population.
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Allen KB, Icke KJ, Thourani VH, Naka Y, Grubb KJ, Grehan J, Patel N, Guy TS, Landolfo K, Gerdisch M, Bonnell M. Sternotomy closure using rigid plate fixation: a paradigm shift from wire cerclage. Ann Cardiothorac Surg 2018; 7:611-620. [PMID: 30505745 DOI: 10.21037/acs.2018.06.01] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Rigid plate fixation (RPF) is the cornerstone in managing fractures and osteotomies except for sternotomy, where most cardiac surgeons continue to use wire cerclage (WC). Results of a multicenter randomized trial evaluating sternal healing, sternal complications, patient reported outcome measures (PROMs), and costs after sternotomy closure with RPF or WC are summarized here. Methods Twelve US centers randomized 236 patients to either RPF (n=116) or WC (n=120). The primary endpoint, sternal healing at 6 months, was evaluated by a core laboratory using computed tomography and a validated 6-point scale (greater scores represent greater healing). Secondary endpoints assessed through 6 months included sternal complications and PROMs. Costs from the time of sternal closure through 90 days and 6 months were analyzed by a health economic core laboratory. Results RPF compared to WC resulted in better sternal healing scores at 3 (2.6±1.1 vs. 1.8±1.0; P<0.0001) and 6 months (3.8±1.0 vs. 3.3±1.1; P=0.0007) and higher sternal union rates at 3 [41% (42/103) vs. 16% (16/102); P<0.0001] and 6 months [80% (81/101) vs. 67% (67/100); P=0.03]. There were fewer sternal complications with RPF through 6 months [0% (0/116) vs. 5% (6/120); P=0.03] and a trend towards fewer sternal wound infections [0% (0/116) vs. 4.2% (5/120); P=0.06]. All PROMs including sternal pain, upper extremity function (UEF), and quality-of-life scores were numerically better in RPF patients compared to WC patients at all follow-up time points. Although RPF was associated with a trend toward higher index hospitalization costs, a trend towards lower follow-up costs resulted in total costs that were $1,888 less at 90 days in RPF patients compared to WC patients (95% CI: -$8,889 to $4,273; P=0.52) and $1,646 less at 6 months (95% CI: -$9,127 to $4,706; P=0.61). Conclusions Sternotomy closure with RPF resulted in significantly better sternal healing, fewer sternal complications, improved PROMs and was cost neutral through 90 days and 6 months compared to WC.
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Allen KB, Thourani VH, Naka Y. The right wiring configuration for sternal closure: Science or mythology? J Thorac Cardiovasc Surg 2017; 154:2004-2005. [PMID: 29132894 DOI: 10.1016/j.jtcvs.2017.08.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 08/26/2017] [Indexed: 11/30/2022]
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Allen KB, Yuh DD, Schwartz SB, Lange RA, Hopkins R, Bauer K, Marders JA, Delgado Donayre J, Milligan N, Wentz C. Nontuberculous Mycobacterium Infections Associated With Heater-Cooler Devices. Ann Thorac Surg 2017; 104:1237-1242. [DOI: 10.1016/j.athoracsur.2017.04.067] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 03/21/2017] [Accepted: 04/04/2017] [Indexed: 11/27/2022]
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Allen KB, Thourani VH, Naka Y. Sternal healing comes from stable beginnings. J Thorac Cardiovasc Surg 2017; 154:943-944. [PMID: 28826161 DOI: 10.1016/j.jtcvs.2017.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 05/05/2017] [Indexed: 11/30/2022]
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Chhatriwalla AK, Allen KB, Saxon JT, Cohen DJ, Aggarwal S, Hart AJ, Baron SJ, Dvir D, Borkon AM. Bioprosthetic Valve Fracture Improves the Hemodynamic Results of Valve-in-Valve Transcatheter Aortic Valve Replacement. Circ Cardiovasc Interv 2017; 10:CIRCINTERVENTIONS.117.005216. [DOI: 10.1161/circinterventions.117.005216] [Citation(s) in RCA: 150] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 06/05/2017] [Indexed: 11/16/2022]
Abstract
Background—
Valve-in-valve (VIV) transcatheter aortic valve replacement (TAVR) may be less effective in small surgical valves because of patient/prosthesis mismatch. Bioprosthetic valve fracture (BVF) using a high-pressure balloon can be performed to facilitate VIV TAVR.
Methods and Results—
We report data from 20 consecutive clinical cases in which BVF was successfully performed before or after VIV TAVR by inflation of a high-pressure balloon positioned across the valve ring during rapid ventricular pacing. Hemodynamic measurements and calculation of the valve effective orifice area were performed at baseline, immediately after VIV TAVR, and after BVF. BVF was successfully performed in 20 patients undergoing VIV TAVR with balloon-expandable (n=8) or self-expanding (n=12) transcatheter valves in Mitroflow, Carpentier-Edwards Perimount, Magna and Magna Ease, Biocor Epic and Biocor Epic Supra, and Mosaic surgical valves. Successful fracture was noted fluoroscopically when the waist of the balloon released and by a sudden drop in inflation pressure, often accompanied by an audible snap. BVF resulted in a reduction in the mean transvalvular gradient (from 20.5±7.4 to 6.7±3.7 mm Hg,
P
<0.001) and an increase in valve effective orifice area (from 1.0±0.4 to 1.8±0.6 cm
2
,
P
<0.001). No procedural complications were reported.
Conclusions—
BVF can be performed safely in small surgical valves to facilitate VIV TAVR with either balloon-expandable or self-expanding transcatheter valves and results in reduced residual transvalvular gradients and increased valve effective orifice area.
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Baron SJ, Arnold SV, Herrmann HC, Holmes DR, Szeto WY, Allen KB, Chhatriwalla AK, Vemulapali S, O'Brien S, Dai D, Cohen DJ. Impact of Ejection Fraction and Aortic Valve Gradient on Outcomes of Transcatheter Aortic Valve Replacement. J Am Coll Cardiol 2017; 67:2349-2358. [PMID: 27199058 DOI: 10.1016/j.jacc.2016.03.514] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 03/07/2016] [Accepted: 03/08/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND In patients with aortic stenosis undergoing transcatheter aortic valve replacement (TAVR), studies have suggested that reduced left ventricular (LV) ejection fraction (LVEF) and low aortic valve gradient (AVG) are associated with worse long-term outcomes. Because these conditions commonly coexist, the extent to which they are independently associated with outcomes after TAVR is unknown. OBJECTIVES The purpose of this study was to evaluate the impact of LVEF and AVG on clinical outcomes after TAVR and to determine whether the effect of AVG on outcomes is modified by LVEF. METHODS Using data from 11,292 patients who underwent TAVR as part of the Transcatheter Valve Therapies Registry, we examined rates of 1-year mortality and recurrent heart failure in patients with varying levels of LV dysfunction (LVEF <30% vs. 30% to 50% vs. >50%) and AVG (<40 mm Hg vs. ≥40 mm Hg). Multivariable models were used to estimate the independent effect of AVG and LVEF on outcomes. RESULTS During the first year of follow-up after TAVR, patients with LV dysfunction and low AVG had higher rates of death and recurrent heart failure. After adjustment for other clinical factors, only low AVG was associated with higher mortality (hazard ratio: 1.21; 95% confidence interval: 1.11 to 1.32; p < 0.001) and higher rates of heart failure (hazard ratio: 1.52; 95% confidence interval: 1.36 to 1.69; p <0.001), whereas the effect of LVEF was no longer significant. There was no evidence of effect modification between AVG and LVEF with respect to either endpoint. CONCLUSIONS In this series of real-world patients undergoing TAVR, low AVG, but not LV dysfunction, was associated with higher rates of mortality and recurrent heart failure. Although these findings suggest that AVG should be considered when evaluating the risks and benefits of TAVR for individual patients, neither severe LV dysfunction nor low AVG alone or in combination provide sufficient prognostic discrimination to preclude treatment with TAVR.
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Allen KB, Vamanan K, Borkon AM, Aggarwal S, Hawa Z, Davis JR, Pak A. PC110 Carotid Access to Deliver Large Endovascular Devices in Patients With Inadequate Iliofemoral Access. J Vasc Surg 2017. [DOI: 10.1016/j.jvs.2017.03.320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Allen KB, Thourani VH, Naka Y, Grubb KJ, Grehan J, Patel N, Guy TS, Landolfo K, Gerdisch M, Bonnell M, Cohen DJ. Randomized, multicenter trial comparing sternotomy closure with rigid plate fixation to wire cerclage. J Thorac Cardiovasc Surg 2017; 153:888-896.e1. [DOI: 10.1016/j.jtcvs.2016.10.093] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 10/11/2016] [Accepted: 10/12/2016] [Indexed: 11/26/2022]
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Saxon JT, Allen KB, Cohen DJ, Chhatriwalla AK. Bioprosthetic Valve Fracture During Valve-in-valve TAVR: Bench to Bedside. Interv Cardiol 2017; 13:20-26. [PMID: 29593832 DOI: 10.15420/icr.2017:29:1] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Valve-in-valve (VIV) transcatheter aortic valve replacement (TAVR) has been established as a safe and effective means of treating failed surgical bioprosthetic valves (BPVs) in patients at high risk for complications related to reoperation. Patients who undergo VIV TAVR are at risk of patient-prosthesis mismatch, as the transcatheter heart valve (THV) is implanted within the ring of the existing BPV, limiting full expansion and reducing the maximum achievable effective orifice area of the THV. Importantly, patient-prosthesis mismatch and high residual transvalvular gradients are associated with reduced survival following VIV TAVR. Bioprosthetic valve fracture (BVF) is as a novel technique to address this problem. During BPV, a non-compliant valvuloplasty balloon is positioned within the BPV frame, and a highpressure balloon inflation is performed to fracture the surgical sewing ring of the BPV. This allows for further expansion of the BPV as well as the implanted THV, thus increasing the maximum effective orifice area that can be achieved after VIV TAVR. This review focuses on the current evidence base for BVF to facilitate VIV TAVR, including initial bench testing, procedural technique, clinical experience and future directions.
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Shamim S, Magalski A, Chhatriwalla AK, Allen KB, Huber KC, Main ML. Transesophageal echocardiographic diagnosis of a WATCHMAN left atrial appendage closure device thrombus 10 years following implantation. Echocardiography 2016; 34:128-130. [DOI: 10.1111/echo.13413] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 10/13/2016] [Accepted: 10/24/2016] [Indexed: 11/29/2022] Open
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Allen KB, Aggarwal S, Davis JR, Laster S, Vamanan K, Borkon AM. PC004. Thoracic Endovascular Aortic Repair of the Ascending and Descending Thoracic Aorta Utilizing Left Ventricular Transapical Access. J Vasc Surg 2016. [DOI: 10.1016/j.jvs.2016.03.262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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McCabe JM, Huang PH, Cohen DJ, Blackstone EH, Welt FG, Davidson MJ, Kaneko T, Eng MH, Allen KB, Xu K, Lowry AM, Lei Y, Rajeswaran J, Brown DL, Mack MJ, Webb JG, Smith CR, Leon MB, Eisenhauer AC. Surgical Versus Percutaneous Femoral Access for Delivery of Large-Bore Cardiovascular Devices (from the PARTNER Trial). Am J Cardiol 2016; 117:1643-1650. [PMID: 27036077 DOI: 10.1016/j.amjcard.2016.02.041] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 02/16/2016] [Accepted: 02/16/2016] [Indexed: 12/20/2022]
Abstract
It is unclear if surgical exposure confers a risk advantage compared with a percutaneous approach for patients undergoing endovascular procedures requiring large-bore femoral artery access. From the randomized controlled Placement of Aortic Transcatheter Valve trials A and B and the continued access registries, a total of 1,416 patients received transfemoral transcatheter aortic valve replacement, of which 857 underwent surgical, and 559 underwent percutaneous access. Thirty-day rates of major vascular complications and quality of life scores were assessed. Propensity matching was used to adjust for unmeasured confounders. Overall, there were 116 major vascular complications (8.2%). Complication rates decreased dramatically during the study period. In unadjusted analysis, major vascular complications were significantly less common in the percutaneous access group (35 [6.3%] vs 81 [9.5%] p = 0.032). However, among 292 propensity-matched pairs, there was no difference in major vascular complications (22 [7.5%] vs 28 [9.6%], p = 0.37). Percutaneous access was associated with fewer total in-hospital vascular complications (46 [16%] vs 66 [23%], p = 0.036), shorter median procedural duration (97 interquartile range [IQR 68 to 166] vs 121 [IQR 78 to 194] minutes, p <0.0001), and median length of stay (4 [IQR 2 to 8] vs 6 [IQR 3 to 10] days, p <0.0001). There were no significant differences in quality of life scores at 30 days. Surgical access for large-bore femoral access does not appear to confer any advantages over percutaneous access and may be associated with more minor vascular complications.
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Allen KB, Borkon AM, Aggarwal S, Davis JR, Laster S, Cohen DJ, Chhatriwalla AK, Hart A, Baron SJ. The Descending Thoracic Aorta: Forgotten Vascular Access for Endovascular Device Delivery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2016. [DOI: 10.1177/155698451601100211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Allen KB, Johnson LM, Borkon AM, Aggarwal S, Davis JR, Cohen DJ, Chhatriwalla AK, Grantham A, Hart A. Combined Transcatheter Aortic Valve Replacement and Thoracic Endovascular Aortic Repair Using Transapical Access. Ann Thorac Surg 2015; 100:723-7. [PMID: 26234852 DOI: 10.1016/j.athoracsur.2014.10.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Revised: 08/23/2014] [Accepted: 10/10/2014] [Indexed: 11/18/2022]
Abstract
Vascular complications remain an important consideration when selecting access for delivery of large endovascular devices. With the advent of transcatheter aortic valve replacement, transapical access has become an acceptable technique when transfemoral or direct transaortic access is contraindicated. We report the use of the transapical approach during thoracic aortic endovascular repair in 2 patients, one of which included concomitant delivery of a transcatheter aortic valve replacement device. To our knowledge, this is the first reported case of a hybrid single-stage transcatheter aortic valve replacement and thoracic aortic endovascular repair using transapical access.
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