Safety and efficacy of the subclavian approach for transcatheter aortic valve implantation with the CoreValve revalving system

2-year results of CoreValve implantation through the subclavian access: a propensity-matched comparison with the femoral access

OBJECTIVES

The goal of this study was to assess the procedural and 2-year results of the subclavian approach for transcatheter aortic valve implantation (TAVI) compared with those of the femoral approach by using propensity-matched analysis.

BACKGROUND

The subclavian approach with the CoreValve prosthesis (Medtronic, Inc., Minneapolis, Minnesota) represents an interesting opportunity when the femoral access is unfeasible.

METHODS

All consecutive patients enrolled in the Italian CoreValve Registry who underwent TAVI with the subclavian approach were included. Propensity score analysis was used to identify a matching group of patients undergoing femoral TAVI.

RESULTS

Subclavian approach was used in 141 patients (61% men; median age 83 years; median logistic European System for Cardiac Operative Risk Evaluation score 23.7%). The femoral group of 141 patients was matched for baseline clinical characteristics, except for peripheral artery disease. The 2 groups showed similar procedural success (97.9% vs. 96.5%; p = 0.47), major vascular complications (5.0% vs. 7.8%; p = 0.33), life-threatening bleeding events (7.8% vs. 5.7%; p = 0.48), and combined safety endpoint (19.9% vs. 25.5%; p = 0.26). The subclavian group showed lower rates of acute kidney injury/stage 3 (4.3% vs. 9.9%; p = 0.02), of minor vascular complications at the 18-F sheath insertion site (2.1% vs. 11.3%; p = 0.003), and of all types of bleeding events related to vascular complications. Survival at 2 years was 74.0 ± 4.0% in the subclavian group compared with 73.7 ± 3.9% in the femoral group (p = 0.78). The 2-year freedom from cardiovascular death was 87.2 ± 3.1% versus 88.7 ± 2.8% in the subclavian versus femoral group, respectively (p = 0.84).

CONCLUSIONS

The subclavian approach for TAVI is safe and feasible, with procedural and medium-term results similar to the femoral approach. Subclavian access should be considered a valid option not only when the femoral approach is impossible but also when it is difficult, albeit feasible.

[Selection of patients for transcatheter aortic valve implantation]

A good selection of patients is a crucial step before transcatheter aortic valve implantation (TAVI) in order to select the good indications and choose the access route. TAVI should be considered only in patients with symptomatic severe aortic stenosis and either contraindication or high surgical risk. Indication for TAVI should be discussed in a multidisciplinary team meeting. Echocardiography and/or CT scan are mandatory to evaluate the aortic annulus size and select the good prosthesis size. The possibility of transfemoral implantation is evaluated by angiography and CT scan, and based on the arterial diameters, but also on the presence of tortuosities and arterial calcifications.

Clinical outcomes after transcatheter aortic valve replacement using valve academic research consortium definitions: a weighted meta-analysis of 3,519 patients from 16 studies

OBJECTIVES

This study sought to perform a weighted meta-analysis to determine the rates of major outcomes after transcatheter aortic valve replacement (TAVR) using Valve Academic Research Consortium (VARC) definitions and to evaluate their current use in the literature.

BACKGROUND

Recently, the published VARC definitions have helped to add uniformity to reporting outcomes after TAVR.

METHODS

A comprehensive search of multiple electronic databases from January 1, 2011, through October 12, 2011, was conducted using predefined criteria. We included studies reporting at least 1 outcome using VARC definitions.

RESULTS

A total of 16 studies including 3,519 patients met inclusion criteria and were included in the analysis. The pooled estimate rates of outcomes were determined according to VARC's definitions: device success, 92.1% (95% confidence interval [CI]: 88.7% to 95.5%); all-cause 30-day mortality, 7.8% (95% CI: 5.5% to 11.1%); myocardial infarction, 1.1% (95% CI: 0.2% to 2.0%); acute kidney injury stage II/III, 7.5% (95% CI: 5.1% to 11.4%); life-threatening bleeding, 15.6% (95% CI: 11.7% to 20.7%); major vascular complications, 11.9% (95% CI: 8.6% to 16.4%); major stroke, 3.2% (95% CI: 2.1% to 4.8%); and new permanent pacemaker implantation, 13.9% (95% CI: 10.6% to 18.9%). Medtronic CoreValve prosthesis use was associated with a significant higher rate of new permanent pacemaker implantation compared with the Edwards prosthesis (28.9% [95% CI: 23.0% to 36.0%] vs. 4.9% [95% CI: 3.9% to 6.2%], p < 0.0001). The 30-day safety composite endpoint rate was 32.7% (95% CI: 27.5% to 38.8%) and the 1-year total mortality rate was 22.1% (95% CI: 17.9% to 26.9%).

CONCLUSIONS

VARC definitions have already been used by the TAVR clinical research community, establishing a new standard for reporting clinical outcomes. Future revisions of the VARC definitions are needed based on evolving TAVR clinical experiences.

[Transcatheter aortic valve implantation : what do anesthetists need to know?]

Surgical replacement of aortic valves is the gold standard for therapy of high grade aortic valve stenosis. However, the changes in demography confront the responsible medical discipline with an increasingly higher risk profile of patients which necessitates the development of new less invasive alternative forms of treatment for the surgical therapy of aortic valve stenosis. This developmental process has progressed from mini-thoracotomy to transcatheter aortic valve implantation (TAVI). The TAVI procedure is a new therapeutic option for treatment of patients with high grade aortic valve stenosis and high perioperative morbidity and mortality risks with conventional aortic valve replacement. Because TAVI can be carried out while the heart is still beating and without a sternotomy or heart-lung maschine, this procedure is particularly suitable for elderly multimorbid patients and/or patients with previous cardiac surgery. The initial results of large prospective multicenter studies underline the value of TAVI in the modern treatment of high risk patients with symptomatic aortic valve stenosis. In addition to an understanding of the surgical procedure, anesthetists must have precise knowledge of the perioperative anesthesia management and possible complications of the procedure.

Percutaneous Valve Therapy: Choosing the Appropriate Patients and Outcomes

Surgical aortic valve replacement (SAVR) is the current gold standard for the treatment of severe symptomatic aortic stenosis (AS), but transcatheter aortic valve implantation (TAVI) currently represents a viable alternative to conventional SAVR for patients with AS at high risk of operative mortality. On multivariate analysis it has been shown that female gender is independently associated with better recovery of the left ventricular systolic function after TAVI and that left ventricular hypertrophy reverses more frequently in female patients after SAVR. During follow-up, however, women remain significantly more symptomatic compared with men, mainly because they present with more advanced valve disease at a significantly older age.

Impact of coronary artery disease in elderly patients undergoing transcatheter aortic valve implantation: insight from the Italian CoreValve Registry

BACKGROUND

Coronary artery disease (CAD) commonly coexists with degenerative aortic stenosis. The impact of CAD in patients undergoing transcatheter aortic valve implantation (TAVI) raises concerns due to the lack of comprehensive and consistent data on this topic. We sought to evaluate the impact of CAD on clinical outcomes in patients undergoing TAVI.

METHODS

Consecutive patients(N=663) who underwent TAVI with the 18-French CoreValve ReValving System (CRS) (Medtronic Inc, MN USA) from June 2007 through December 2009 at 14 institutions across Italy were included in this prospective web-based registry. Four patients were excluded from the analysis due to failure to successfully release the prosthesis inside the native aortic valve. Previous percutaneous or surgical myocardial revascularizations were used to identify the existence of concomitant CAD (N=251; 38%). The primary endpoint was the incidence of Major Adverse Cerebrovascular and Cardiac Events (MACCE) and all-cause death in CAD and no-CAD groups.

RESULTS

Patients with CAD were no more likely to develop MACCE within 12-months of the procedure than those who did not (CAD group vs no-CAD group, 15.7% vs 18.3%; adjusted hazard ratio [HR] 0.76; 95% confidence interval [CI] 0.42 to 1.36; p=0.353). The 12-month mortality was 14.5% and 15.9% in CAD group and no-CAD group, respectively (adjusted HR 0.74; 95% CI 0.40 to 1.36; p=0.331).

CONCLUSIONS

Coexisting CAD does not impact procedural outcomes and mid-term incidence of MACCE and survival in elderly patients undergoing TAVI with CRS prosthesis.

Transcatheter aortic valve implantation: the evolution of prostheses, delivery systems and approaches

It is two decades since the first report of transcatheter implantation of a stented aortic valve in an animal. The first implantation of a transcatheter aortic valve in a human was accomplished just one decade ago dramatically demonstrating the promise and feasibility of this new therapy. Over the past 10 years, there have been rapid developments in valves, delivery systems and technical approaches. Today, transcatheter valve implantation is a technical possibility for the great majority of patients with aortic stenosis. The next 10 years may well see this become the dominant therapy for aortic stenosis.

Patient selection for transcatheter aortic valve implantation: patient risk profile and anatomical selection criteria

Patient selection plays a crucial role in the success of transcatheter aortic valve implantation (TAVI). It requires meticulous attention to the smallest of details and needs to be performed in a systematic manner for every patient. In essence, the patient must be assessed from access to implantation site. Becoming over "complacent" and "routine" may lead to failure and impact patient safety. TAVI is indicated for high or prohibitive surgical risk patients with severe aortic stenosis. Some patients, however, are too high risk even for TAVI. In addition to patient risk evaluation, anatomical selection criteria need to be considered. Multimodality imaging, using a combination of angiography, echocardiography and multislice computed tomography, is necessary to determine the anatomical suitability for the procedure.

Safety of a conservative strategy of permanent pacemaker implantation after transcatheter aortic CoreValve implantation

BACKGROUND

Conduction abnormalities are frequent after transcatheter aortic valve implantation with the CoreValve (Medtronic, Minneapolis, MN) and are often treated with liberal permanent pacemaker (PPM) implantation. Our aim was to assess the 1-year outcome of a conservative approach to pacing and to identify its predictors.

METHODS

We analyzed 275 consecutive patients without a PPM before transcatheter aortic valve implantation who underwent successful CoreValve implantation at our 3 centers, sharing a conservative approach to pacing.

RESULTS

Of the 47 patients (17.1%) who developed postprocedural complete atrioventricular block, 14 recovered spontaneous atrioventricular conduction <72 hours and did not receive a PPM. Sixty-six patients (24.0%) received a PPM before discharge, and 74 more patients (26.9%) developed a new left bundle-branch block (LBBB). Independent predictors of PPM implantation were as follows: lower CoreValve implantation below the aortic annulus (odds ratio [OR] 1.16/mm, 95% CI 1.03-1.30, P = .01), right bundle-branch block (OR 3.72, 95% CI 1.5-9.2, P = .004), left anterior hemiblock (OR 2.34, 95% CI 1.1-5.1, P = .03), and longer PR interval (OR 1.02/ms, 95% CI 1.00-1.04, P = .03). One-year survival was similar between patients who received a PPM and patients who did not receive a PPM (P = .90), with no case of sudden death in the latter group, and between patients with a new LBBB not receiving a PPM and patients without postprocedural LBBB (P = .37).

CONCLUSION

A high CoreValve implantation level and avoidance of prophylactic pacing in patients with new LBBB without persistent bradyarrhythmias allowed for a relatively low rate of PPM implantation. This conservative approach spared unwarranted pacing and did not affect 1-year survival.

Transcutaneous aortic valve implantation using the axillary/subclavian access with patent left internal thoracic artery to left anterior descending artery: feasibility and early clinical outcomes

OBJECTIVE

Both retrograde femoral and subclavian artery catheterization techniques have been described as the most common methods for the implantation of the Medtronic CoreValve percutaneous aortic valve (Medtronic Inc, Minneapolis, Minn). The subclavian artery has been shown to be a safe and effective alternative access route in patients with unfavorable femoral access. Of the patients who are identified as candidates for subclavian artery access, a subset possess a patent left internal thoracic artery to left anterior descending artery. This patent left internal thoracic artery presents an additional anatomic and clinical variable that must be taken into consideration to ensure procedural safety and efficacy. We describe the Medtronic CoreValve percutaneous aortic valve implantation using the subclavian arterial approach in patients with a patent left internal thoracic artery and report our study's findings.

METHODS

The CoreValve percutaneous aortic valve is a self-expandable nitinol-based frame with a porcine pericardial valve. The subclavian access was created by a small infraclavicular surgical incision to expose the artery. Rapid ventricular pacing was used to reduce cardiac output to perform the balloon aortic valvuloplasty via a 12F sheath inserted into the subclavian artery. An 18F sheath was then inserted into the artery down into the ascending aorta and used for introduction of the delivery catheter and implantation of the percutaneous aortic valve.

RESULTS

With the use of this method, 19 patients (76 ± 13 years) whose surgical risk was deemed excessive because of severe comorbidity and in whom transfemoral catheterization was considered unfeasible or at risk of severe complications have received implants. Subclavian artery or left internal thoracic artery injury did not occur in any patient. Two deaths occurred. One patient died of right coronary artery occlusion during the procedure, and one patient died 48 hours after the procedure as the result of a tamponade after the temporary pacemaker wire ablation.

CONCLUSIONS

This initial experience suggests that subclavian transarterial aortic valve implantation in patients with a patent left internal thoracic artery to left anterior descending artery is feasible and safe with satisfactory short-term outcomes.

Survival and predictive factors of mortality after 30 days in patients treated with percutaneous implantation of the CoreValve aortic prosthesis

BACKGROUND

Few data exist on the clinical impact of transcatheter aortic valve implantation (TAVI) in patients with symptomatic aortic stenosis and a high surgical risk. The aim of this study was to determine the survival and the factors predicting mortality after 30 days post-TAVI with the CoreValve prosthesis (Medtronic, Minneapolis, MN).

METHODS

From April 2008 to October 2010, the CoreValve prosthesis (Medtronic) was implanted in 133 consecutive high-risk surgical patients with symptomatic severe aortic stenosis.

RESULTS

The mean age was 79.5 ± 6.7 years. The logistic European System for Cardiac Operative Risk Evaluation was 21.5% ± 14%. The implantation success rate was 97.7%. In-hospital mortality was 4.5%, and the combined end point of death, vascular complications, myocardial infarction, or stroke had a rate of 9%. Survival at 12 and 24 months was 84.5% and 79%, respectively, after a mean follow-up of 11.3 ± 8 months. The New York Heart Association functional class improved from 3.3 ± 0.5 to 1.18 ± 0.4 and remained stable at 1 year. A high Charlson index (hazard ratio [HR] 1.44, 95% CI 1.09-1.89, P < .01) and a worse Karnofsky score before the procedure (HR 0.95, 95% CI 0.92-0.99, P = .021) were predictors of mortality after 30 days.

CONCLUSIONS

Transcatheter aortic valve implantation with the CoreValve prosthesis for patients with aortic stenosis and a high surgical risk is a safe, efficient option resulting in a medium-term clinical improvement. Survival during follow-up depends on the associated comorbidities. Early mortality beyond 30 days is predicted by preoperative comorbidity scores and the functional status of the patient.

Most Important Papers in Transcatheter Aortic Valve Replacement and Transcatheter Aortic-Valve Implantation

The following are highlights from the series, Circulation: Cardiovascular Interventions Topic Review . This series summarizes the most important manuscripts, as selected by the editors, which have published in the Circulation portfolio. The studies included in this article represent the most noteworthy research in the areas of transcatheter aortic valve replacement and transcatheter aortic-valve implantation.

Transcatheter Aortic Valve Implantation: Experience with the CoreValve Device

The field of transcatheter aortic valve implantation has been rapidly evolving. The Medtronic CoreValve first emerged on the landscape in 2004 with initial first human studies, and it is currently being studied in the Pivotal US trial. This article details the current experience with the self-expanding aortic valve with a focus on clinical results and ongoing challenges.

Transcatheter Aortic Valve Implantation: Upcoming New Devices

Transcatheter aortic valve implantation (TAVI) is an alternative to surgical aortic valve replacement in high-risk patients with symptomatic severe aortic stenosis. Several upcoming devices will optimize and facilitate the procedure: periprosthetic aortic regurgitation will be reduced by larger prosthesis sizes and repositionable next-generation transcatheter heart valves. Alternative access routes and smaller sheaths will reduce the rate of vascular complications. Cerebral protection devices might reduce the rate of strokes and silent cerebral embolism. Abandonment of balloon valvuloplasty and rapid ventricular pacing might facilitate the procedure and improve outcome. Thus, younger and healthier patients could benefit from TAVI in the near future.

Computed tomography in the evaluation for transcatheter aortic valve implantation (TAVI)

If left untreated, symptomatic, severe aortic stenosis (AS) is associated with a dismal prognosis. Open-heart surgical valve replacement is the treatment of choice and is associated with excellent short and long-term outcome. However, many older patients with multiple co-morbidities and anticipated increased surgical risk are excluded from surgical intervention. For these patients, transcatheter aortic valve implantation (TAVI) is emerging as a viable treatment alternative. Transcatheter valvular heart procedures are characterized by lack of exposure and visualization of the operative field, therefore relying on image guidance, both for patient selection and preparation and the implantation procedure itself. This article describes the role of multi-detector row computed tomography (MDCT) for detailed assessment of the aortic valve, aortic root, and iliac arteries in the context of TAVI.

Early and mid-term outcomes in patients undergoing transcatheter aortic valve implantation after previous coronary artery bypass grafting

OBJECTIVES

Surgical aortic valve replacement in patients with previous coronary artery bypass grafting (CABG) carries a high mortality. Transcatheter aortic valve implantation (TAVI) has been shown to be successful in high risk subgroups of patients. Our goal is therefore to evaluate the impact of a history of CABG on the outcome of patients who undergo TAVI.

METHODS

From October 2006 to June 2010, among the 201 patients selected to undergo TAVI, 54 (27%) had a history of CABG. Outcomes were prospectively collected.

RESULTS

The 30-day outcome was not different between patients with previous CABG vs. those without, in particular as regards mortality (respectively, 5.6% vs. 10.9%; P = 0.25). Mid-term survival (mean FU: 7 ± 9 months) was not different at 2 years between patients with previous CABG vs. patients without (65.7 ± 6.2% vs. 80.0 ± 7.7% respectively; P = 0.12). In multivariate analysis, CABG was not associated with an excess mid-term mortality after TAVI.

CONCLUSIONS

Previous CABG does not adversely affect outcome in patients undergoing TAVI. If confirmed by larger prospective series and ideally by a randomized trial comparing CABG vs. redo surgery, this observation might lead the heart team to consider TAVI as an attractive option in the population of high risk patients with aortic stenosis and previous CABG.

Transaxillary Approach Short- and Mid-Term Results in a Single-Center Experience

Objective

Transcatheter aortic valve implantation (TAVI) is increasingly accepted as an alternative procedure in patients with severe, symptomatic aortic stenosis and high risk for surgical aortic valve replacement. Transfemoral (TF) approach is the first option when feasible, but in case of peripheral vascular disease this approach is precluded. In our institution, for this kind of patients we considered transaxillary (TAx) approach as second choice and transapical (TAp) or transaortic (TAa) as last routes. This study describes short- and mid-term morbidity and mortality for TAx approach.

Methods

From November 2007 to March 2011, 284 patients underwent TAVI at our site; 229 treated by TF approach, 22 TAp, 2 TAa, and 31 TAx. Four patients were treated with an Edwards Sapien valve (Edwards Lifesciences, Inc., Irvine, CA USA) with TAx approach and 27 with CoreValve Revalving System (Medtronic Inc., Minneapolis, MN USA). TAx TAVI was performed in cath-laboratory with local anesthesia and mild sedation by a multispeciality valve team. We analyzed major adverse cardiac and cerebrovascular events, major adverse valve-related events, vascular complications, and 30 days and 6 months mortality.

Results

The procedural success rate (successful implantation of the device without intraprocedural mortality or need to conversion to open heart surgery) was 96.8% (30/31). Major adverse valve-related events were 12.9% (4/31). 30-day mortality was 6.4% (2/31) and actuarial survival at 6 months was 82.95% ± 7.96%. In one patient, procedure was converted to a TF CoreValve in emergency for hemodynamic instability after valvuloplasty due to severe difficulty to introduce the Edwards valve in the subclavian artery.

Conclusions

TAx approach is a feasible and technically simple procedure with encouraging results considering morbidity and mortality at short- and mid-term follow-up. TAx is a valid solution in patients with contraindications to TF approach and it is an alternative approach potentially less invasive than TAp or TAa.

Current state of symptomatic aortic valve stenosis in the Japanese elderly

BACKGROUND

There have been few reports regarding treatment selection and prognosis of symptomatic aortic valve stenosis (AS) in the elderly in Japan.

METHODS AND RESULTS

Sixty-one patients hospitalized between January 2000 and December 2007 for symptomatic severe AS were investigated. The average observation period was 27 months. Thirty-seven patients (61%) were diagnosed with AS for the first time on hospitalization. Thirty-six patients had onset of symptoms within 1 month before admission. Thirty-six patients received aortic valve replacement (group S) and 25 received medical therapy (group M). The patients in group M were older than those in group S (84.1 ± 5.3 years vs. 74.2 ± 4.6 years, P<0.001). Maximum flow velocity measured by echocardiography was lower in group M (4.5 ± 0.3 m/s vs. 4.9 ± 0.5 m/s, P<0 .01), but there was no difference in valve area between the 2 groups (0.62 ± 0.19 cm² vs. 0.57 ± 0.15 cm², P=0.12). One-year mortality rate derived from the Kaplan-Meier curve was higher in group M than group S (53.1% vs. 6.4%, respectively). On multivariate analysis, the only independent favorable prognostic factor was aortic valve replacement (HR: 0.02, 95%CI: 0.01-0.15, P<0.01).

CONCLUSIONS

Medical therapy is often selected for treatment of symptomatic AS in the elderly, but the prognosis is very poor. Symptomatic severe aortic stenosis should be treated surgically, or with transcatheter aortic valve implantation in cases with high surgical risk.

The valve-in-valve technique for treatment of aortic bioprosthesis malposition an analysis of incidence and 1-year clinical outcomes from the italian CoreValve registry

OBJECTIVES

We appraised the incidence and clinical outcomes of patients who were treated with the valve-in-valve (ViV) technique for hemodynamically destabilizing paraprosthetic leak (PPL).

BACKGROUND

Device malpositioning causing severe PPL after transcatheter aortic valve implantation is not an uncommon finding. It occurs after release of the prosthesis, leading to hemodynamic compromise. It can be managed successfully in selected cases with implantation of a second device inside the malpositioned primary prosthesis (ViV technique).

METHODS

Consecutive patients (n = 663) who underwent transcatheter aortic valve implantation with the 18-F CoreValve ReValving System (Medtronic, Inc., Minneapolis, Minnesota) at 14 centers across Italy were included in this prospective web-based registry. We identified patients treated with the ViV technique for severe PPL and analyzed their clinical and echocardiographic outcomes. Primary end points were major adverse cerebrovascular and cardiac events and prosthesis performance at the 30-day and midterm follow-up.

RESULTS

Overall procedural success was obtained in 650 patients (98.0%). The ViV technique was used in 24 (3.6%) of 663 patients. The 30-day major adverse cerebrovascular and cardiac event rates were 7.0% and 0% in patients undergoing the standard procedure and ViV technique, respectively (p = 0.185); the mortality rates were 5.6% versus 0% in patients undergoing the standard procedure and ViV technique, respectively (p = 0.238). There was an improvement in the mean transaortic gradient in all patients without significant difference between the 2 groups (from 52.1 ± 17.1 mm Hg and 45.4 ± 14.8 mm Hg [p = 0.060] to 10.1 ± 4.2 mm Hg and 10.5 ± 5.2 mm Hg, respectively [p = 0.838]). At 12 months, the major adverse cerebrovascular and cardiac event rates in the standard procedure and ViV technique groups were 4.5% and 14.1%, respectively (p = 0.158), and the mortality rates were 4.5% versus 13.7%, respectively (p = 0.230).

CONCLUSIONS

This large, multicenter registry provides important information about the feasibility, safety, and efficacy of the ViV technique with the third-generation CoreValve ReValving System. The clinical and echocardiographic end points compare favorably with those of patients undergoing the standard procedure. The ViV technique offers a viable therapeutic option in patients with acute significant PPL without recourse to emergent surgery.

Effect of experience on results of transcatheter aortic valve implantation using a Medtronic CoreValve System

Outcome after transcatheter aortic valve implantation (TAVI) depends on the patient risk profile, operator experience, progress in technology, and technique. We sought to compare the results of TAVI during the initiation phase and after certification to perform TAVI with the Medtronic CoreValve System without proctoring. A total of 165 consecutive patients was categorized into a first cohort of 33 patients treated before certification (November 2005 to December 2007) and a second cohort of 132 patients treated after certification (January 2008 to October 2010). The study end points were selected and defined according to the Valve Academic Research Consortium recommendations. Compared to cohort 2, the patients in cohort 1 more frequently had New York Heart Association class III-IV (100% vs 71%, p <0.001), hypertension (67% vs 39%, p = 0.004), and aortic regurgitation grade III-IV (46% vs 22%, p = 0.006) before TAVI. Over time, the patients in cohort 2 more frequently underwent a truly percutaneous approach (98% vs 82%, p = 0.002) without circulatory support (96% vs 67%, p <0.001) but with more concomitant percutaneous coronary intervention (11% vs 0%, p = 0.042) than the patients in cohort 1. They also more often received a 29-mm prosthesis (72% vs 24%, p <0.001), required less postimplantation balloon dilation (10% vs 27%, p = 0.008), and had less aortic regurgitation grade III-IV after TAVI (12% vs 30%, p = 0.010). The clinical outcome showed a nonsignificant reduction in the combined safety end point (30% to 17%) but a significant reduction in cerebrovascular events (21% to 7%, p = 0.020) and life-threatening bleeding (15% to 5%, p = 0.044) in cohort 2. However, the reduction in overall bleeding and vascular complications (25% and 14%, respectively) was not significant. In conclusion, TAVI became significantly less complex and was associated with better results over time but remained associated with a high frequency of periprocedural major cardiovascular complications.

Computed tomography evaluation for transcatheter aortic valve implantation (TAVI): imaging of the aortic root and iliac arteries

For patients with severe aortic stenosis, open-heart surgical valve replacement remains the current clinical standard with documented, excellent long-term outcome. Over the past few years, transcatheter aortic valve implantation (TAVI) has developed into a treatment alternative for high-risk patients with severe aortic stenosis. Because transcatheter valvular procedures are characterized by lack of exposure of the operative field, image guidance is critical. This Pictorial Essay describes the role of 3-dimensional imaging with multidetector row computed tomography for detailed reconstructions of the aortic valve, aortic root, and iliac arteries in the context of TAVI.

How should I treat acute valve regurgitation?

BACKGROUND

An 81-year-old male with symptoms of angina and dyspnoea (NYHA 3), a history of coronary bypass surgery, a transaortic peak gradient of 109 mmHg on transthoracic echocardiography and a logistic Euro-SCORE of 21.6 was deemed suboptimal for surgery by a multidisciplinary team and was accepted for TAVI.

INVESTIGATION

Preprocedural diameter of the native aortic root was 24.4 mm on transthoracic echocardiography (TTE), 26.9 mm on contrast angiography and 26.8 mm by 30.2 mm on multislice computed tomography (MSCT).

DIAGNOSIS

heavy calcification of the aortic root and coronary arteries by MSCT.

TREATMENT

Transcatheter aortic calve replacement with an 29 mm CoreValve prosthesis.

WITHDRAWN: Very Early Improvement in Valvuloarterial Impedance Induced by Transcatheter Aortic Valve Implantation (CoreValve) in Symptomatic Aortic Stenosis

The editors have requested that the article be withdrawn because of concern that some of its contents appear quite similar to portions of another publication from the same group of investigators. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.

Incidence, prognostic value and management of vascular complications with transfemoral transcatheter aortic valve implantation

Inoperable or high-risk patients with severe aortic stenosis who undergo transcatheter aortic valve implantation (TAVI) have better outcomes compared with those treated with standard medical therapy. As for any other invasive procedure, peri-procedural complications may occur, reducing the procedural success rate and potentially affecting short- and mid-term outcomes. The transfemoral approach prevails over other possible access-site options in most registries. The use of large introducer sheaths and the need for double arterial vascular access can lead to higher rates of vascular complications in this elderly population, with a high prevalence of baseline peripheral artery disease. In this article, we review the results of recent clinical trials and major registries using the two different bioprosthesis currently available for TAVI, focusing on access site-related complications with transfemoral TAVI, their management and relationship with in-hospital and 30-day survival. Awareness of the mechanisms behind these complications might help in their prevention, recognition and management and may ultimately improve the clinical outcome of TAVI procedures.