2018 AATS/ACC/SCAI/STS expert consensus systems of care document: Operator and institutional recommendations and requirements for transcatheter aortic valve replacement

Management of Surgical Aortic Valve Replacement Degeneration With Transcatheter Aortic Valve Implantation (TAVI in SAVR): Experience in Nicaragua

Severe aortic valve stenosis poses a significant risk for the aging population, often escalating from mild symptoms to life-threatening heart failure and sudden death. Without timely intervention, this condition can lead to disastrous outcomes. The advent of transcatheter aortic valve implantation (TAVI) has gained popularity, emerging as an effective alternative for managing severe aortic stenosis (AS) in high-risk patients experiencing deterioration of previously implanted bioprosthetic surgical aortic valves (SAV), which introduces complex challenges such as device compatibility and anatomical considerations. We report the case of a 76-year-old male with a history of stage III hypertension, compensated type 2 diabetes, and aortic valve disease who underwent bioprosthetic valve replacement in 2013. His medications included metoprolol, metformin/glibenclamide, and levothyroxine. He presented with moderate exertional dyspnea (NYHA II) over four months, relieved by rest. Physical examination revealed a crescendo-decrescendo systolic murmur at the aortic focus. The aortic prosthesis stenosis was confirmed by a transthoracic echocardiogram. A CT angiogram showed bioprosthetic degeneration and significant calcification, allowing for transcatheter aortic valve implantation in the surgical aortic valve. The procedure was successfully performed via the transfemoral route using a 21.5 mm MyVal balloon-expandable valve. The intervention improved the patient's quality of life, resolving NYHA class III dyspnea and enabling greater independence in daily activities. Echocardiographic findings demonstrated a significant reduction in the transvalvular gradient, enhancing cardiac function and eliminating the immediate risk of valvular dysfunction progression, contributing to increased life expectancy and emotional well-being. This case highlights the feasibility and clinical benefits of transcatheter aortic valve implantation in surgical aortic valves for managing valve degeneration in a resource-limited setting, thereby representing a significant advancement in the treatment of aortic valve disease. The successful outcome demonstrates the importance of adopting innovative, minimally invasive techniques, particularly in regions with limited advanced interventions, by alleviating dyspnea, enhancing cardiac function, and significantly improving the patient's quality of life, emotional well-being, and prognosis.

Preoperative visit-care for transcatheter aortic valve replacement: a review

AIM

The aim of this review is to evaluate and summarize the evidence for preoperative visit-care of transcatheter aortic valve replacement (TAVR) and to provide evidence-based support for clinical intervention.

DESIGN

The review presents an evidence summary report, following the standard of the Fudan University Center for Evidence-based Nursing.

METHODS

Literature related to preoperative visit-care for transcatheter aortic valve replacement have been retrieved based on the "6S" pyramid model of evidence. The types of literature included systematic reviews, expert consensus, evidence summary, and guidelines.

DATA SOURCES

Up To Date, Cochrane Library, Joanna Briggs Institute, National Institute for Health and Care Excellence, Medlive, American Heart Association, Registered Nurses Association of Ontario, Scottish Intercollegiate Guidelines Network, European Society of Cardiology, American College of Cardiology, PubMed, CINAHL, Wanfang database, VIP database, Chinese biomedical literature database, CNKI. The search period is limited to the time when each database was established until February 2024.

RESULTS

A total of 18 articles were included in this review, consisting of 1 systematic review, 1 evidence summary, 3 guidelines and 13 expert consensuses. This review summarized 30 pieces of the best evidence for preoperative visit-care for transcatheter aortic valve replacement, encompassing three evidence themes: multidisciplinary team collaboration, preoperative assessment, and preoperative education.

CONCLUSION

The study has established an ideal foundation of evidence for preoperative visit-care in TAVR. However, throughout the particular application process, it was crucial to assess the feasibility and relevance of the evidence in clinical practice by taking into account elements such as the application setting, recommendations from experts with diverse expertise, and the preferences of the patients.

The interventional care for patients undergoing transcatheter aortic valve replacement: Establishing indicators for optimal interventional care

OBJECTIVE

We evaluate the quality of interventional care for patients undergoing transcatheter aortic valve replacement (TAVR) using a set of quality indicators.

METHODS

We developed an initial list of quality indicators by incorporating current guidelines, observing practice discrepancies, and basing it on the Donabedian "structure, process, and outcome" three-dimensional quality evaluation model as the framework. The Delphi method was utilized in two rounds of consultation involving 31 experts to evaluate and revise indicators at all levels.

RESULTS

The response rate of expert questionnaires was 100% for both rounds, and the expert authority coefficients were 0.913 and 0.940, respectively. The Kendall harmony coefficients were 0.221 and 0.195, respectively, with P < 0.05. Eventually, a quality evaluation system of interventional care for patients undergoing TAVR was constructed, consisting of three structural indicators, nine process indicators, and 42 outcome indicators.

CONCLUSIONS

The quality evaluation system for interventional care of TAVR sought to establish specific, objective, and quantifiable criteria for assessing the quality of care. It is recommended to apply the set of quality indicators across hospitals to enhance the quality of care for TAVR.

Savings associated with surgical aortic valve replacement with a RESILIA tissue valve based on seven-year COMMENCE trial results

BACKGROUND

Bioprostheses with RESILIA tissue demonstrate a reduction in calcification and improve health outcomes in pre-clinical and clinical studies. Prior economic analyses which relied on 5 years of evidence from the COMMENCE trial demonstrate financial savings for RESILIA tissue valves relative to mechanical valves after surgical aortic valve replacement (SAVR). Given the recent release of 7-year COMMENCE data, this economic evaluation updates the estimate for long-run savings of bioprosthetic valves with RESILIA.

METHODS

Simulation models estimated disease progression across two hypothetical SAVR cohorts (tissue vs. mechanical) of 10,000 patients each in the US. The primary comparison calculated the SAVR-related expenditures associated with each valve type ($US, 2023). Health outcome probabilities were based on the COMMENCE trial though year 7 and projected for an additional 8 years based on prior studies of tissue and mechanical SAVR. Costs for key outcomes (mortality, reoperation, bleeding, thromboembolism, endocarditis) and anticoagulant monitoring were sourced from the literature. Incidence rates of health outcomes associated with mechanical valves relied on relative risks of tissue valve versus mechanical valve patients.

RESULTS

Seven-year savings are $13,415 (95% CI = $10,472-$17,321) per patient when comparing RESILIA versus mechanical SAVR. Projected 15-year savings were $23,001 ($US, 2023; 95% CI = $17,802-$30,421). Most of the 15-year savings are primarily attributed to lower anti-coagulation monitoring costs ($21,073 in ACM savings over 15 years), but lower bleeding cost (savings: $2,294) and thromboembolism-related expenditures (savings: $852) also contribute. Reoperation and endocarditis expenditures were slightly larger in the RESILIA cohort. If reoperation relative risk reverts from 1.1 to 2.2 (the level in legacy tissue valves) after year 7, savings are $18,064. RESILIA SAVR also reduce costs relative to legacy tissue valves.

CONCLUSION

Patients receiving RESILIA tissue valves are projected to have lower SAVR-related health expenditures relative to mechanical and legacy tissue valves.

Transcatheter Aortic Valve Implantation Access Sites: Same Goals, Distinct Aspects, Various Merits and Demerits

Transcatheter aortic valve implantation (TAVI) has been established as a safe and efficacious treatment for patients with severe symptomatic aortic stenosis (AS). Despite being initially developed and indicated for high-surgical-risk patients, it is now offered to low-risk populations based on the results of large randomized controlled trials. The most common access sites in the vast majority of patients undergoing TAVI are the common femoral arteries; however, 10-20% of the patients treated with TAVI require an alternative access route, mainly due to peripheral atherosclerotic disease or complex anatomy. Hence, to achieve successful delivery and implantation of the valve, several arterial approaches have been studied, including transcarotid (TCr), axillary/subclavian (A/Sc), transapical (TAp), transaortic (TAo), suprasternal-brachiocephalic (S-B), and transcaval (TCv). This review aims to concisely summarize the most recent literature data and current guidelines as well as evaluate the various access routes for TAVI, focusing on the indications, the various special patient groups, and the advantages and disadvantages of each technique, as well as their adverse events.

A scoping review to identify competencies for transcatheter cardiovascular procedures

OBJECTIVES

Transcatheter procedures are increasingly being recognized as a priority for cardiac surgeons and cardiac surgery trainees. The optimal method of teaching these procedures during residency training has not been established. We used an evidence-based approach to systematically review the literature and identify competencies to inform future paradigms of transcatheter training in cardiac surgery.

METHODS

A scoping review was conducted to retrieve relevant literature on the performance of transcatheter cardiovascular procedures, identify competencies required by surgical residents learning to perform these procedures, and develop a preliminary list of competencies for consideration during transcatheter training. MEDLINE, Scopus, and ERIC were queried until April 1, 2020, using a systematic search strategy. No limitations were placed on publication date or type.

RESULTS

A total of 1456 sources of evidence were retrieved. After deduplication and screening, there remained 33 that were included in the scoping review, published between 2006 and 2020. The distribution of publication types included 10 comparative studies (30.3% of total), 8 societal statements (24.2% of total), 5 surveys and 5 opinion articles (each 15.2% of total), 2 editorials and 2 descriptions of a simulator (each 6.1% of total), and 1 narrative review (3.0% of total). From these, a total of 400 items were identified and organized into 97 competencies.

CONCLUSIONS

Evidence on the competencies required to perform transcatheter cardiovascular procedures is available from a variety of sources. The identified competencies may be a useful resource for developing curricula and teaching transcatheter procedures to cardiac surgery residents.

The Safety of Early Discharge Following Transcatheter Aortic Valve Implantation Among Patients in Northern Ontario and Rural Areas Utilizing the Vancouver 3M TAVI Study Clinical Pathway

Background

Early hospital ( < 48 hours) discharge following transcatheter aortic valve implantation (TAVI) is an increasingly adopted practice; however, data on the safety of such an approach among patients residing in North Ontario, including remote and medically underserved areas, are lacking.

Methods

This retrospective study included patients who underwent TAVI in Sudbury, Ontario. The safety of early discharge after implementation of the Vancouver 3M (multidisciplinary, multimodality, but minimalist) clinical pathway was assessed. The primary endpoint was 30-day mortality. Resource utilization before vs after 3M clinical pathway implementation was also compared.

Results

A total of 291 patients who underwent TAVI between 2012 and 2021 were included in the study. One in-hospital death (0.6%) occurred after the 3M clinical pathway implementation, with no mortality observed beyond hospital discharge. Eleven patients (6.7%) required rehospitalization within 30 days. The need for mechanical ventilation and surgical vascular cut-down declined from 100% and 97%, respectively, at baseline, to 6% and 2%. The number of patients receiving TAVI on a given procedural day increased from 2 to 3 patients. The median post-TAVI hospital length of stay decreased from 5 days (2-6 days) to 1 day (1-3 days) after 3M clinical pathway implementation.

Conclusions

Following TAVI, early discharge of selected patients residing in Northern Ontario, including rural areas, using the Vancouver 3M clinical pathway was associated with favourable outcomes, short length of stay, and more-efficient resource utilization. These data can help improve healthcare efficiency and bridge variations in TAVI funding and accessibility in underserved locations.

Incidence, Risk Factors, and Outcomes of Coronary Obstruction Following Valve-in-Valve Transcatheter Aortic Valve Replacement

There is scant information about the incidence, risk factors, and outcomes of coronary obstruction (CO) following valve-in-valve transcatheter aortic valve replacement (VIV-TAVR). A meta-analysis of the published studies from January 2000 to April 2020 was conducted, and the endpoint was CO. A total of 2858 patients were enrolled in this study. The mean age was 77.7 ± 9.8, and 39.9% of them were female. The Society of Thoracic Surgeons (STS) score, European System for Cardiac Operative Risk Evaluation (EuroSCORE), and Logistic EuroSCORE were 8.9 ± 7.8, 16.0 ± 10.9, and 26.3 ± 16.3, respectively. The overall incidence of CO was 2.58%. CO incidence between patients with prior stented and stentless valves were significantly different (1.67% versus 7.17%), with an odds ratio (OR) of 0.25 and a 95% confidence interval (CI) of 0.14-0.44 (P < 0.00001). The first-generation valves were significantly associated with higher CO incidence compared with the second-generation valves (7.09% versus 2.03%; OR, 2.44; 95%CI, 1.06-5.62; P = 0.04), while no statistical difference was found between self-expandable valves and balloon-expandable valves (2.45% versus 2.60%; OR, 0.99; 95%CI, 0.55-1.79; P = 0.98). Virtual transcatheter to coronary ostia (VTC) distance (3.3 ± 2.1 mm, n = 29 versus 5.8 ± 2.4 mm, n = 169; mean difference, -2.70; 95%CI, -3.46 to -1.95; P < 0.00001) and the sinus of Valsalva (SOV) diameter (27.5 ± 3.8 mm, n = 23 versus 32.3 ± 4.0 mm, n = 101; mean difference, -3.80; 95%CI, -6.55 to -1.05; P = 0.007) were enormously shorter in patients with CO. The 24-hour, in-hospital, and 30-day mortality of patients with CO were 10.5%, 30.8%, and 37.1%, respectively. In conclusion, device selections, VTC distances, and SOV diameters may be important factors in assessing the CO risk in VIV-TAVR.