Contemporary strategy for aortic valve stenosis in octogenarians

Transcatheter aortic valve replacement program in the post-food and drug administration approval era: early outcomes at an academic medical center

OBJECTIVE

Transcatheter aortic valve replacement (TAVR) has recently become a suitable alternative for treatment of symptomatic aortic stenosis in patients who are at very high risk for morbidity and mortality with conventional corrective surgery. In the fall of 2011, the Food and Drug Administration approved the use of TAVR, allowing for reimbursement at institutions outside of investigative trials. We report the initiation of a TAVR-based program at an academic tertiary care facility that did not participate in the Placement of Aortic Transcatheter Valves (PARTNER) 1 or PARTNER II trials.

METHODS

A total of 160 patients were evaluated for TAVR from May 2012 through June 2013. Transcatheter aortic valve replacement was found to be appropriate for 50 (31%).

RESULTS

In this experience, morbidity and mortality were similar to those reported for the PARTNER trial (30-day hospital mortality was 8%). A single case of presumed cerebrovascular accident was observed. These results demonstrate that the real-world application can be done with comparable results. Implementation of lessons learned in the trials allowed a very short learning curve and excellent results after only a limited number of patients. Use of computed tomography reconstructed images for operative planning, including fluoroscopic angle, facilitated minimal use of contrast in each case.

CONCLUSIONS

Transcatheter aortic valve replacement is a viable option for patients at very high risk for surgical intervention in the post-Food and Drug Administration approval era. Real-world results comparable with published outcomes from experienced centers involved in the PARTNER trial can be achieved.

Effects of tolvaptan in the early postoperative stage after heart valve surgery: results of the STAR (Study of Tolvaptan for fluid retention AfteR valve surgery) trial

PURPOSE

The purpose of this study was to assess the efficacy of tolvaptan, a vasopressin V2 receptor antagonist, for the management of postoperative surgical fluid retention after heart valve surgery.

METHODS

This was a prospective observational study of 64 patients with heart valve disease who underwent valve surgery between 2013 and 2014. Those in the tolvaptan group received tolvaptan in addition to conventional diuretic therapy. The results were compared to the results of 55 patients who underwent heart valve surgery between 2007 and 2010 and received conventional postoperative diuretics alone.

RESULTS

The time to return to the preoperative BW was significantly shorter in the patients who received tolvaptan (6.1 ± 3.8 vs. 8.7 ± 6.7 days, p < 0.05), while the level of sodium was significantly decreased in the patients who received conventional diuretics. The degree of increase in the creatinine level tended to be smaller in the tolvaptan group. The response to tolvaptan was related to the postoperative degree of BW increase and the preoperative creatinine level.

CONCLUSIONS

Tolvaptan was effective in treating fluid retention during the early postoperative stage in cardiac surgery patients, without increased renal failure or abnormal electrolyte levels. This new type of diuretic therapy may be a suitable option for postoperative fluid management in patients undergoing cardiac surgery.