Immediate and Intermediate Outcome After Transapical Versus Transfemoral Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement in Germany with need for a surgical bailout

BACKGROUND

In transcatheter aortic valve replacement (TAVR), complications may force the need for a surgical bailout, but knowledge is rare about outcomes in Germany.

METHODS

Using national health records, we investigated all TAVR in German hospitals between 2007 and 2020, focusing on 2018-2020. We extracted data on those interventions with need for a surgical bailout.

RESULTS

A total of 159,643 TAVR were analyzed, with an overall rate of surgical bailout of 2.30 %, an overall in-hospital mortality of 3.85 %, and in-hospital mortality in case of bailout of 16.51 %. The number of all annual TAVR procedures increased substantially (202 to 22,972), with the rate of surgical bailout declining from 27.23 to 0.61 % and overall mortality from 11.39 to 2.29 %. However, in-hospital mortality after bailout was still high (28.37 % in 2020). The standardized rates of overall mortality and surgical bailout between 2018 and 2020 were significantly lower for balloon-expandable and self-expanding transfemoral TAVR than for transapical TAVR after risk adjustment [transapical/transfemoral balloon-expandable/transfemoral self-expanding TAVR: in-hospital mortality: 5.66 % (95 % CI 4.81 %; 6.52 %)/2.30 % (2.03 %; 2.57 %)/2.32 % (2.07 %; 2.57 %); surgical bailout: 2.33 % (1.68 %; 2.97 %)/0.79 % (0.60 %; 0.98 %)/0.42 % (0.31 %; 0.53 %)]. Coronary artery disease [risk-adjusted OR = 1.50 (1.21; 1.85), p < 0.001] and atrial fibrillation [OR = 1.29 (1.07; 1.57), p = 0.009] were found to be the main risk factors for bailout.

CONCLUSIONS

Rates of TAVR with need for a surgical bailout and overall in-hospital mortality have declined noticeably over the years in Germany. However, the outcomes are still unfavorable after surgical bailout, as in-hospital mortality is continuously high. We present risk factors for surgical bailout to improve preparation of subsequent measures. It must be a major goal to further reduce the rate of surgical bailouts in the future.

Ten-Year Experience with a Transapical Approach for Transcatheter Aortic and Mitral Valve Implantation

BACKGROUND

The transfemoral approach represents the optimal access for TAVI due to its low invasiveness; however, up to 10-15% of TAVI candidates are considered unsuitable for femoral access because of significant peripheral vascular disease and need alternative access.

METHODS

This is a single-center retrospective observational study including all consecutive adult patients undergoing transcatheter procedures through a TA approach from March 2015 to April 2024.

RESULTS

213 patients underwent transcatheter aortic or mitral valve implantation through a TA approach and were enrolled in this study. The mean age of the patients was 79.5 ± 5.7 years, and 54% of the patients were males. The mean Euroscore II was 7.9 ± 6.4%. One-third of the patients had previous cardiac surgery. The overall mean survival time was 5.3 ± 0.3 years. Nine (4%) patients developed infective endocarditis (IE) during the follow-up.

CONCLUSIONS

The transapical approach for transcatheter procedures is a safe and effective procedure for patients unsuitable for TF access with low periprocedural mortality and a low rate of post-procedural complications when performed by experienced surgeons and cardiologists.

Transcarotid versus transthoracic transcatheter aortic valve replacement: A systematic review and meta-analysis

BACKGROUND

Transthoracic approaches may be contraindicated in some patients and may be associated with poorer outcomes. Therefore other alternative access routes are increasingly being performed. We conducted a systematic review of the literature on Transcarotid transcatheter aortic valve replacement (TC-TAVR) and meta-analysis comparing outcomes of TC-TAVR and other access routes.

METHODS

We comprehensively searched for controlled randomized and non-randomized studies from 4 online databases. We presented data using risk ratios (95 % confidence intervals) and measured heterogeneity using Higgins' I2.

RESULTS

Sixteen observational studies on Transcarotid TAVR were included in the analysis; 4 studies compared 180 TC-TAVR patients vs 524 TT-TAVR patients. The mean age and STS score for patients undergoing TC-TAVR were 80 years and 7.6 respectively. For TT-TAVR patients, the mean age and STS score were 79.7 years and 8.7 respectively. TC-TAVR patients had lower 30-day MACE [7.8 % vs 13.7 %; OR 0.54 (95 % CI 0.29-0.99, P = 0.05)] and major or life-threatening bleeding [4.0 % vs 14.2 %; OR 0.25 (95 % CI 0.09-0.67, P = 0.006)]. There was no significant difference in 30-day: mortality [5.0 % vs 8.6 %; OR 0.61 (95 % CI 0.29-1.30, P = 0.20)], stroke or transient ischemic attack [2.8 % vs 4.0 %; OR 0.65 (95 % CI 0.25-1.73, P = 0.39)] and moderate or severe aortic valve regurgitation [5.0 % vs 4.6 %; OR 1.14. (95 % CI 0.52-2.52, P = 0.75)]. There was a trend towards fewer major vascular complications in TC-TAVR [3.0 % vs 7.8 %; OR 0.42 (95 % CI 0.16-1.12, P = 0.08)].

CONCLUSION

Compared with transthoracic TAVR, TC-TAVR patients had lower odds of 30-day MACE and life-threatening bleeding and no differences in 30-day mortality, stroke or TIA, aortic valve regurgitation.

Procedural success in transaxillary transcatheter aortic valve implantation according to type of transcatheter heart valve: results from the multicenter TAXI registry

BACKGROUND

Transaxillary (TAx) transcatheter aortic valve implantation (TAVI) is a preferred alternative access in patients ineligible for transfemoral TAVI.

AIMS

This study used the Trans-AXillary Intervention (TAXI) registry to compare procedural success according to different types of transcatheter heart valves (THV).

METHODS

For the TAXI registry anonymized data of patients treated with TAx-TAVI were collected from 18 centers. Acute procedural, early and 1-month clinical outcomes were adjudicated in accordance with standardized VARC-3 definitions.

RESULTS

From 432 patients, 368 patients (85.3%, SE group) received self-expanding (SE) THV and 64 patients (14.8%, BE group) received balloon-expandable (BE) THV. Imaging revealed lower axillary artery diameters in the SE group (max/min diameter in mm: 8.4/6.6 vs 9.4/6.8 mm; p < 0.001/p = 0.04) but a higher proportion of axillary tortuosity in BE group (62/368, 23.6% vs 26/64, 42.6%; p = 0.004) with steeper aorta-left ventricle (LV) inflow (55° vs 51°; p = 0.002) and left ventricular outflow tract (LVOT)-LV inflow angles (40.0° vs 24.5°; 0.002). TAx-TAVI was more often conducted by right sided axillary artery in the BE group (33/368, 9.0% vs 17/64, 26.6%; p < 0.001). Device success was higher in the SE group (317/368, 86.1% vs 44/64, 68.8%, p = 0.0015). In logistic regression analysis, BE THV were a risk factor for vascular complications and axillary stent implantation.

CONCLUSIONS

Both, SE and BE THV can be safely used in TAx-TAVI. However, SE THV were more often used and were associated with a higher rate of device success. While SE THV were associated with lower rates of vascular complications, BE THV were more often used in cases with challenging anatomical circumstances.

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.

Outcomes of Alternative Access Transcatheter Aortic Valve Replacement Procedures

Alternative access transcatheter aortic valve replacement (TAVR) consists primarily of 4 different options: transcaval, transaxillary, transcarotid, and transapical. While many centers have a preferred alternative access site, few papers have compared the outcomes of TAVR with each alternative access site. In this review, we examine the outcomes of TAVR at each alternative access site, focusing on mortality, stroke, bleeding, pacemaker insertion, paravalvular leakage, and discharge to home. Notable findings include higher mortality in the transapical group and higher stroke rate in the transaxillary group. On the basis of these data, we suggest that transcarotid TAVR might represent the second choice of approach for TAVR when alternate access is required.

Innovative use of a self-expanding valve for valve-in-valve transcatheter mitral valve replacement: experience from a four-year single-center study

Background

Valve-in-valve transcatheter mitral valve replacement (ViV-TMVR) is a minimally invasive option for patients with bioprosthetic mitral valve failure. Since January 2019, our center has been using a new innovative option, J-Valve, to treat patients with bioprosthetic mitral valve failure who were at high risk for open heart surgery. The aim of this study is to explore the effectiveness and safety of J-Valve and report the results from the four-year follow-up period of the innovative application of the transcatheter valve.

Methods

Patients who underwent the ViV-TMVR procedure between January 2019 and September 2022 in our center were included in the study. J-Valve™ system (JC Medical Inc., Suzhou, China) with three U-shape grippers was used for ViV-TMVR via transapical approach. Data on survival, complications, transthoracic echocardiographic results, New York Heart Association functional class in heart failure, and patient-reported health-related quality of life according to the Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) were collected during the four-year follow up.

Results

Thirty-three patients (mean age 70.1 ± 1.1 years, 13 men) were included and received ViV-TMVR. The surgery success rate was 97%: only one patient was converted to open-heart surgery due to intraoperative valve embolization to the left ventricle. During the first 30 days all-cause mortality was 0%, risk of stroke 2.5% and risk of mild paravalvular leak 15.2%; mitral valve hemodynamics improved (179.7 ± 8.9 at 30 days vs. 269 ± 49 cm/s at baseline, p < 0.0001). Median time from operation to discharge was six days, and there were no readmissions within 30 days from operation. The median and maximum follow-up durations were 28 and 47 months, respectively; during the entire follow-up, all-cause mortality was 6.1%, and the risk of cerebral infarction 6.1%. Cox regression analysis did not identify any variables significantly associated with survival. The New York Heart Association functional class and the KCCQ-12 score improved significantly compared with their preoperative values.

Conclusion

The use of J-Valve for ViV-TMVR is safe and effective with a high success rate, low mortality and very few associated complications, representing an alternative surgical strategy for the elderly, high-risk patients with bioprosthetic mitral valve failure.

Treatment of pure aortic regurgitation using surgical or transcatheter aortic valve replacement between 2018 and 2020 in Germany

Background

In pure aortic regurgitation, transcatheter aortic valve replacement (TAVR) is not yet used on a regular base. Due to constant development of TAVR, it is necessary to analyze current data.

Methods

By use of health records, we analyzed all isolated TAVR or surgical aortic valve replacements (SAVR) for pure aortic regurgitation between 2018 and 2020 in Germany.

Results

4,861 procedures-4,025 SAVR and 836 TAVR-for aortic regurgitation were identified. Patients treated with TAVR were older, showed a higher logistic EuroSCORE, and had more pre-existing diseases. While results indicate a slightly higher unadjusted in-hospital mortality for transapical TAVR (6.00%) vs. SAVR (5.71%), transfemoral TAVR showed better outcomes, with self-expanding compared to balloon-expandable transfemoral TAVR having significantly lower in-hospital mortality (2.41% vs. 5.17%; p = 0.039). After risk adjustment, balloon-expandable as well as self-expanding transfemoral TAVR were associated with a significantly lower mortality vs. SAVR (balloon-expandable: risk adjusted OR = 0.50 [95% CI 0.27; 0.94], p = 0.031; self-expanding: OR = 0.20 [0.10; 0.41], p < 0.001). Furthermore, the observed in-hospital outcomes of stroke, major bleeding, delirium, and mechanical ventilation >48 h were significantly in favor of TAVR. In addition, TAVR showed a significantly shorter length of hospital stay compared to SAVR (transapical: risk adjusted Coefficient = -4.75d [-7.05d; -2.46d], p < 0.001; balloon-expandable: Coefficient = -6.88d [-9.06d; -4.69d], p < 0.001; self-expanding: Coefficient = -7.22 [-8.95; -5.49], p < 0.001).

Conclusions

TAVR is a viable alternative to SAVR in the treatment of pure aortic regurgitation for selected patients, showing overall low in-hospital mortality and complication rates, especially with regard to self-expanding transfemoral TAVR.

Transcatheter Aortic Valve Replacement in Patients With Reduced Ejection Fraction and Nonsevere Aortic Stenosis

BACKGROUND

The potential benefit of transcatheter aortic valve replacement (TAVR) in patients with nonsevere aortic stenosis (AS) and heart failure is controversial. This study aimed to assess outcomes of patients with nonsevere low-gradient AS (LGAS) and reduced left ventricular ejection fraction undergoing TAVR or medical management.

METHODS

Patients undergoing TAVR for LGAS and reduced left ventricular ejection fraction (<50%) were included in a multinational registry. True-severe low-gradient AS (TS-LGAS) and pseudo-severe low-gradient AS (PS-LGAS) were classified according to computed tomography-derived aortic valve calcification thresholds. A medical control group with reduced left ventricular ejection fraction and moderate AS or PS-LGAS was used (Medical-Mod). Adjusted outcomes between all groups were compared. Among patients with nonsevere AS (moderate or PS-LGAS), outcomes after TAVR and medical therapy were compared using propensity score-matching.

RESULTS

A total of 706 LGAS patients undergoing TAVR (TS-LGAS, N=527; PS-LGAS, N=179) and 470 Medical-Mod patients were included. After adjustment, both TAVR groups showed superior survival compared with Medical-Mod patients (all P<0.001), while no difference was found between TS-LGAS and PS-LGAS TAVR patients (P=0.96). After propensity score-matching among patients with nonsevere AS, PS-LGAS TAVR patients showed superior 2-year overall (65.4%) and cardiovascular survival (80.4%) compared with Medical-Mod patients (48.8% and 58.5%, both P≤0.004). In a multivariable analysis including all patients with nonsevere AS, TAVR was an independent predictor of survival (hazard ratio, 0.39 [95% CI, 0.27-0.55]; P<0.0001).

CONCLUSIONS

Among patients with nonsevere AS and reduced left ventricular ejection fraction, TAVR represents a major predictor of superior survival. These results reinforce the need for randomized-controlled trials comparing TAVR versus medical management in heart failure patients with nonsevere AS.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT04914481.

Effect of TAVR Approach and Other Baseline Factors on the Incidence of Acute Kidney Injury: A Systematic Review and Meta-Analysis

Background

Acute kidney injury (AKI) is a well-known complication following a transcatheter aortic valve replacement (TAVR) and is associated with higher morbidity and mortality.

Objective

We aim to compare the risk of developing AKI after transfemoral (TF), transapical (TA), and transaortic (TAo) approaches following TAVR.

Methods

We searched Medline and EMBASE databases from January 2009 to January 2021. We included studies that evaluated the risk of AKI based on different TAVR approaches. After extracting each study's data, we calculated the risk ratio and 95% confidence intervals using RevMan software 5.4. Publication bias was assessed by the forest plot.

Results

Thirty-six (36) studies, consisting of 70,406 patients undergoing TAVR were included. Thirty-five studies compared TF to TA, and only seven investigations compared TF to TAo. AKI was documented in 4,857 out of 50,395 (9.6%) patients that underwent TF TAVR compared to 3,155 out of 19,721 (16%) patients who underwent TA-TAVR, with a risk ratio of 0.49 (95% CI, 0.36–0.66; p < 0.00001). Likewise, 273 patients developed AKI out of the 1,840 patients (14.8%) that underwent TF-TAVR in contrast to 67 patients out of the 421 patients (15.9%) that underwent TAo-TAVR, with a risk ratio of 0.51 (95% CI, 0.27–0.98; p = 0.04). There was no significant risk when we compared TA to TAo approaches, with a risk ratio of 0.89 (95% CI, 0.29–2.75; p = 0.84).

Conclusion

The risk of post-TAVR AKI is significantly lower in patients who underwent TF-TAVR than those who underwent TA-TAVR or TAo-TAVR.

The Role of Transcatheter Aortic Valve Replacement in Asymptomatic Aortic Stenosis: A Feasibility Analysis

Surgical aortic valve replacement (SAVR) is the current treatment of choice for good surgical candidates with moderate to severe symptomatic aortic stenosis (AS). As transcatheter aortic valvular replacement (TAVR) has shown an improved one and two-year all-cause mortality, it has been chosen for moderately symptomatic severe AS patients. The purpose of this review was to perform a clinical comparison of TAVR vs. SAVR and to analyze the Health Index Factor (HIF) that makes TAVR a treatment of choice in asymptomatic AS patients. 

An extensive literature search of PubMed, Cochrane, and Embase databases was performed using the keywords “Aortic stenosis”, “SAVR”, “TAVR”, and “Asymptomatic”. A total of 45 prospective randomized clinical trials in the English language that were published from the year 2000 onwards were included in the final analysis. It has been found that 59.3% of asymptomatic AS patients are likely to die in the next five years without proactive treatment. Multiple studies have proven that early intervention with aortic valve replacement is superior to conservative treatment in severe asymptomatic AS; however, the choice between SAVR and TAVR is not well established. The NOTION Trial, SURTAVI Trail, and PARTNER 3 study have shown the non-inferiority of TAVR over SAVR, during one-year follow-up for low surgical risk patients. Evolut Low-Risk study and Early TAVR are the only two prospective studies performed to date that have enrolled patients with asymptomatic severe AS. The Evolut Trial demonstrated no difference in all-cause mortality at 30 days (1.3% vs. 4.8%. p=0.23), and 12 days (1.3% vs. 6.5%, p=0.11). Additionally, TAVR also decreases the risk of post-procedural atrial fibrillation, acute kidney injury (AKI), and rehospitalization, and leads to significant improvement in the mean trans-aortic pressure gradient. TAVR also showed marked improvement in the 30-day Quality of Life (QOL) index, where SAVR did not report any significant change in the QOL index. However, the official recommendations of Early TAVR are still awaited. TAVR has consistently shown a statistically non-significant difference in case mortality, risk of stroke, and rehospitalization with moderate to high surgical risk patients whereby recent initial trials have shown significant improvement in the QOL index and hemodynamic index for patients with asymptomatic disease. More extensive studies are required to prove the risk stratifications, long-term outcomes, and clinical characteristics that would make TAVR a preferred intervention in asymptomatic patients.

Declining Trend of Transapical Access for Transcatheter Aortic Valve Replacement in Patients with Aortic Stenosis

Introduction

The last decade has witnessed major evolution and shifts in the use of transcatheter aortic valve replacement (TAVR) for severe aortic stenosis (AS). Included among the shifts has been the advent of alternative access sites for TAVR. Consequently, transapical access (TA) has become significantly less common. This study analyzes in detail the trend of TA access for TAVR over the course of 7 years.

Methods

The national inpatient sample database was reviewed from 2011-2017 and patients with AS were identified by using validated ICD 9-CM and ICD 10-CM codes. Patients who underwent TAVR through TA access were classified as TA-TAVR, and any procedure other than TA access was classified as non-TA-TAVR. We compared the yearly trends of TA-TAVR to those of non-TA-TAVR as the primary outcome.

Results

A total of 3,693,231 patients were identified with a diagnosis of AS. 129,821 patients underwent TAVR, of which 10,158 (7.8%) underwent TA-TAVR and 119,663 (92.2%) underwent non-TA-TAVR. After peaking in 2013 at 27.7%, the volume of TA-TAVR declined to 1.92% in 2017 (p < 0.0001). Non-TA-TAVR started in 2013 at 72.2% and consistently increased to 98.1% in 2017. In-patient mortality decreased from a peak of 5.53% in 2014 to 3.18 in 2017 (p=0.6) in the TA-TAVR group and from a peak of 4.51% in 2013 to 1.24% in 2017 (p=0.0001) in the non-TA-TAVR group.

Conclusion

This study highlights a steady decline in TA access for TAVR, higher inpatient mortality, increased length of stay, and higher costs compared to non-TA-TAVR.

Influence of center surgical aortic valve volume on outcomes of transcatheter aortic valve replacement

Objective

Methods

Results

Conclusions

Transapical Transcatheter Aortic Valve Replacement: A Real-World Early and Mid-Term Outcome of a Third-Level Centre

Background: Transapical transcatheter aortic valve replacement (TA-TAVR) is generally considered to be associated with higher morbidity compared with transfemoral-TAVR. However, TA-TAVR remains a feasible alternative for patients who are unsuitable for TF-TAVR. It has been shown that outcomes after TAVR are linked to the operator’s expertise. Therefore, the purpose of this study is to report short- and mid-term outcomes after TA-TAVR performed by an expert Heart-Team of a third-level centre. Methods: From 2015 to 2022, 154 consecutive patients underwent TA-TAVR. The outcomes were analysed according to the VARC-3 criteria. Kaplan–Meier curves were estimated for major clinical events at mid-term follow-up. Results: The mean age of the population was 79.3 years and the STS risk-score of mortality was 4.2 ± 3.6%. Periprocedural mortality was 1.9%. Acute kidney injury and prolonged ventilation occurred in 1.9%. Incidence of stroke was 0.6%. Pacemaker implantation rate was 1.9%. Freedom from cardiovascular mortality was 75.7%, and 60.2% at 3 and 5 years. Freedom from stroke was 92.3% and 88.9% at 3 and 5 years, respectively; freedom from endocarditis was 94.4% and 90.8% at 3 and 5 years, respectively. Conclusion: TA-TAVR may be considered a safe and effective alternative approach in patients unsuitable for TF-TAVR, especially when performed by a proficient Heart-Team.

Combined Coronary CT Angiography and Evaluation of Access Vessels for TAVR Patients in Free-Breathing with Single Contrast Medium Injection Using a 16-cm-Wide Detector CT

RATIONALE AND OBJECTIVES

To investigate the feasibility of combining coronary computed tomography (CT) angiography (CCTA) and CTA to evaluate access vessels for transcatheter aortic valve replacement (TAVR) patients in free-breathing and with single contrast medium injection using a 16-cm-wide detector CT.

MATERIALS AND METHODS

One hundred and twenty-one consecutive patients (73.33 ± 6.43 years) referred for TAVR underwent a serious CT scans in free-breathing after one contrast injection: ECG-triggered one-heartbeat axial CCTA, followed by non-ECG-gated neck, thoracic, and abdominal CTA. Patient weight-dependent contrast dose volume at 1.0 mL/kg was used. CT attenuation values of the coronary, neck, aortic, iliac, and femoral arteries were measured and their image quality was evaluated with a 4-point score method. Stenosis (≥50%) in CCTA was evaluated using invasive coronary angiography result as a reference standard. Radiation and contrast doses were assessed.

RESULTS

The total dose-length-product for the entire examination was 411.4 ± 91.2 mGy.cm, and the total contrast dose was 57.3 ± 9.9 mL. There were adequate attenuations (>400 HU) in all arteries, and the peripheral access vessels and aortic annulus were evaluable in all patients. In neck CTA, 5 patients had vascular tortuosity, 6 patients had aberrant arteries and there were 212 plaques and 13 severe stenoses among the patients. In CCTA, on the per-segment, per-vessel, and per-patient analysis, CCTA showed a sensitivity and negative predictive value of (95% and 99%), (95% and 99%), and (96% and 98%), respectively, for the entire patient cohort, and (92% and 98%), (92% and 98%), and (88% and 93%), respectively, for patients with atrial fibrillation or heart rate higher than 75 beats.

CONCLUSION

It is feasible to perform a combined CCTA and CTA for evaluating access vessels for TAVR patients in free-breathing with single contrast injection. This approach generates acceptable image quality for all vessels and a high negative predictive value in excluding coronary artery disease with relatively low radiation and contrast doses.

Clinical Outcome and Safety of Transcaval Access for Transcatheter Aortic Valve Replacement as Compared to Other Alternative Approaches

Background: A small proportion of patients in need of transcatheter aortic valve replacement (TAVR) are not suitable for the transfemoral approach due to peripheral artery disease. Alternative TAVR approaches are associated with short- and long-term hazards. A novel technique of caval-aortic (transcaval) access for TAVR has been utilized as an alternative access technique.

Aim: To compare safety and efficacy of transcaval access as compared to other alternative access (axillary or apical) for TAVR.

Methods: A single-center, retrospective analysis of consecutive patients undergoing alternative access for TAVR. Events were adjudicated according to VARC-2 criteria.

Results: A total of 185 patients were included in the present analysis. Mean age was 81 years with a small majority for male gender (54%). Of the entire cohort, 20 patients (12%) underwent transcaval TAVR, and 165 patients (82%) underwent TAVR using alternative access. Overall, baseline characteristics were comparable between the two groups. General anesthesia was not utilized in transcaval patients; however, it was routinely used in nearly all alternative access patients. TAVR device success was comparable between the two groups (95%). Acute kidney injury occurred significantly less frequently among transcaval patients as compared to alternative access patients (5 vs. 12%, p = 0.05). Hospital stay was shorter for transcaval patients (6.3 days vs. 14.4; p < 0.001). No difference in early or 30-day mortality (10 vs. 7.9%, p = 0.74) was noted between groups.

Conclusions: In patients who cannot undergo TAVR via the trans-femoral approach due to peripheral vascular disease, transcaval access is a safe approach as compared to other alternative access techniques, with lower risk of kidney injury and shorter hospital stay.

Clinical outcomes following transapical TAVR with ACURATE neo in the CHANGE neo TA study

Background

A transapical (TA) approach to transcatheter aortic valve replacement (TAVR) may be used when a transfemoral (TF) approach is not feasible. The CHANGE neo TA study evaluated patients treated in routine clinical practice via TA-TAVR with the ACURATE neo bioprosthetic aortic valve.

Methods and results

This single-arm post-market study had a planned enrolment of 200 subjects; enrolment was terminated early due to declining TA-TAVR procedures at participating centers. Final enrolment was 107 patients (mean age: 79.3 years; 54.2% female; mean STS score at baseline: 6.2%). The mortality rate in the intent-to-treat population was 11.2% at 30 days (primary endpoint) and 25.6% at 12 months. The VARC-2 composite endpoint for 30-day safety occurred in 24.3% of patients. Six patients (5.6%) received a permanent pacemaker within 30 days. Site-reported echocardiographic data showed early improvements in mean aortic valve gradient (baseline: 38.8 [SD 13.1] mmHg, discharge: 6.7 [SD 3.7] mmHg) and effective orifice area (baseline: 0.7 [SD 0.2] cm², discharge: 1.9 [SD 0.6] cm²), and the discharge rate of paravalvular regurgitation was low (74.7% none/trace, 24.2% mild, 1.1% severe).

Conclusions

TA-TAVR with the ACURATE neo valve system yields acceptable clinical outcomes, providing an alternative for patients with aortic stenosis who are not candidates for TF-TAVR.

Access options for transcatheter mitral valve implantation in patients with prior surgical bioprosthesis

BACKGROUND

Transcatheter mitral valve-in-valve (TMVIV) procedure, either transapical (TA) or trans-septal (TS) has become a valuable alternative to conventional redo surgery in case of failing mitral bioprosthesis with good clinical outcomes. Here we present our fourteen-year institutional experience.

METHODS

All consecutive patients treated with TMVIV with either TA or TS access at our centre between July 2007 and July 2020 were included. Periprocedural and 30-day follow-up (FU) results are reported and TA and TS data are compared.

RESULTS

Eighty-two patients were included, of those 60 (73.2%) were TA while 22 (26.8%) were TS. Men represented 51.2% of the population with a mean age of 77.3±9.0 years. STS score and EuroSCORE II were 11.4%±6.2% and 11.5%±6.5% respectively. Baseline characteristics of TA and TS groups were comparable. TMVIV was performed at a median time of 9.3 years [interquartile range (IQR), 7.9-12.0 days] from the initial mitral valve surgery. Balloon expandable transcatheter heart valve (THV) prostheses (Edwards LifeSciences Corp., Irvine, CA, USA) were used exclusively. Technical success was 97.6% (96.7% and 100.0% for TA and TS respectively) with two (2.4%) periprocedural death, both in the TA group (P=0.533). We observed four (4.9%) left ventricular outflow tract (LVOT) obstructions with one being hemodynamically significant. Six (7.3%) major bleeding occurred in the TA group, not significantly different from TS group (P=0.279). The median length of stay was 6 days (IQR, 4-12 days, 1.5 vs. 7.0 days for TS and TA groups respectively, P=0.001). The overall 30-day mortality rate was 3.7%. We also observed three (3.7%) structural valve deteriorations and in one (1.2%) case the patient required redo mitral surgery at two months. Eighty-seven-point-eight percent of patients were I-II New York Heart Association (NYHA) class. At 30-day FU mean transmitral valve gradient was 7.3±2.7 mmHg and one patient (1.2%) had mitral regurgitation greater than mild. TA and TS groups were comparable.

CONCLUSIONS

Our 14-year single-center experience with TMVIV confirms procedural safety and is an effective alternative to redo surgery with comparable results with both TA and TS. With device, technical improvements and increasing operators' experience, TS is the preferred option for TMVIV. However, in some highly selected patient, TA may still play an important role.

All roads lead to Rome, but some are safer

Since the first in-human implantation, trans-catheter aortic valve replacement (TAVR) has shown an exciting development in both technical and technological terms, becoming the standard of care for many patients, even not only inoperable ones.  Although trans-femoral (TF) access has the scepter of first-line route for TAVR, in some cases, this access is not feasible, so several alternative routes were introduced over time. The network meta-analysis by Hameed et al. has the great merit to provide a comprehensive picture. Hence, through either direct and indirect comparison, the authors confirmed as TF is the gold standard as access, followed by trans-carotid and trans-subclavian. Conversely, trans-thoracic (trans apical and trans-aortic) routes are the least safe and should be reserved only to sporadic cases.

Dose approach matter? A meta-analysis of outcomes following transfemoral versus transapical transcatheter aortic valve replacement

Background

Transcatheter aortic valve replacement (TAVR) has gained increasing acceptance for patients with aortic disease. Both transfemoral (TF-TAVR) and transapical (TA-TAVR) approach were widely adopted while their performances are limited to a few studies with controversial results. This meta-analysis aimed to compare the mortality and morbidity of complications between TF- versus TA-TAVR based on the latest data.

Methods

Electronic databases were searched until April 2021. RCTs and observational studies comparing the outcomes between TF-TAVR versus TA-TAVR patients were included. Heterogeneity assumption was assessed by an I² test. The pooled odds ratios(OR) or mean differences with corresponding 95% confidence intervals (CI) were used to evaluate the difference for each end point using a fixed-effect model or random-effect model based on I² test.

Results

The meta-analysis included 1 RCT and 20 observational studies, enrolling 19,520 patients (TF-TAVR, n = 11,986 and TA-TAVR, n = 7,534). Compared with TA-TAVR, TF-TAVR patients showed significantly lower rate of postoperative in-hospital death (OR = 0.67, 95% CI 0.59–0.77, P < 0.001) and 1-year death (OR = 0.53, 95% CI 0.41–0.69, P < 0.001). Incidence of major bleeding and acute kidney injury were lower and length of hospital stay was shorter, whereas those of permanent pacemaker and major vascular complication were higher in TF-TAVR patients. There were no significant differences between TF-TAVR versus TA-TAVR for stroke and mid-term mortality.

Conclusions

There were fewer early deaths in patients with transfemoral approach, whereas the number of mid-term deaths and stroke was not significantly different between two approaches. TF-TAVR was associated with lower risk of bleeding, acute kidney injury as well as shorter in-hospital stay, but higher incidence of vascular complication and permanent pacemaker implantation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02158-4.

Transapical approach versus transcervical approach for transcatheter aortic valve replacement: a retrospective monocentric study

OBJECTIVES

Transfemoral approach is the standard access-route for transcatheter aortic valve replacement (TAVR). However, alternative approaches are needed in a number of patients and accesses such as transapical (TA) TAVR or transcervical (TC) are used. We aimed to compare clinical and echocardiographic outcomes after TA-TAVR or TC-TAVR.

METHODS

All patients who underwent TA- and TC-TAVR for severe aortic stenosis in our institution between 2008 and 2020 were retrospectively included. End points included 30-day all-cause mortality, procedural complications (according to the Valve Academic Research Consortium-2 criteria), procedure duration, intensive care unit (ICU) length of stay (LOS) and overall hospital LOS. For 30-day all-cause mortality, we furthermore used a Cox proportional-hazards model to adjust for significant between-group differences in baseline characteristics as well as difference in year of intervention.

RESULTS

TAVR was performed in 176 patients, using a TA approach (n = 127) or a TC approach (n = 49). Baseline clinical and echocardiographic characteristics were comparable between the 2 groups, except age and peripheral artery disease. All-cause 30-day mortality rates were not significantly different (8.5% in the TA group vs 2.3% in the TC group, P = 0.124). TC approach was associated with significantly shorter procedure duration {71.0 [interquartile range (IQR) 52.5-101.0] vs 93 [IQR 80.0-120.0] min, P < 0.001}, shorter ICU LOS [0.0 (IQR 0.0-0.0) vs 1.0 (IQR 1.0-3.0) days, P < 0.001] and shorter hospital LOS [7.0 (IQR 5.0-9.5) vs 14.0 (IQR 10.0-22.0) days, P < 0.001].

CONCLUSIONS

The TC approach may be a good first-choice alternative in case of contraindications to transfemoral-TAVR.

Current Devices and Complications Related to Transcatheter Mitral Valve Replacement: The Bumpy Road to the Top

Mitral regurgitation is the most common valvular lesion in the developed world, with increasing prevalence, morbidity, and mortality. The experience with surgical mitral valve repair or replacement is very well-validated. However, more than 45% of these patients get denied surgery due to an elevated risk profile and advanced disease of the left ventricle at the time of presentation, promoting the need for less invasive transcatheter options such as transcatheter repair and transcatheter mitral valve replacement (TMVR). Early available TMVR studies have shown promising results, and several dedicated devices are under clinical evaluation. However, TMVR is still in the early developmental stages and is associated with a non-negligible risk of periprocedural and post-procedural complications. In this review, we discuss the current challenges facing TMVR and the potential TMVR-related complications, offering an overview on the measures implemented to mitigate these complications, and future implications.

A step-by-step guide to transseptal valve-in-valve transcatheter mitral valve replacement

With the recent success of transcatheter aortic valve replacement (TAVR), transcatheter options for the management of mitral valve pathology have also gained considerable attention. Valve-in-valve (ViV) transcatheter mitral valve replacement (TMVR) is one such technique that has emerged as a safe and effective therapeutic option for patients with degenerated mitral valve bioprostheses at high-risk for repeat surgical mitral valve replacement. Several access strategies, including trans-apical, transseptal, trans-jugular, and trans-atrial access have been described for ViV-TMVR. Initial experiences were performed primarily via a trans-apical approach through a left mini-thoracotomy because it offers direct access and coaxial device alignment. With the advancements in TMVR technology, such as the development of smaller delivery catheters with high flexure capabilities, the transseptal approach via the femoral vein has emerged as the preferred option. This technique offers the advantages of a totally percutaneous approach, avoids the need to enter the thoracic cavity or pericardial space, and provides superior outcomes compared to a trans-apical approach. In this review, we outline key aspects of patient selection, imaging, procedural techniques, and examine contemporary clinical outcomes of transseptal ViV-TMVR.

A case report of a transcarotid transcatheter aortic valve implantation with concomitant carotid endarterectomy

BACKGROUND

Transcarotid transcatheter aortic valve implantation (TAVI) is a worthwhile substitute in patients who might otherwise be inoperable; however, it is applied in <10% of TAVI cases. In patients with established carotid artery stenosis, the risk of complications is increased with the transcarotid access route.

CASE SUMMARY

We report a case of concomitant transcarotid TAVI and carotid endarterectomy (CEA) in a patient with bovine aortic arch and previous complex infrarenal EndoVascular Aortic Repair (EVAR). The integrity and positioning of the previous EVAR endograft was risked by transfemoral access. The right subclavian artery was only 4.5 mm and the left subclavian was totally occluded so transcarotid access was chosen. The patient recovered well, with no neurological deficit and was discharged home after 72 h. He was last seen and was doing well 6 months post-procedure.

DISCUSSION

In patients with severe aortoiliac disease, or previous aortic endografting, transfemoral access for TAVI can be challenging or even prohibitive. Alternative access sites such as transapical or transaortic are associated with added risk because they carry increased risk of major adverse cardiovascular events, longer intensive care unit and hospital stay, and increased cost. A transcaval approach for TAVI has also been reported but was not suitable for our patient due to prior EVAR. Concomitant TAVI via transcarotid access and CEA can be successful in experienced hands. This case highlights the importance of a team-based approach to complex TAVI cases in high-risk patients with complex vascular access.

Presence of mitral stenosis is a risk factor of new development of acute decompensated heart failure early after transcatheter aortic valve implantation

AIMS

Acute decompensated heart failure (ADHF) can occur early after transcatheter aortic valve implantation (TAVI), but the risk factors or mechanisms associated with it have not been fully determined. This hypothesis-generating study aimed to investigate the clinical indices associated with the development of ADHF within 72 hours after TAVI and to improve procedural approaches for TAVI.

METHOD AND RESULTS

In this single-centre hypothesis generating prospective observational study, we enrolled 156 consecutive patients with severe aortic stenosis who underwent TAVI between January 2016 and February 2018 at our institution. We set the primary endpoint as the new development of ADHF within 72 hours after TAVI, and clinical indices associated with it were evaluated using a multivariable logistic model. The median age of the patients was 83 (quartile range 80-86) years, 48 (30.8%) were men and the median Society of Thoracic Surgery-Predicted Risk of Mortality was 7.1 (range 5.2-10.4). Mitral stenosis (MS), defined as mean transmitral valve pressure gradient ≥5 mm Hg, was present in 15 (9.6%) patients. After TAVI, the invasive mean transaortic valve pressure gradient (mAVPG) decreased from 48 (36-66) to 7 (5-11) mm Hg, and 12 (7.7%) patients developed ADHF within 72 hours after TAVI. Multivariable logistic regression analysis showed that MS (adjusted OR, 14.227; 95% CI 2.654 to 86.698; p=0.002) and greater decreases in mAVPG (1.038; 1.003 to 1.080; p=0.044) were associated with ADHF.

CONCLUSIONS

MS and drastic improvement of mAVPG were associated with new development of ADHF within 72 hours after TAVI.

Kidney injury as post-interventional complication of TAVI

Transcatheter aortic valve implantation (TAVI) is an accepted treatment approach of aortic stenosis. In the beginning, this technique was executed in high-risk patients only. Today, intermediate-risk patients are also amenable for TAVI, as long as the transfemoral approach is chosen. Numerous predictors have been identified that could lead to periprocedural complications and are defined by patient co-morbidities as well as being inherent to the technical approach. Although vascular complications and postinterventional paravalvular regurgitation have been minimized over the past years by revised technologies and techniques, there is a prevailing individual risk brought about by the specific pathophysiology of the cardiorenal syndrome.

Transcatheter aortic valve implantation in Italy: an uneven growth

Transcatheter aortic valve implantation (TAVI) is the treatment of choice in patients with severe symptomatic aortic stenosis who are not suitable for surgery. The procedure has become the preferred strategy in patients at intermediate/high surgical risk with favourable clinical and anatomical characteristics. The collected scientific evidences, as well as the technologic innovations shaping the newer devices, allowed for a progressive reduction of the procedure-related complications as a well as a simplification of the procedure itself, promoting the gradual expansion of the indication for TAVI with the consequent increase in the estimated number of procedures performed each year. There are significant geographic and socio-economic disparities in the use of TAVI around the world and in Italy as well, reflecting an application of the procedure directly related to the economic prosperity of the Health System of the Country examined. The Italian situation, similar to the worldwide reality, reveals an uneven application of the procedure, signalling a disparity in the socio-economic and organizational capabilities of each single region. Standardization of patient selection for treatment, and of the clinical pathway for TAVI are crucial for an homogeneous integration of this new technology in the current Health Care System.

Transcatheter aortic valve implantation versus surgical aortic valve replacement for treatment of severe aortic stenosis: comparison of results from randomized controlled trials and real-world data

Objective

Results from randomized controlled trials (RCTs) and real-world study (RWS) appear to be discordant. We aimed to investigate whether data derived from RCTs and RWS evaluating long-term all-cause mortality of transcatheter aortic valve implantation (TAVI) versus surgical aortic valve replacement (SAVR) in patients with severe aortic stenosis (AS) were in agreement.

Methods

RCTs or RWS comparing TAVI and SAVR, reporting longterm (≥2-year follow-up) all-cause mortality, were identified. We also carried out subgroup analyses to access the effect in different subgroups. A pre-designated data extraction form including 5 domains and 26 items was used to explore the relationship between RCTs and RWS. Mortality and effect in different subgroups were evaluated using random-effects meta-analyses.

Results

Five RCTs (5421 participants, TAVI: 2759, SAVR: 2662) and 33 RWS (20839 participants; TAVI: 6585, SAVR: 14254) were identified. Pooled RCT analysis showed no difference in all-cause mortality between TAVI and SAVR (HR=0.97, 95% CI: 0.88-1.07; P=0.55). In RWS, TAVI was associated with an increased risk of allcause mortality (HR=1.46, 95% CI: 1.26-1.69; P<0.001) compared to SAVR.

Conclusion

These results highlight the inconsistencies between RCTs and RWS in assessing long-term all-cause mortality in the treatment of AS using TAVI or SAVR, which may be caused by interactions of clinical characteristics or study design. RCTs as well as RWS are both developing and improving; the advantages of one kind of design, measurement and evaluation can and should be thoughtfully referred to the other.

TAVI in Patients with Mitral Annular Calcification and/or Mitral Stenosis

BACKGROUND

 We herein aimed for analysis of influence of mitral annular calcification (MAC) and mitral stenosis (MS) on outcomes in transcatheter aortic valve implantation (TAVI).

METHODS

 Between 11/2009 and 06/2017, 1,058 patients underwent TAVI in the presence of concomitant MAC or MS at our center. Subgroups were built and multivariate logistic regression, COX regression, Kaplan-Meier survival analyses, and receiver operating characteristics method were performed.

RESULTS

 Thirty-day mortality was 7.5% (79/1,058) with highest mortality in patients severe MS (MAC: 3.4% vs. mild MS: 5.9% vs. moderate MS: 15.0% vs. severe MS: 72.7%; p < 0.001). Moderate-to-severe MS (odds ratio [OR]: 7.75, confidence interval [CI]: 3.94-16.26, p < 0.001), impaired left ventricular ejection fraction (OR: 1.38, CI: 1.10-1.72, p < 0.01), and coronary artery disease (OR: 1.36, CI: 1.11-1.67, p < 0.01) were predictive of 30-day survival. Left ventricular systolic/end-diastolic pressure drop of <59.5 mm Hg / <19.5 mm Hg was associated with increased mortality.

CONCLUSIONS

 TAVI in the presence of MAC and mild MS is associated with acceptable acute outcomes but should be considered high-risk procedures in patients with moderate and especially those with severe MS. Our results suggest adverse hemodynamics after TAVI with concomitant MS, which may be caused by underfilling of the left ventricle leading to low-cardiac output.

Minimally Invasive Aortic Valve Replacement with Sutureless Valves: Results From an International Prospective Registry

Objective

To report the early and mid-term results of patients who underwent minimally invasive aortic valve replacement (MI-AVR) with a sutureless prosthesis from an international prospective registry.

Methods

Between March 2011 and September 2018, among 957 patients included in the prospective observational SURE-AVR (Sorin Universal REgistry on Aortic Valve Replacement) registry, 480 patients underwent MI-AVR with self-expandable Perceval aortic bioprosthesis (LivaNova PLC, London, UK) in 29 international institutions through either minithoracotomy ( n = 266) or ministernotomy ( n = 214). Postoperative, follow-up, and echocardiographic outcomes were analyzed for all patients.

Results

Patient age was 76.1 ± 7.1 years; 64.4% were female. Median EuroSCORE I was 7.9% (interquartile range [IQR], 4.8 to 10.9). Median cardiopulmonary bypass and cross-clamp times were 81 minutes (IQR 64 to 100) and 51 minutes (IQR 40 to 63). First successful implantation was achieved in 97.9% of cases. Two in-hospital deaths occurred, 1 for noncardiovascular causes and 1 following a disabling stroke. In the early (≤30 days) period, stroke rate was 1.4%. Three early explants were reported: 2 due to nonstructural valve dysfunction (NSVD) and 1 for malpositioning. One mild and 1 moderate paravalvular leak were reported. In 16 patients (3.3%) pacemaker implantation was needed. Mean follow-up was 2.4 years (maximum = 7 years). During follow-up 5 explants were reported, 3 due to endocarditis and 2 due to NSVD. Follow-up stroke rate was 2.5%. Three structural valve deteriorations not requiring reintervention were reported. Five-year survival was 91.45%.

Conclusions

In this large prospective international registry, MI-AVR with Perceval valve confirmed to be safe, reproducible, and effective in an intermediate-risk population, providing excellent clinical recovery both in early and mid-term follow-up.

Determinants of prolonged hospitalization in patients who underwent trans-femoral transcatheter aortic valve implantation

Introduction

Transcatheter aortic valve implantation (TAVI) has grown to be an alternative treatment for severe symptomatic aortic valve stenosis (AS) in elderly patients. Although TAVI is a less invasive surgery than surgical aortic valve replacement, some patients may require prolonged hospitalization.

Aim

To find the determinants of prolonged hospitalization in patients who underwent trans-femoral TAVI.

Material and methods

A total of 94 AS patients who underwent trans-femoral TAVI were included as the final study population, and divided into the conventional hospitalization group (≤ 21 days) (n = 74) and prolonged hospitalization group (> 21 days) (n = 20). We compared clinical characteristics between the two groups, and multivariate logistic regression analysis was performed to find the determinants of prolonged hospitalization.

Results

In multivariate logistic regression analysis, moderate or severe mitral regurgitation (OR = 4.49, 95% CI: 1.16-17.47, p = 0.03), taking statins or angiotensin converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARB) on admission (statins: OR = 0.13, 95% CI: 0.02-0.71, p = 0.02, ACE inhibitors/ARB: OR = 0.25, 95% CI: 0.06-0.96, p = 0.04), estimated glomerular filtration rate (eGFR) (per 15 ml/min/1.73 m² incremental) (OR = 0.49, 95% CI: 0.26-0.90, p = 0.02) and current chopsticks user (OR = 0.05, 95% CI: 0.01-0.41, p < 0.01) were significantly associated with prolonged hospitalization.

Conclusions

Moderate or severe mitral regurgitation was significantly associated with prolonged hospitalization, while current chopsticks user, eGFR (per 15 ml/min/1.73 m² incremental), taking ACE inhibitors/ARB or statins before the procedure were inversely associated with prolonged hospitalization in patients who underwent trans-femoral TAVI.

Causes and predictors of readmission after transcatheter aortic valve implantation : A meta-analysis and systematic review

BACKGROUND

Since readmission rate is an important clinical index to determine the quality of inpatient care and hospital performance, the aim of this study was to explain the causes and predictors of readmission following transcatheter aortic valve implantation (TAVI) at short-term and mid-term follow-up.

METHODS AND RESULTS

A systematic review and meta-analysis of all published articles from Embase, Pubmed/MEDLINE, and Ovid was carried out. In all, 10 studies including 52,702 patients were identified. The pooled estimate for the overall event rate was 0.15, and cardiovascular causes were the main reason for 30-day readmission (0.42, 95% confidence interval [CI]: 0.39-0.45). In addition, the pooled incidence of 1‑year readmission was 0.31, and cardiovascular events were still the main cause (0.41, 95% CI: 0.33-0.48). Patients with major and life-threatening bleeding, new permanent pacemaker implantation, and clinical heart failure were associated with a high risk for early readmission after TAVI. Moreover, an advanced (≥3) New York Heart Association classification, acute kidney injury, paravalvular leak, mitral regurgitation (≥ moderate), and major bleeding predicted unfavorable outcome to 1‑year readmission. Female gender and transfemoral TAVI was associated with a lower risk for unplanned rehospitalization.

CONCLUSIONS

This meta-analysis found cardiovascular factors to be the main causes for both 30-day and 1‑year rehospitalization. Heart failure represented the most common cardiovascular event at both short-term and mid-term follow-up. Several baseline characteristics and procedure-related factors were deemed unfavorable predictors of readmission. Importantly, transfemoral access and female gender were associated with a lower risk of readmission.

Should All Low-risk Patients Now Be Considered for TAVR? Operative Risk, Clinical, and Anatomic Considerations

PURPOSE OF REVIEW

This article reviews the current data on TAVR in low-risk patients with severe, symptomatic aortic stenosis, highlights the results of the recently published Medtronic Low Risk Randomized Study and PARTNER 3 trials, and describes specific clinical, anatomic, and procedural considerations regarding the optimal treatment choice in this population.

RECENT FINDINGS

In low-risk patients, the Medtronic Low Risk Randomized Study demonstrated TAVR to be non-inferior to surgery with respect to the composite endpoint of death or disabling stroke while PARTNER 3 trial proved TAVR to be superior to surgery with regard to the composite endpoint of death, stroke, or rehospitalization. Recent trials demonstrate the safety and efficacy of TAVR in low-risk patients and have led to an FDA indication for the use of TAVR in these patients. However, the lack of long-term data on the rate of transcatheter valve deterioration in the younger population, higher incidence of paravalvular leak and pacemaker implantation following TAVR, along with certain intrinsic anatomic factors remain potential challenges to generalize TAVR in all low surgical risk patients. We describe specific clinical, anatomic, and procedural considerations regarding the optimal treatment choice for low-risk patients with severe, symptomatic AS.

Appetite Predicts Clinical Outcomes in High Risk Patients Undergoing Trans-Femoral TAVI

Transcatheter aortic valve implantation (TAVI) has been recognized as a standard therapy for severe aortic valve stenosis. However, since some patients who receive TAVI have poor outcomes, the predictors of clinical outcomes after TAVI are important. The aim of this study was to investigate the association between appetite and long-term clinical outcomes.We screened consecutive cases who received TAVI at our medical center between July 2014 and October 2018. A total of 139 patients who received transfemoral TAVI were included as the final study population. They were divided into a good appetite group (n = 105) and a less appetite group (n = 34) according to their dietary intake rate (> 90%: good appetite group, ≤ 90%: less appetite group). We defined the intake rate as the average for breakfast, lunch, and dinner on the day just before discharge. We defined two-year major adverse cardiovascular and cerebrovascular events (MACCE) as a composite of cardiovascular death, myocardial infarction, any coronary revascularization, history of hospitalization due to heart failure, and disabling acute cerebral infarction. Kaplan-Meier analyses and multivariate Cox regression analysis were performed.The median duration of the follow-up period was 372 (189-720) days. Kaplan-Meier curves showed that the less appetite group got MACCE more frequently (event free rate of the less appetite group: 76.5% versus the good appetite group: 94.3%, Log Rank P = 0.01). In multivariate Cox regression analysis, having less appetite was a significant predictor of two-year MACCE (HR 5.26, 95%CI 1.66-16.71, P < 0.01).In conclusion, among the patients who received transfemoral TAVI, appetite status just before discharge was significantly associated with long-term outcome.

Transcatheter aortic valve replacement with a focus on transcarotid: a review of the current literature

Valve replacement in high-risk patients with severe aortic stenosis has undergone a huge paradigm shift in the recent years in terms of procedural details and vascular access site for patients who have poor peripheral access. Carotid artery is one of the more promising access sites which has been proven to provide a good alternative site with comparable outcomes to transfemoral approach. In this manuscript, we will provide a review of the current literature on transaortic, transapical, transaxillary and transcarotid approaches to transcatheter aortic valve replacement (TAVR) while focusing on the transcarotid approach.

Early Experience With Transcatheter Mitral Valve Replacement: A Systematic Review

Background

Transcatheter mitral valve replacement (TMVR) has emerged as an alternative therapeutic option for the treatment of severe mitral regurgitation in patients with prohibitive or high surgical risk. The aim of this systematic review is to evaluate the clinical procedural characteristics and outcomes associated with the early TMVR experience.

Methods and Results

Published studies and international conference presentations reporting data on TMVR systems were identified. Only records including clinical characteristics, procedural results, and 30‐day and midterm outcomes were analyzed. A total of 16 publications describing 308 patients were analyzed. Most patients (65.9%) were men, with a mean age of 75 years (range: 69–81 years) and Society for Thoracic Surgery Predicted Risk of Mortality score of 7.7% (range: 6.1–8.6%). The etiology of mitral regurgitation was predominantly secondary or mixed (87.1%), and 81.5% of the patients were in New York Heart Association class III or IV. A transapical approach was used in 81.5% of patients, and overall technical success was high (91.7%). Postprocedural mean transmitral gradient was 3.5 mm Hg (range: 3–5.5 mm Hg), and only 4 cases (1.5%) presented residual moderate to severe mitral regurgitation. Procedural and all‐cause 30‐day mortality were 4.6% and 13.6%, respectively. Left ventricular outflow obstruction and conversion to open heart surgery were reported in 0.3% and 4% of patients, respectively. All‐cause and cardiovascular‐related mortality rates were 27.6% and 23.3%, respectively, after a mean follow‐up of 10 (range: 3 to 24) months.

Conclusions

TMVR was a feasible, less invasive alternative for treating severe mitral regurgitation in patients with high or prohibitive surgical risk. TMVR was associated with a high rate of successful valve implantation and excellent hemodynamic results. However, periprocedural complications and all‐cause mortality were relatively high.

Influence of preoperative serum creatinine level and intraoperative volume of contrast medium on the risk of acute kidney injury after transfemoral transcatheter aortic valve implantation: a retrospective observational study

Objective

This study aimed to determine if contrast medium volume (CMV) is a risk factor for acute kidney injury (AKI) during transcatheter aortic valve implantation (TAVI) via a transfemoral approach performed without major complications. All TAVI procedures performed at our institution between March 2014 and March 2018 were retrospectively reviewed. AKI was diagnosed using the Acute Kidney Injury Network classification based on the Valve Academic Research Consortium-2 definition. Procedures performed via a transapical approach and those in which circulatory dynamics failed intraoperatively were excluded.

Results

Eighty-one (96.4%) of 100 patients scheduled for TAVI were enrolled; seven (8.6%) developed AKI and 74 (91.4%) did not. The serum creatinine (SCr) level was significantly higher (p < 0.05) and the estimated glomerular filtration rate was significantly lower in the AKI group (p < 0.05). The CMV was significantly higher in the AKI group (103 ml vs 84 ml, p < 0.05), as was the CMV × SCr/BW value (3.34 vs 1.49, p < 0.01). The area under the curve for CMV × SCr/BW was 0.9228 and the cut-off value was 2.99. The CMV, SCr, and estimated glomerular filtration rate affect the likelihood of AKI after transfemoral TAVI and a CMV × SCr/BW value > 2.99 accurately predicts AKI.

Electronic supplementary material

The online version of this article (10.1186/s13104-019-4527-2) contains supplementary material, which is available to authorized users.

Association Between Hospital Volume and 30-Day Readmissions Following Transcatheter Aortic Valve Replacement

Importance

With the approval of transcatheter aortic valve replacement (TAVR) for patients with severe symptomatic aortic stenosis at intermediate surgical risk, TAVR volume is projected to increase exponentially in the United States. The 30-day readmission rate for TAVR was recently reported at 17.9%. The association between institutional TAVR volume and the 30-day readmission metric has not been examined.

Objective

To assess the association between hospital TAVR volume and 30-day readmission.

Design, Setting, and Participants

In this observational study, we used the 2014 Nationwide Readmissions Database to identify hospitals with established TAVR programs (performing at least 5 TAVRs in the first quarter of 2014). Based on annual TAVR volume, hospitals were classified as low (<50), medium (≥50 to <100), and high (≥100) volume. Rates, causes, and costs of 30-day readmissions were compared between low-, medium-, and high-volume hospitals. Data were analyzed from November to December 2016.

Exposure

Transcatheter aortic valve replacement.

Main Outcomes and Measures

Thirty-day readmissions.

Results

Of 129 hospitals included in this study, 20 (15.5%) were categorized as low volume, 47 (36.4%) as medium volume, and 62 (48.1%) as high volume. Of 16 252 index TAVR procedures, 663 (4.1%), 3067 (18.9%), and 12 522 (77.0%) were performed at low-, medium-, and high-volume hospitals, respectively. Thirty-day readmission rates were significantly lower in high-volume compared with medium-volume (adjusted odds ratio, 0.76; 95% CI, 0.68-0.85; P < .001) and low-volume (adjusted odds ratio, 0.75; 95% CI, 0.60-0.92; P = .007) hospitals. Noncardiac readmissions were more common in low-volume hospitals (65.6% vs 60.6% in high-volume hospitals), whereas cardiac readmissions were more common in high-volume hospitals (39.4% vs 34.4% in low-volume hospitals). There were no significant differences in length of stay and costs per readmission among the 3 groups (mean [SD], 5.5 [5.0] days vs 5.9 [7.5] days vs 6.0 [5.8] days; P = .74, and $13 886 [18 333] vs $14 135 [17 939] vs $13 432 [15 725]; P = .63, respectively).

Conclusions and Relevance

We report for the first time, to our knowledge, an inverse association between hospital TAVR volume and 30-day readmissions. Lower readmission at higher-volume hospitals was associated with significantly lower cost to the health care system.

Heart valve disease in elderly

The incidence of heart valve disease increases significantly with age. Degenerative abnormalities associated with severe aortic stenosis and mitral and tricuspid regurgitation are found in not less than 10% of the population aged ≥ 75 years. Surgical treatment has been considered for years to be the treatment of choice. However, it was not uncommonly associated with high perioperative morbidity and mortality due to frequent comorbidities and overall frailty conditions of these patients. Conventional risk scores such as Society of Thoracic Surgeons and European System for Cardiac Operative Risk Evaluation may underestimate the risk of surgery in elderly patients, leading to inappropriate surgical indication. On the other hand, at least 30% of patients with severe conditions are left untreated due to prohibitive surgical risk. Interventional procedures, which are in continuous development, may be actually considered for high risk patients and, as recent results suggest, also for intermediate risk patients.

Transcatheter aortic valve replacement for pure aortic valve regurgitation: "on-label" versus "off-label" use of TAVR devices

INTRODUCTION

Transcatheter aortic valve replacement (TAVR) has become the mainstay of treatment for aortic stenosis in patients with high surgical risk. Pure aortic regurgitation (PAR) is considered a relative contraindication for TAVR; however, TAVR is increasingly performed in PAR patients with unfavorable risk profile. Herein, we aim to summarize available data on TAVR for PAR with special emphasis on "on-label" versus "off-label" TAVR devices.

METHODS AND RESULTS

Pubmed was searched for studies of patients undergoing TAVR for PAR. Primary outcome was 30 day-mortality. Pooled estimated event rates were calculated. Twelve studies including a total of 640 patients were identified until December 2017. Among these, 208 (33%) patients were treated with devices with CE-mark approval for PAR ("on-label"; JenaValve and J valve). Overall, the procedural success rate was 89.9% (95% CI 81.1-96.1%; I² 80%). Major bleeding was reported in 6.4% (95% CI 2.9-10.8%; I² 48%). All-cause mortality at 30 days was 10.4% (95% CI 7.1-14.2%; I² 20%). Stroke occurred in 2.2% (95% CI 0.9-3.9%; I² 0%). A permanent pacemaker was required in 10.7% (95% CI 7.3-14.6%; I² 23%). At 30 days after TAVR, ≥ moderate AR post-interventional was observed in 11.5% (95% CI 2.9-23.6%; I² 90%). In the "on-label"-group, success rate was 93.0% (95% CI 85.9-98.1%; I² 52%). 30-day-mortality was 9.1% (95% CI 3.7-16.0%; I² 36%). More than trace AR was present in 2.8% (95% CI 0.1-7.6%; I² 0%). Compared to first-generation devices, second-generation devices were associated with significantly lower 30-day-mortality (r = - 0.10; p = 0.02), and significantly higher procedural success rates (r = 0.28; p < 0.001). Compared to other second-generation devices, the use of J valve or JenaValve was not associated with altered mortality (r = 0.04; p = 0.50), rates of > trace residual AR (r = - 0.05; p = 0.65) but with a significantly higher procedural success (r = 0.15; p = 0.042).

CONCLUSION

Based on this summary of available observational data TAVR for PAR is feasible and safe in patients deemed inoperable. First-generation TAVR devices are associated with inferior outcome and should be avoided. The "on-label" use of PAR-certified TAVR devices is associated with a significantly higher procedural success rate and might be favorable compared to other second-generation devices.

Outcomes following transcatheter transseptal versus transapical mitral valve-in-valve and valve-in-ring procedures

Introduction: Transcatheter mitral valve-in-valve (ViV) & valve-in-ring (ViR) are relatively novel therapeutic alternatives for patients with degenerated bioprostheses or failed annuloplasty rings whose reoperative risk is too high. The predominant procedural access for both procedures is transapical or transseptal. However, whether there are differences in outcomes of this procedure using transseptal versus transapical access has not yet been defined. Methods: We conducted a systematic review of all published articles from MEDLINE and EMBASE to explore the outcomes of these two procedural approaches. Results:total of 55 studies including 183 patients (154 ViV and 29 ViR) were included. Patients that underwent ViV (101 transapical and 53 transseptal) using the transseptal approach required more iatrogenic atrial septal defect (ASD) closure (19% versus 0.0 %; P < 0.001) and hence had a lower device success rate (68% versus 89%; P = 0.001). However, there was no significant difference between the two groups in procedural success and all-cause mortality at 30 days. Overall severe bleeding complications (major or life threatening) were not different the two groups (3.7% versus 7.9%; P = 0.321). In the ViR group (19 transapical and 10 transseptal), no difference in procedural success, device success or 30-day outcomes were identified between transseptal and transapical groups, although sample size was small. Conclusion: In conclusion, mitral ViV and ViR using the two different procedural approaches appear to confer equal and reasonable 30-day outcomes.