Transcatheter aortic valve implantation: review of the nature, management, and avoidance of procedural complications

Valve-in-Valve Transcatheter Aortic Valve Replacement Versus Redo-Surgical Aortic Valve Replacement in Patients With Aortic Stenosis: A Systematic Review and Meta-analysis

Aortic stenosis is a common and significant valve condition requiring bioprosthetic heart valves with transcatheter aortic valve replacement (TAVR) being strongly recommended for high-risk patients or patients over 75 years. This meta-analysis aimed to pool existing data on postprocedural clinical as well as echocardiographic outcomes comparing valve-in-valve (ViV)-TAVR to redo-surgical aortic valve replacement to assess the short-term and medium-term outcomes for both treatment methods. A systematic literature search on Cochrane Central, Scopus, and Medline (PubMed interface) electronic databases from inception to August 2023. We used odds ratios (OR) for dichotomous outcomes and mean differences (MD) for continuous outcomes. Twenty-four studies (25,216 patients) were pooled with a mean follow-up of 16.4 months. The analysis revealed that ViV-TAVR group showed a significant reduction in 30-day mortality (OR 0.50, 95% confidence interval [CI] 0.43 to 0.58, p <0.00001), new-onset atrial fibrillation (OR 0.34, 95% CI 0.17 to 0.67, p = 0.002), major bleeding event (OR 0.28, 95% CI 0.17 to 0.45, p <0.00001) and lower rate of device success (OR 0.25, 95% CI 0.12 to 0.53, p = 0.0003). There were no significant differences between either group when assessing 1-year mortality, stroke, myocardial infarction, postoperative left ventricular ejection fraction, and effective orifice area. ViV-TAVR cohort showed a significantly increased incidence of paravalvular leaks, aortic regurgitation, and increased mean aortic valve gradient. ViV-TAVR is a viable short-term option for older patients with high co-morbidities and operative risks, reducing perioperative complications and improving 30-day mortality with no significant cardiovascular adverse events. However, both treatment methods present similar results on short-term to medium-term complications assessment.

Coronary Risk in Transcatheter Aortic Valve Replacement, Overview of Data, Challenges, and Best Practices

Coronary artery obstruction is a rare complication of transcatheter aortic valve replacement (TAVR). This risk increases in TAVR-valve-in-valve procedure. Several anatomic risk factors were described in many studies to identify the predictive elements of coronary artery occlusion on computed tomography cardiac scan. Rescue percutaneous coronary intervention was the first approach described to treat this complication with a high mortality rate. Later on, preventive chimney stenting technique was evaluated and results showed that is a safe and effective strategy but it leads to a difficult coronary access later. New preventive techniques are being evaluated recently (Basilica and Shorctut).

Acute Mitral Valve Regurgitation Caused by Left Ventricular Pacing Wire During Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement is quickly becoming the standard of care for patients with severe aortic stenosis thanks to its minimally invasive nature and favorable outcomes. Recently, left ventricular pacing has been proposed as a safer alternative to traditional right heart pacing, which could simplify the transcatheter aortic valve replacement procedure overall, although procedural complications may still occur. This report describes a rare case of left ventricular pacing wire-induced acute severe mitral valve regurgitation during transcatheter aortic valve replacement.

Three-step surgical management algorithm for annular rupture in transcatheter aortic valve replacement

Objective

Whereas transcatheter aortic valve replacement is widely implemented, annular rupture is a devastating complication and could be highly mortal. However, owing to its rare incidence, the optimal treatment algorithm has not been established. Thus, we evaluated the feasibility and effectiveness of a 3-step algorithm to treat annulus rupture.

Methods

From 2009 to 2022, 8 patients of 1083 transcatheter aortic valve implantation (0.8%) developed annulus rupture and were treated with the three-step algorithm. The algorithm was composed of a first step (pericardial drainage and protamine neutralization with blood pressure control), second step (manual hemostatic compression via full/partial sternotomy), and a third step (conservative treatment or radical surgical correction).

Results

The median age at the procedure was 85 (78-88) years and 7 female patients were included in this study. Two (25%) patients had end-stage renal failure under hemodialysis, and median Society of Thoracic Surgeons score was 8.9% (2.1%-23.2%). The implanted transcatheter heart valves (THVs) were 7 balloon-expandable THVs and 1 self-expandable THV with balloon postdilatation. Under this strategy, 8 (100%) patients underwent pericardial drainage as first step and 5 patients achieved hemostasis. Of these, patient 1 demonstrated bleeding from left sinus of Valsalva and required a Bentall procedure. Although the etiology of this phenomenon was not investigated by contrast-enhanced computed tomography, it might be derived from pseudoaneurysm rupture or delayed annular rupture. In 2 patients, the second step treatment was needed for hemostasis. Third-step treatment was conducted in 1 patient. Postoperatively, 6 patients could be discharged without critical complications whereas 2 patients died during the hospitalization. There were no other complications during the followed-up (584 [7-1614]) days.

Conclusions

In accordance with the three-step algorithm, 6 patients, including those with high-risk or inoperative status, survived.

General Anesthesia Versus Local Anesthesia in Patients Undergoing Transcatheter Aortic Valve Replacement: An Updated Meta-Analysis and Systematic Review

OBJECTIVES

For patients with aortic stenosis, transcatheter aortic valve replacement (TAVR) offers a less invasive treatment modality than conventional surgical valve replacement. Although the surgery is performed traditionally under general anesthesia (GA), recent studies have described success with TAVR using local anesthesia (LA) and/or conscious sedation. The study authors performed a pairwise meta-analysis to compare the clinical outcomes of TAVR based on operative anesthesia management.

DESIGN

A random effects pairwise meta-analysis via the Mantel-Haenszel method.

SETTING

Not applicable, as this is a meta-analysis.

PARTICIPANTS

No individual patient data were used.

INTERVENTIONS

Not applicable, as this is a meta-analysis.

MEASUREMENTS AND MAIN RESULTS

The authors comprehensively searched the PubMed, Embase, and Cochrane databases to identify studies comparing TAVR performed using LA or GA. Outcomes were pooled as risk ratios (RR) or standard mean differences (SMD) and their 95% CIs. The authors' pooled analysis included 14,388 patients from 40 studies (7,754 LA; 6,634 GA). Compared to GA TAVR, LA TAVR was associated with significantly lower rates of 30-day mortality (RR 0.69; p < 0.01) and stroke (RR 0.78; p = 0.02). Additionally, LA TAVR patients had lower rates of 30-day major and/or life-threatening bleeding (RR 0.64; p = 0.01), 30-day major vascular complications (RR 0.76; p = 0.02), and long-term mortality (RR 0.75; p = 0.009). No significant difference was seen between the 2 groups for a 30-day paravalvular leak (RR 0.88, p = 0.12).

CONCLUSIONS

Transcatheter aortic valve replacement performed using LA is associated with lower rates of adverse clinical outcomes, including 30-day mortality and stroke. No difference was seen between the 2 groups for a 30-day paravalvular leak. These results support the use of minimally invasive forms of TAVR without GA.

The Prognostic Significance of Uric Acid/Albumin Ratio in Patients with Aortic Stenosis Following Transcatheter Aortic Valve Implantation for Major Adverse Cardiac and Cerebral Events

Background: The goal of this study was to examine if the uric acid/albumin ratio (UAR) could predict major adverse cardiac and cerebral events (MACCEs) such as stroke, readmission, and short-term all-cause death in aortic stenosis (AS) patients, after transcatheter aortic valve implantation (TAVI). Material and Methods: A total of 150 patients who had TAVI for AS between 2013 and 2022 were included in our study, retrospectively. Before the TAVI, each patient’s baseline uric acid/albumin was determined. The study’s major endpoint was MACCEs, which included stroke, re-hospitalization, and 12-month all-cause death. Results: The UAR was found to be higher in TAVI patients who developed MACCEs than in those who did not develop them. Multivariate Cox regression analysis revealed that the UAR (HR: 95% CI; 2.478 (1.779–3.453) p < 0.01), was an independent predictor of MACCEs in AS patients after TAVI. The optimal value of the UAR for MACCEs in AS patients following TAVI was >1.68 with 88% sensitivity and 66% specificity (AUC (the area under the curve): 0.899, p < 0.01). We noted that the AUC of UAR in predicting MACCEs was significantly higher than the AUC of albumin (AUC: 0.823) and uric acid (AUC: 0.805, respectively). Conclusion: MACCEs in AS patients who received TAVI may be predicted by high pre-procedural uric acid/albumin levels. The uric acid/albumin ratio (UAR) can be used to determine MACCEs in such patients following TAVI because it is inexpensive and straightforward to calculate inflammatory parameters.

Valve-Related Complications in TAVI Leading to Emergent Cardiac Surgery

Transcatheter aortic valve implantation (TAVI) is now a standard procedure for the treatment of symptomatic aortic valve stenosis in many patients. In Germany, according to the annual reports from the German Institute for Quality Assurance and Transparency in Healthcare (Institut für Qualitätssicherung und Transparenz im Gesundheitswesen), the rate of serious intraprocedural complications, such as valve malpositioning or embolization, coronary obstruction, aortic dissection, annular rupture, pericardial tamponade, or severe aortic regurgitation requiring emergency cardiac surgery has decreased markedly in recent years from more than 5.5% in 2012 to 2.0% in 2019. However, with increased use, the total number of adverse events remains about 500 per year, about 100 of which require conversion to sternotomy. These, sometimes, fatal events can occur at any time and are still challenging. Therefore, the interdisciplinary TAVI heart team should be prepared and aware of possible rescue strategies.

How accurate are manufacturers' recommendations in determining ineligibility for transfemoral transcatheter aortic valve implantation?

INTRODUCTION

Up to one-third of patients indicated for transcatheter aortic valve implantation (TAVI) may be unsuitable for transfemoral TAVI (TF-TAVI) according to manufacturers' recommendations and numerous professional societies.

OBJECTIVE

This study aimed to investigate the predictive value of manufacturers' guidelines for major vascular access site complications using the Perclose ProGlide device.

METHODS

Among 208 patients undergoing TF-TAVI, 144 patients (69.2%) were deemed eligible for TF-TAVI according to the manufacturer's instructions. A minimal lumen diameter (MLD) of the femoral artery below the manufacturer's specified limits and/or the presence of circumferential calcification were the reasons for ineligibility. Calcium score (CS), sheath-to-femoral artery ratio (SFAR) and MLD were estimated from computed tomography imaging. Vascular complications (VCs) (defined according to VARC-2 criteria) were retrospectively compared.

RESULTS

Patients in the ineligible group had higher SFAR (1.13±0.15 vs. 0.88±0.107, p<0.001) and CS (1.66±0.99 vs. 1.24±0.73; p=0.003), and significantly lower MLD (7.72±1.03 vs. 6.31±0.96 mm; p<0.001) compared to the eligible group. Major (6.3% vs. 12.3%, p=0.13) and minor VCs (10.4% vs. 15.6%, p=0.29) were similar in the eligible and ineligible groups. The ineligible group had higher rates of rupture (0.7% vs. 6.3%; p=0.03). SFAR was the only independent predictor of major VCs (OR 469.1, 95% CI 4.95-44466.57, p=0.008).

CONCLUSION

The TAVI team should not decide whether the patient is suitable for a femoral approach based solely on the manufacturer's criteria, and should incorporate additional factors that could be predictive of major VCs.

Vascular management during transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR), as an alternative to open heart surgery, has been established as the standard therapy for patients with severe aortic valve stenosis. Vascular access management, the first step in a TAVR procedure, should be managed properly. Moreover, the transfemoral and alternatives such as the transaxillary/subclavian, transcarotid, transapical, and transcaval approaches are considered access routes during TAVR. More than 90% of cases can be treated via the transfemoral approach in the current TAVR era, whereas other approaches should be considered in patients in whom the transfemoral approach is not suitable. Vascular complications regardless of access route differences are a specific issue of TAVR caused by the use of large sheaths. With the increased number of TAVR cases, we must manage vascular complications and decrease the morbidity and mortality rates associated with TAVR procedures. Thus, this study aimed to review the vascular complications during TAVR and summarize their prognosis, prevention, and adequate management.

The role of stress echocardiography in transcatheter aortic valve implantation and transcatheter edge-to-edge repair era: A systematic review

OBJECTIVES

In the last decade, percutaneous treatment of valve disease has changed the approach toward the treatment of aortic stenosis (AS) and mitral regurgitation (MR). The clinical usefulness of stress echocardiography (SE) in the candidates for transcatheter aortic valve implantation (TAVI) and transcatheter edge-to-edge repair (TEER) of MR remains to be established. Therefore, the key aim of this review is to assess the main applications of SE in patients undergoing TAVI or TEER.

METHODS

We searched for relevant studies to be included in the systematic review on PubMed (Medline), Cochrane library, Google Scholar, and Biomed Central databases. The literature search was conducted in February 2022. The inclusion criteria of the studies were: observational and clinical trials or meta-analysis involving patients with AS or MR evaluated with SE (excluding those in which SE was used only for screening of pseudo-severe stenosis) and treated with percutaneous procedures.

RESULTS

Thirteen studies published between 2013 and 2021 were included in the review: five regarding candidates for TEER and eight for TAVI. In TEER candidates, seeing an increase in MR grade, and stroke volume of >40% during SE performed before treatment was, respectively, related to clinical benefits (p = 0.008) and an increased quality of life. Moreover, overall, 25% of patients with moderate secondary MR at rest before TEER had the worsening of MR during SE. At the same time, in SE performed after TEER, an increase in mean transvalvular diastolic gradient and in systolic pulmonary pressure is expected, but without sign and symptoms of heart failure. Regarding TAVI, several studies showed that contractile reserve (CR) is not predictive of post-TAVI ejection fraction recovery and mortality in low-flow low-gradient AS either at 30 days or at long-term.

CONCLUSION

This systematic review shows in TEER candidates, SE has proved useful in the optimization of patient selection and treatment response, while its role in TAVI candidates is less defined. Therefore, larger trials are needed to test and confirm the utility of SE in candidates for percutaneous procedures of valve diseases.

Dos and don'ts in large animal models of aortic insufficiency

Aortic insufficiency caused by paravalvular leakage (PVL) is one of the most feared complications following transcatheter aortic valve replacement (TAVI) in patients. Domestic pigs (Sus scrofa domestica) are a popular large animal model to study such conditions and develop novel diagnostic and therapeutic techniques. However, the models based on prosthetic valve implantation are time intensive, costly, and often hamper further hemodynamic measurements such as PV loop and 4D MRI flow by causing implantation-related wall motion abnormalities and degradation of MR image quality. This study describes in detail, the establishment of a minimally invasive porcine model suitable to study the effects of mild-to-moderate “paravalvular“ aortic regurgitation on left ventricular (LV) performance and blood flow patterns, particularly under the influence of altered afterload, preload, inotropic state, and heart rate. Six domestic pigs (Swiss large white, female, 60–70 kg of body weight) were used to establish this model. The defects on the hinge point of aortic leaflets and annulus were created percutaneously by the pierce-and-dilate technique either in the right coronary cusp (RCC) or in the non-coronary cusp (NCC). The hemodynamic changes as well as LV performance were recorded by PV loop measurements, while blood flow patterns were assessed by 4D MRI. LV performance was additionally challenged by pharmaceutically altering cardiac inotropy, chronotropy, and afterload. The presented work aims to elaborate the dos and don'ts in porcine models of aortic insufficiency and intends to steepen the learning curve for researchers planning to use this or similar models by giving valuable insights ranging from animal selection to vascular access choices, placement of PV Loop catheter, improvement of PV loop data acquisition and post-processing and finally the induction of paravalvular regurgitation of the aortic valve by a standardized and reproducible balloon induced defect in a precisely targeted region of the aortic valve.

Perioperative left ventricular perforation in incomplete TAVI and completion of the procedure after surgical repair

BACKGROUND

The use of transcatheter aortic valve implantation (TAVI) continues to grow worldwide. Despite increased operator experience, evolution of the technique, and deflectable catheters, major complications still occur in ≤ 6% up to 8% of cases. Such major complications have been associated with a 2- to threefold increase in 30-day mortality. Complications specifically involving the aorta, aortic valve annulus, or left ventricle are rare, occurring in only 0.2-1.1% of cases.

CASE PRESENTATION

We report the case of a 65-year-old female patient with left ventricular lateral wall perforation during incomplete implantation of a TAVI device, and successive percutaneous completion after surgical repair of the lesion under cardiopulmonary bypass. The surgical strategy and the type of surgical treatment depend on the type of perforation. In general, repair of the lesion and aortic valve replacement are performed. Removal of the TAVI prosthesis and excision of the native aortic valve are standard parts of this repair.

CONCLUSION

Here we propose a safe alternative for the completion of the TAVI approach after surgical repair, which requires close coordination between the members of the heart team (anesthesiologist, perfusionist, cardiologist, nurse and cardiac surgeon).

Left Main Protection During Transcatheter Aortic Valve Replacement With a Balloon-Expandable Valve

Background

Coronary obstruction during transcatheter aortic valve replacement (TAVR) is a rare, yet life-threatening, complication. The routine use of left main (LM) protection with or without stent placement in high-risk patients remains controversial. The aim of this study was to evaluate the outcomes of LM protection during TAVR and identify anatomic factors associated with need for stent placement.

Methods

We retrospectively reviewed all TAVR cases (native and valve-in-valve) performed in our institution between 2014 and 2019 and identified patients who underwent LM protection with a coronary wire, balloon, and/or stent during the procedure. We compared the pre-TAVR computed tomography aortic root characteristics, procedural data, short-, and long-term outcomes among the patients who eventually received an LM stent and those who did not.

Results

Among 1925 TAVR patients, 41 (2.1%) underwent LM protection, and 10 of them (25%) had eventually a stent placed in the LM for threatened obstruction after valve deployment. In the native TAVR group (n = 35), 8 patients underwent LM stenting. A larger TAVR prosthesis, larger annular circumference (83.8 vs 76.1 ​mm; P = .038), lower ratio of sinotubular junction diameter to prosthesis size (1.02 vs 1.11; P = .032), and longer left coronary cusp (15.1 vs 13.9 ​mm; P = .18) were associated with higher incidence of LM stenting. In the valve-in-valve TAVR group (n = 6), 5 patients had a valve-to-coronary distance of less than 4 ​mm, and 2 of them received an LM stent. Both stent and nonstent groups had excellent outcomes with no major adverse cardiovascular events or coronary obstruction at 30 ​days. After a median follow-up of 351 ​days, 4 patients died (9.7%) (1 in the stent and 3 in the nonstent group), without any cases of late coronary obstruction or percutaneous coronary intervention in either group.

Conclusions

LM protection with a coronary guidewire, balloon, or stent is a safe and effective method of coronary protection during TAVR in appropriately selected high-risk patients. Annular circumference, prosthesis size, left coronary cusp length, LM ostial height, and ratio of sinotubular junction to prosthesis size are important predictors of stent deployment.

Assessment of Coronary Artery Obstruction Risk During Transcatheter Aortic Valve Replacement Utilising 3D-Printing

BACKGROUND

Current imaging techniques may inadequately rule out coronary artery obstruction (CAO), a potentially fatal complication during transcatheter aortic valve replacement (TAVR). Advancements in three-dimensional (3D)-printing allow the development of models capable of replicating cardiac anatomy and predicting CAO. We sought to simulate TAVR utilising 3D-printed cardiac models to improve CAO risk assessment and procedural safety.

METHODS

Thirteen (13) patients with aortic stenosis at high-risk of CAO during TAVR were selected for 3D-printed modelling. The relevant anatomy for TAVR was precisely reconstructed with Materialise Heart Print-Flex (Materialse, Leuven, Belgium) technology. An appropriately sized valve prosthesis was deployed in each 3D-model and coronary ostia assessed for obstruction.

RESULTS

Model-derived results were compared to clinical outcomes in 13 cases. One high-risk case underwent TAVR resulting in left main obstruction and subsequent stenting. This outcome was accurately predicted by the 3D-model simulation. Two (2) high-risk TAVR cases were abandoned following transient CAO during balloon aortic valvuloplasty (BAV). The 3D-model simulations correlated with these findings, demonstrating CAO either by a calcium nodule or the native valve leaflet. In another two cases, BAV was uncertain, however the 3D-simulation demonstrated patency and successful TAVR was undertaken. In remaining cases, no obstruction was demonstrated in-vitro, and all underwent uncomplicated TAVR.

CONCLUSIONS

In this proof-of-concept study, 3D-model TAVR simulation correlates well to clinical outcomes. 3D-models of patients at high-risk of CAO may be utilised in pre-procedural planning to accurately predict this complication. As lower-risk surgical cohorts are considered for TAVR, 3D-models may minimise complications leading to safer patient outcomes.

Rare Cause of Severe Mitral Regurgitation after TAVI: Case Report and Literature Review

Pre-procedure mitral regurgitation (MR) is a frequent coexistent finding in patients undergoing transcatheter aortic valve replacement (TAVR), and most of them (up to 55%) experience a significant improvement in MR after the procedure. Although seldom described, mitral valve perforation after TAVR is a potentially serious complication that physicians should be aware of, as moderate or severe MR in TAVR recipients is associated with a high early mortality rate. We herein describe the case of a 65-year-old man presenting with worsening heart failure symptoms 5 months after TAVR due to an intraprocedural anterior mitral leaflet perforation and discuss the diagnostic process and therapeutic course of the case. Furthermore, we draw attention to the essential role of echocardiography in the management of TAVR procedures, taking into account its ability in detecting early complications, and emphasize the value of CT as a main determinant to predict long-term MR improvement after TAVR and to assess the potential candidates for double valve repair with percutaneous techniques.

Recommendations in pre-procedural imaging assessment for TAVI intervention: SIC-SIRM position paper part 2 (CT and MR angiography, standard medical reporting, future perspectives)

Non-invasive cardiovascular imaging owns a pivotal role in the preoperative assessment of patient candidates for transcatheter aortic valve implantation (TAVI), providing a wide range of crucial information to select the patients who will benefit the most and have the procedure done safely. This document has been developed by a joined group of experts of the Italian Society of Cardiology and the Italian Society of Medical and Interventional Radiology and aims to produce an updated consensus statement about the pre-procedural imaging assessment in candidate patients for TAVI intervention. The writing committee consisted of members and experts of both societies who worked jointly to develop a more integrated approach in the field of cardiac and vascular radiology. Part 2 of the document will cover CT and MR angiography, standard medical reporting, and future perspectives.

Vascular complications after transcatheter transfemoral aortic valve implantation: Modified sheath-to-femoral artery ratio as a new predictor

OBJECTIVE

Vascular complications (VCs) contribute to increased morbidity and mortality in patients who have undergone transcatheter aortic valve implantation (TAVI); however, studies on their incidence and predictors show conflicting results. In this study, we sought to assess the incidence, impact, and predictors of VCs in transfemoral (TF) TAVI and also investigated the predictive role of manufacturer's size charts and a new predictor modified sheath-to-femoral artery ratio.

METHODS

A total of 223 patients undergoing TF-TAVI were categorized into 2 groups. The patients were divided as eligible and ineligible according to the manufacturer's guidelines (MG), and the same patient cohort was dichotomized into eligible and ineligible on the basis of sheath-to-femoral artery ratio (SFAR) value of less than or greater than or equal to modified SFAR (md-SFAR). VCs (defined according to the Valve Academic Research Consortium II criteria) were retrospectively compared.

RESULTS

According to the manufacturer's size charts, 65 patients were unsuitable; however, 35 patients were ineligible for TF-TAVI per the md-SFAR criteria. Although VCs occurred in 42 (18.8%) patients, 17 (27.7%) of those patients were classified as ineligible according to MG, whereas 14 (41.2%) were classified as ineligible in the md-SFAR group. In a multiple logistic regression analysis that included md-SFAR, MG, SFAR ≥1.05, peripheral artery disease, and minimum iliofemoral artery diameter, only md-SFAR was the independent predictor of VCs (odds ratio=3.71, 95% confidence interval=1.13-12.53, p=0.031).

CONCLUSION

According to our results, md-SFAR might provide better patient selection to prevent VCs and improve outcomes in TF-TAVI procedures.

Distance between valvular leaflet and coronary ostium predicting risk of coronary obstruction during TAVR

Background

The aim of this study was to evaluate the role of the distance between the aortic valve in projected position to the coronary ostium to determine risk of coronary artery obstruction after transcatheter aortic valve replacement (TAVR).

Methods

An Expected Leaflet-to-ostium Distance (ELOD) was obtained on pre-TAVR planning computed tomography by subtracting leaflet thickness and the distances from the center to the annular rim at annulus level and from the center to the coronary ostium at mid-ostial level. Variables were compared between patients with and without coronary obstruction and the level of association between variables was assessed using log odds ratio (OR).

Results

A total of 177 patients with 353 coronary arteries was analyzed. Mean annulus diameters (22.8 ± 2.8 mm and 23.4 ± 1.0 mm, p > 0.05) and mean sinus of Valsalva (SOV) diameters (31.2 ± 3.6 mm and 31.9 ± 3.6 mm, p > 0.05) were similar between patients with lower and higher coronary heights, respectively. There were three coronary obstruction cases. ELOD ≤ 2 mm in combination with leaflet length longer than mid-ostial height allowed for discrimination of cases with and without coronary obstruction. There was a significant association between coronary obstruction event and ELOD ≤ 2 mm (log OR = 6.180, p < 0.001).

Conclusions

Our study showed that a combination of ELOD < 2 mm and a longer leaflet length than mid-ostial height may be associated with increased risk for coronary obstruction during TAVR.

Vascular Complications in TAVR: Incidence, Clinical Impact, and Management

Transcatheter aortic valve replacement (TAVR) has replaced surgical aortic valve replacement as the new gold standard in elderly patients with severe aortic valve stenosis. However, alongside this novel approach, new complications emerged that require swift diagnosis and adequate management. Vascular access marks the first step in a TAVR procedure. There are several possible access sites available for TAVR, including the transfemoral approach as well as transaxillary/subclavian, transcarotid, transapical, and transcaval. Most cases are primarily performed through a transfemoral approach, while other access routes are mainly conducted in patients not suitable for transfemoral TAVR. As vascular access is achieved primarily by large bore sheaths, vascular complications are one of the major concerns during TAVR. With rising numbers of TAVR being performed, the focus on prevention and successful management of vascular complications will be of paramount importance to lower morbidity and mortality of the procedures. Herein, we aimed to review the most common vascular complications associated with TAVR and summarize their diagnosis, management, and prevention of vascular complications in TAVR.

Optical Fiber Array Sensor for Force Estimation and Localization in TAVI Procedure: Design, Modeling, Analysis and Validation

Transcatheter aortic valve implantation has shown superior clinical outcomes compared to open aortic valve replacement surgery. The loss of the natural sense of touch, inherited from its minimally invasive nature, could lead to misplacement of the valve in the aortic annulus. In this study, a cylindrical optical fiber sensor is proposed to be integrated with valve delivery catheters. The proposed sensor works based on intensity modulation principle and is capable of measuring and localizing lateral force. The proposed sensor was constituted of an array of optical fibers embedded on a rigid substrate and covered by a flexible shell. The optical fibers were modeled as Euler–Bernoulli beams with both-end fixed boundary conditions. To study the sensing principle, a parametric finite element model of the sensor with lateral point loads was developed and the deflection of the optical fibers, as the determinant of light intensity modulation was analyzed. Moreover, the sensor was fabricated, and a set of experiments were performed to study the performance of the sensor in lateral force measurement and localization. The results showed that the transmitted light intensity decreased up to 24% for an external force of 1 N. Additionally, the results showed the same trend between the simulation predictions and experimental results. The proposed sensor was sensitive to the magnitude and position of the external force which shows its capability for lateral force measurement and localization.

Immediate aortic dissection after transcatheter aortic valve replacement: A case report and review of the literature

-Aortic dissection of descending aorta was detected by intraoperative TEE in a case of 67-year-old man with symptomatic severe aortic stenosis after TAVR. -Transesophageal echocardiogram after TAVR procedure is helpful to detect this rare complication.

Prognostic Value of Systemic Immune-Inflammation Index for Major Adverse Cardiac Events and Mortality in Severe Aortic Stenosis Patients after TAVI

Background and objectives: In this study, we aimed to evaluate whether the systemic immune-inflammation index (SII) has a prognostic value for major adverse cardiac events (MACEs), including stroke, re-hospitalization, and short-term all-cause mortality at 6 months, in aortic stenosis (AS) patients who underwent transcatheter aortic valve implantation (TAVI). Materials and Methods: A total of 120 patients who underwent TAVI due to severe AS were retrospectively included in our study. The main outcome of the study was MACEs and short-term all-cause mortality at 6 months. Results: The SII was found to be higher in TAVI patients who developed MACEs than in those who did not develop them. Multivariate Cox regression analysis revealed that the SII (HR: 1.002, 95%CI: 1.001–1.003, p < 0.01) was an independent predictor of MACEs in AS patients after TAVI. The optimal value of the SII for MACEs in AS patients following TAVI was >1.056 with 94% sensitivity and 96% specificity (AUC (the area under the curve): 0.960, p < 0.01). We noted that the AUC value of SII in predicting MACEs was significantly higher than the AUC value of the C-reactive protein (AUC: 0.960 vs. AUC: 0.714, respectively). Conclusions: This is the first study to show that high pre-procedural SII may have a predictive value for MACEs and short-term mortality in AS patients undergoing TAVI.

Thirty-day incidence of stroke after transfemoral transcatheter aortic valve implantation: meta-analysis and mixt-treatment comparison of self-expandable versus balloon-expandable valve prostheses

AIMS

Stroke is a major complication after transcatheter aortic valve implantation (TAVI). Although multifactorial, it remains unknown whether the valve deployment system itself has an impact on the incidence of early stroke. We performed a meta- and network analysis to investigate the 30-day stroke incidence of self-expandable (SEV) and balloon-expandable (BEV) valves after transfemoral TAVI.

METHODS AND RESULTS

Overall, 2723 articles were searched directly comparing the performance of SEV and BEV after transfemoral TAVI, from which 9 were included (3086 patients). Random effects models were used for meta- and network meta-analysis based on a frequentist framework. Thirty-day incidence of stroke was 1.8% in SEV and 3.1% in BEV (risk ratio of 0.62, 95% confidence interval (CI) 0.49-0.80, p = 0.004). Treatment ranking based on network analysis (P-score) revealed CoreValve with the best performance for 30-day stroke incidence (75.2%), whereas SAPIEN had the worst (19.0%). However, network analysis showed no inferiority of SAPIEN compared with CoreValve (odds ratio 2.24, 95% CI 0.70-7.2).

CONCLUSION

Our analysis indicates higher 30-day stroke incidence after transfemoral TAVI with BEV compared to SEV. We could not find evidence for superiority of a specific valve system. More randomized controlled trials with head-to-head comparison of SEV and BEV are needed to address this open question.

Case report: takotsubo cardiomyopathy after transcatheter aortic valve-in-valve replacement

Background 

Transcatheter aortic valve implantation (TAVI) has become a first-line therapeutic option in patients with severe, symptomatic aortic stenosis at increased surgical risk. Despite its success, the TAVI procedure has been associated with acute life-threatening complications as myocardial infarction secondary to periprocedural coronary occlusion, annular rupture, or vascular injury.

Case summary 

A 79-year-old woman with a dysfunctional bioprosthetic valve following previous surgical valve replacement was hospitalized in our institution to perform a Valve-in-Valve Transcatheter Aortic Valve Replacement (ViV TAVR). Shortly after the implantation of an Evolut R valve (without complication), left ventricle dysfunction with apical akinesia and basal hyperkinesia was identified during bedside transthoracic echocardiography, in spite of a good prosthesis implantation and function. A concomitant Troponin elevation was noted, and the day-after resting electrocardiogram showed a lateral T-wave inversion. Coronary computed tomography angiography showed no coronary stenosis or occlusion, cardiac magnetic resonance imaging showed no necrosis or fibrosis, and no argument for myocarditis. The patient remained asymptomatic during her hospital stay, and the aforementioned anomalies spontaneously regressed after an in-hospital 2-week surveillance. In the presence of these transient anomalies and after ruling out myocardial infarction and myocarditis, post-procedural stress cardiomyopathy (takotsubo) was diagnosed.

Discussion 

Post-TAVR stress-related cardiomyopathy seems to be an extremely rare entity. To our knowledge, this is the first case of a takotsubo cardiomyopathy after ViV TAVR. Though the association between the two seems likely to be causal, no clear physiopathological explanation can be formulated.

Use of extracorporeal membrane oxygenation as a bridge to transcatheter aortic valve replacement in a patient with aortic stenosis and severe coronary artery disease: a case report

Background

Patients with severe aortic stenosis (AS) often present with multiple comorbidities and suffer from critical coronary artery disease (CAD). Transcatheter aortic valve replacement (TAVR) has become the therapy of choice for moderate to high-risk patients. Venoarterial extracorporeal membrane oxygenation (v-a-ECMO) offers the possibility of temporary cardiac support to manage life-threatening critical situations.

Case summary

Here, we describe the management of a patient with severe AS and CAD with impaired left ventricular ejection fraction (LVEF). We used v-a-ECMO as an emergency strategy in cardiogenic shock during a high-risk coronary intervention to stabilize the patient, and as a further bridge to TAVR.

Discussion

Very high-risk patients with severe AS are unlikely to tolerate the added risk of surgical aortic valve replacement. Using ECMO may help them to benefit from TAVR as the only treatment option available.

Percutaneous Management of a Contained Annular Rupture Occurring With Self-Expanding Transcatheter Aortic Valve Replacement

Annular rupture is a rare catastrophic event during transcatheter aortic valve replacement, often life threatening and requiring emergent surgical repair. We describe, herein, a case of contained annular rupture successfully managed percutaneously with coiling and polymer injection. This is a novel technique to manage this complication. (Level of Difficulty: Advanced.)

Evaluation of Acquired Thrombocytopenia According to the Balloon-Expandable Versus Self-Expandable Valves in Patients Undergoing Transcatheter Aortic Valve Replacement

In patients with severe aortic stenosis, the data about the incidence of acquired thrombocytopenia according to the use of balloon-expandable or self-expandable valves are limited. We investigated the relationship between the post-transcatheter aortic valve replacement (TAVR) thrombocytopenia and the balloon-expandable or self-expandable valves. A total of 127 consecutive patients who underwent TAVR were retrospectively analyzed. Among the study population, 61 (48%) patients underwent TAVR with the balloon-expandable valve and the 66 (52%) patients with the self-expandable valve. Procedural success did not differ between the groups (P = .575). The access site complications and in-hospital mortality were the same across the groups (P = .225 and P = .466). However, paravalvular (PV) leaks were significantly higher in the self-expandable valve group (P = .007). Among all, 65 patients experienced thrombocytopenia, which was more frequent in the self-expandable valve group (63.6 vs 37.7%, P = .005). In multivariate analyses, admission platelet count, PV leak, and self-expandable valve deployment were the predictors of thrombocytopenia (P = .001, P = .002, and P = .021, respectively). The present study showed a higher incidence of acquired thrombocytopenia in the self-expandable valve group. Although the procedural success was similar between the groups, postprocedural PV leaks were more common in the self-expandable valve group.

Automatic Detection of the Aortic Annular Plane and Coronary Ostia from Multidetector Computed Tomography

Anatomic landmark detection is crucial during preoperative planning of transcatheter aortic valve implantation (TAVI) to select the proper device size and assess the risk of complications. The detection is currently a time-consuming manual process influenced by the image quality and subject to operator variability. In this work, we propose a novel automatic method to detect the relevant aortic landmarks from MDCT images using deep learning techniques. We trained three convolutional neural networks (CNNs) with 344 multidetector computed tomography (MDCT) acquisitions to detect five anatomical landmarks relevant for TAVI planning: the three basal attachment points of the aortic valve leaflets and the left and right coronary ostia. The detection strategy used these three CNN models to analyse a single MDCT image and yield three segmentation volumes as output. These segmentation volumes were averaged into one final segmentation volume, and the final predicted landmarks were obtained during a postprocessing step. Finally, we constructed the aortic annular plane, defined by the three predicted hinge points, and measured the distances from this plane to the predicted coronary ostia (i.e., coronary height). The methodology was validated on 100 patients. The automatic landmark detection was able to detect all the landmarks and showed high accuracy as the median distance between the ground truth and predictions is lower than the interobserver variations (1.5 mm [1.1–2.1], 2.0 mm [1.3–2.8] with a paired difference −0.5 ± 1.3 mm and p value <0.001). Furthermore, a high correlation is observed between predicted and manually measured coronary heights (for both R² = 0.8). The image analysis time per patient was below one second. The proposed method is accurate, fast, and reproducible. Embedding this tool based on deep learning in the preoperative planning routine may have an impact in the TAVI environments by reducing the time and cost and improving accuracy.

Fluid Structure Interaction on Paravalvular Leakage of Transcatheter Aortic Valve Implantation Related to Aortic Stenosis: A Patient-Specific Case

This study investigated the impact of paravalvular leakage (PVL) in relation to the different valve openings of the transcatheter aortic valve implantation (TAVI) valve using the fluid structure interaction (FSI) approach. Limited studies were found on the subject of FSI with regards to TAVI-PVL condition, which involves both fluid and structural responses in coupling interaction. Hence, further FSI simulation with the two-way coupling method is implemented to investigate the effects of hemodynamics blood flow along the patient-specific aorta model subjected to the interrelationship between PVL and the different valve openings using the established FSI software ANSYS 16.1. A 3D patient-specific aorta model is constructed using MIMICS software. The TAVI valve identical to Edward SAPIEN XT 26 (Edwards Lifesciences, Irvine, California), at different Geometrical Orifice Areas (GOAs), is implanted into the patient's aortic annulus. The leaflet opening of the TAVI valve is drawn according to severity of GOA opening represented in terms of 100%, 80%, 60%, and 40% opening, respectively. The result proved that the smallest percentage of GOA opening produced the highest possibility of PVL, increased the recirculatory flow proximally to the inner wall of the ascending aorta, and produced lower backflow velocity streamlines through the side area of PVL region. Overall, 40% GOA produced 89.17% increment of maximum velocity magnitude, 19.97% of pressure drop, 65.70% of maximum WSS magnitude, and a decrement of 33.62% total displacement magnitude with respect to the 100% GOA.

MDCT planning of trans catheter aortic valve implantation (TAVI): determination of optimal c-arm angulation

A fluoroscopic view perpendicular to the aortic valve annulus is required during transcatheter aortic valve implantation (TAVI) for obtaining an optimal deployment of the bioprosthesis. By predicting c-arm angulation, pre-procedural MDCT could decrease the number of aortograms, shorten the time of the procedure and reduce the amount of intra-arterial contrast agent. The aim of our study was to assess the accuracy of MDCT in predicting c-arm angulation at the cath. lab. In this single center study, we investigated MDCT prediction of c-arm angulation in patients having undergone a TAVI procedure using SAPIEN 3® (Edwards Lifesciences, USA). Prior to the procedure, an experienced radiologist had reported the angulation using dedicated software (CT_report). After the procedure, a blinded experienced radiologist retrospectively measured the angles using the same method (CT_study). Interobserver variability was drawn from the comparison between CT_report and CT_study. Then, the mean angular difference between the predicted MDCT angles (CT_study) was compared to the working view recorded at the cath. lab. Seventy-nine patients (M/F = 0.65; mean age: 85.2 years ± 5.3) were included. Interobserver variability was 5.9 ± 6.1°. The mean absolute difference between MDCT and fluoroscopy was 8.8 ± 7.1°. The present study showed that MDCT could predict the coplanar fluoroscopic angles prior to TAVI using a balloon-expandable bioprosthesis Sapien 3® placed via a transfemoral approach with a mean angular difference of 8.8 ± 7.1°. Reproducibility was considered good as the mean difference between two independent measures was 5.9 ± 6.1°.

Transapical transcatheter aortic valve implantation for predominant aortic regurgitation with a self-expandable valve

Background

Transcatheter aortic valve implantation (TAVI) has become the gold standard for high-risk severe aortic stenosis. However, the experience of treating aortic regurgitation (AR) with this technology is still limited. Previously, we have demonstrated excellent 1-year outcomes of transapical TAVI with J-Valve^TM (JieCheng Medical Technology Co., Ltd., Suzhou, China) in treating predominant AR, while the mid-term outcomes up to 4 years have never been reported.

Methods

Transapical TAVI with J-Valve^TM to treat predominant AR was performed in 47 patients in Zhongshan Hospital from May 2014 through October 2018. Procedural and clinical outcomes with follow-up up to 4 years were analyzed using Valve Academic Research Consortium-2 criteria (VARC-2).

Results

All patients (age 73.7±7.9 years) were considered to be prohibitive or high-risk for surgical aortic valve replacement (SAVR) (logistic European System for Cardiac Operative Risk Evaluation, 21.1% to 44.4%; mean, 24.3%±5.1%) after evaluated by a multidisciplinary heart team. Transapical implantations were successful in all patients. The clinical outcomes of the entire cohort in the latest follow-up (371 to 1,968 days, median 574 days) included all-cause mortality (6.4%), disabling stroke (2.3%), new permanent pacemaker (6.8%) and valve-related re-intervention (0). Paravalvular leak (PVL) was rate as none or trace in 37 of 44 and mild in 7 of 44 patients at the latest follow-up. Mean transvalvular gradient was favorable after valve implantation during follow-up at 9.3±2.5 mmHg.

Conclusions

This study revealed that, transapical TAVI with J-Valve^TM for treating AR has encouraging mid-term outcomes, and the advantages at one year demonstrated in previous study can be maintained through 4 years.

Rapid ventricular pacing during transcatheter valve procedures using an internal device and programmer: A demonstration of feasibility

OBJECTIVES

To develop a protocol for using a pre-existing, permanent pacemaker or defibrillator device for rapid ventricular pacing during transcatheter valve procedures and demonstrate feasibility.

BACKGROUND

Placement of a passive fixation, temporary pacemaker wire is considered routine during most transcatheter valve procedures to facilitate controlled or rapid ventricular pacing at the time of balloon expansion or valve deployment. Many patients presenting for such procedures have a pre-existing, permanent pacemaker or defibrillator device which could be used for the same function, obviating the need for temporary pacemaker wire placement.

METHODS

We developed a strategy for rapid pacing from the pre-existing device using a programmer during transcatheter valve procedures in consecutive patients over a 3-month period. Complications and clinical outcomes were recorded.

RESULTS

There were 135 transcatheter valve procedures performed during the study. Of these, 28 (20.7%) had pre-existing devices (17 transcatheter aortic valve replacement, 3 aortic valve-in-valve, 2 mitral valve-in-valve, and 6 balloon aortic valvuloplasty). All patients underwent rapid ventricular pacing using a commercially available device programmer. There were no adverse events related to device pacing and no patients required placement of a temporary pacemaker wire during the procedure. At 30-days follow-up, there were no deaths, one major vascular complication related to arterial access, and one patient with renal failure requiring dialysis.

CONCLUSION

Pacing from a commercially available device programmer is safe, feasible, and may reduce both procedural cost and complications such as cardiac tamponade by avoiding placement of a temporary pacemaker lead during transcatheter valve procedures.

Multidetector Computed Tomography (MDCT) Angiography in the Pre-Procedural Assessment of Patients Undergoing Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) initially emerged as an alternative option to surgical aortic valve replacement (SAVR) for patients with severe aortic stenosis who were considered either inoperable or high-risk for surgery. However, since its advent the role of TAVR has been continuously evolving on the basis of clinical trials which showed that TAVR is non-inferior to SAVR in patients with moderate as well as low-risk for surgery. Because of recent technological advances, multidetector computer tomography (MDCT) is inherently suitable for the pre-procedural assessment of patients being considered for TAVR within a very short imaging time, MDCT can measure the diameter of the aortic annulus, provide detailed information regarding the status of the entire thoracoabdominal aorta, and assess the caliber of the peripheral vasculature used for transcatheter heart valve delivery. This information helps interventionists make optimal pre-procedural decisions and avoid complications. To familiarize non-imaging specialists with the role of MDCT in TAVR, we provide a concise overview of our approach to using this modality for the pre-procedural assessment of TAVR candidates.

Modeling risk of coronary obstruction during transcatheter aortic valve replacement

OBJECTIVE

In this study we aimed to evaluate risk of coronary obstruction during transcatheter aortic valve replacement and develop improved criteria based on computational modeling.

METHODS

Patient specific 3-dimensional models were constructed and validated for 28 patients out of 600 patients who were flagged as high risk for coronary obstruction (defined as meeting coronary ostium height < 14 mm and/or sinus of Valsalva diameter [SOVd] < 30 mm). The models consisted finite element analysis to predict the post- transcatheter aortic valve replacement native cusp apposition relative to the coronary ostium and were validated in vitro. The distance from cusp to coronary ostium (DLC) was derived from the 3-dimensional models and indexed with the coronary artery diameter to yield a fractional obstruction measure (DLC/d).

RESULTS

Twenty-two out of 28 high-risk patients successfully underwent transcatheter aortic valve replacement without coronary obstruction and 6 did not. DLC/d between the 2 groups was significantly different (P < .00078), whereas neither coronary ostium height nor SOVd were significantly different (P > .32). A cutoff of DLC/d < 0.7 was predictive with 100% sensitivity and 95.7% specificity. The optimal sensitivity and specificity of coronary ostium height and SOVd in this high-risk group was only 60% and 40%, respectively, for cutoff coronary ostium height of 10 mm and SOVd of 30.5 mm.

CONCLUSIONS

Three-dimensional modeling has the potential to enable more patients to be safely treated with transcatheter aortic valve replacement who have a low-lying coronary ostium or small SOVd. DLC/d is more predictive of obstruction than coronary ostium height and SOVd.

High-pitch Dual-source CT Angiography before TAVI - the Value of ECG Gating

PURPOSE

To investigate image quality, and radiation dose between ECG-gated singlesource and dual-source CT Angiography (CTA) protocols for planning of Trans-catheter Aortic Valve Implantation (TAVI) with a reference non ECG-gated single-source protocol.

METHODS

A total of 120 patients were included in four groups: Non ECG-gated single-source (SS), ECG-gated single-source (SSECG), ECG-gated dual-source high-pitch (DSECG), or non-ECG-gated dual-source high-pitch mode (DS). Qualitative image quality of the aortic annulus, aortic valve, and coronary ostia as well as presence of motion or stair-step artefacts of the thoracic aorta were independently assessed by two readers. Quantitative image quality was assessed to calculate contrast to noise ratio.

RESULTS

Subjective and objective scoring of motion artefacts was significantly reduced in SSECG, DSECG and DS (p= 0.010). The imaging length was comparable between groups. Aortic annulus, aortic valve, and coronary ostia were reliably evaluable in all patients with SSECG, DSECG and DS protocols.

CONCLUSION

High-pitch, dual-source CT angiography of the whole aorta with or without ECG gating is a dose-efficient and time-saving examination strategy before TAVI. However acquisition timing within the cardiac cycle needs to be taken into account.

Reinterventions after freestyle stentless aortic valve replacement: an assessment of procedural risks

OBJECTIVES

Repeat aortic valve interventions after previous stentless aortic valve replacement (AVR) are considered technically challenging with an increased perioperative risk, especially after full-root replacement. We analysed our experience with reinterventions after stentless AVR.

METHODS

A total of 75 patients with previous AVR using a Freestyle stentless bioprosthesis (31 subcoronary, 15 root-inclusion and 29 full-root replacement) underwent reintervention in our centre from 1993 until December 2018. Periprocedural data were retrospectively collected from the department database and follow-up data were prospectively collected.

RESULTS

Median age was 62 years (interquartile range 47-72 years). Indications for reintervention were structural valve deterioration (SVD) in 47, non-SVD in 13 and endocarditis in 15 patients. Urgent surgery was required in 24 (32%) patients. Reinterventions were surgical AVR in 16 (21%), root replacement in 51 (68%) and transcatheter AVR in 8 (11%) patients. Early mortality was 9.3% (n = 7), but decreased to zero in the past decade in 28 patients undergoing elective reoperation. Per indication, early mortality was 9% for SVD, 8% for non-SVD and 13% for endocarditis. Aortic root replacement had the lowest early mortality rate (6%), followed by surgical AVR (13%) and transcatheter AVR (25%, 2 patients with coronary artery obstruction). Pacemaker implantation rate was 7%. Overall survival rate at 10 years was 69% (95% confidence interval 53-81%).

CONCLUSIONS

Repeat aortic valve interventions after stentless AVR carry an increased, but acceptable, early mortality risk. Transcatheter valve-in-valve procedures after stentless AVR require careful consideration of prosthesis leaflet position to prevent obstruction of the coronary arteries.

Safety and effectiveness of a transaortic approach for TAVI: procedural and midterm outcomes of 265 consecutive patients in a single centre

OBJECTIVES

Transcatheter aortic valve implantation with a transaortic approach (TAo-TAVI) is an alternative to transapical or femoral access. We studied the procedural and midterm efficacy and safety of TAo-TAVI with Edwards Sapien XT and Medtronic CoreValve devices.

METHODS

Among 901 patients receiving TAVI since 2006, 265 consecutive patients underwent TAo-TAVI between January 2011 and September 2014. Procedural and midterm results were evaluated according to Valve Academic Research Consortium-2 criteria.

RESULTS

The mean age was 83 ± 5 years. Sapien XT and CoreValve were used in 191 (72.1%) and 74 (27.9%) patients, respectively. Full sternotomy made elective concomitant off-pump coronary artery bypass grafting possible in 38 patients (14.3%) with severe coronary artery disease unsuitable for percutaneous coronary intervention. The device success rate was 95.5%. Postprocedural paravalvular leak  ≥2/4 was observed in 16 patients (6.4%). Emergency open chest surgery was required in 10 patients (3.8%) (3 aortic dissections, 3 valve embolizations, 2 LMCA occlusions, 1 aortic annulus rupture and 1 aortic rupture). Cerebrovascular accidents occurred in 3 patients (1.1%). Transfusions  ≥4 units were required in 36 patients (13.6%). New pacemakers were implanted in 26 patients (9.8%). Thirty-day and 1-year mortality were 8.7% and 16.2%, respectively. Mean follow-up duration was 24 ± 6 months. At 3 years, freedom from all-cause death was 80% ± 4%. New York Heart Association class &lt;III included 81% (n = 172) of patients alive and without prosthetic echocardiographic dysfunction at follow-up (mean gradient 10.5 ± 5.6 mmHg).

CONCLUSION

The TAo-TAVI approach confirms its safety and effectiveness with satisfactory procedural and midterm outcomes with both currently available devices.

Transcatheter Aortic Valve Replacement: Procedure and Outcomes

Initially, transcatheter aortic valve replacement (TAVR) was only used in patients with severe symptomatic aortic stenosis and prohibitive risk for surgical aortic valve replacement. Subsequently, TAVR was extended to patients with high and intermediate surgical risk. Recently, the results of randomized trials in low-surgical-risk patients showed superiority or noninferiority of TAVR versus surgical aortic valve replacement in this population. Procedural outcomes have been improved. Long-term durability of transcatheter heart valves remains to be confirmed. This article presents the evolution and current status of TAVR, with respect to the different types of devices and procedures as well as its outcomes.

TAVI and the future of aortic valve replacement

Aortic valve stenosis (AS) is the most common valvular pathology and has traditionally been managed using surgical aortic valve replacement (SAVR). A large proportion of affected patient demographics, however, are unfit to undergo major surgery given underlying comorbidities. Since its introduction in 2002, transcatheter aortic valve implantation (TAVI) has gained popularity and transformed the care available to different-risk group patients with severe symptomatic AS. Specific qualifying criteria and refinement of TAVI techniques are fundamental in determining successful outcomes for intervention. Given the successful applicability in high-risk patients, TAVI has been further developed and trialed in intermediate and low-risk patients. Within intermediate-risk patient groups, TAVI was shown to be noninferior to SAVR evaluating 30-d mortality and secondary endpoints such as the risk of bleeding, development of acute kidney injury, and length of admission. The feasibility of expanding TAVI procedures into low-risk patients is still a controversial topic in the literature. A number of trials have recently been published which demonstrate TAVI as noninferior and even superior over SAVR for primary study endpoints.

Endovascular Repair of Ruptured Ascending Aorta Secondary to Embolized Transcatheter Aortic Valve

Since its approval by the United States Food and Drug Administration in 2011, transcatheter aortic valve replacement has revolutionized the treatment of aortic valvular disease with a rapid increase in use. Potentially fatal aortic complications are rare, occurring in 0.2% to 1.1% of cases-all reported in the early perioperative period. We present a case of a late ascending aortic pseudoaneurysm with rupture secondary to erosion by an embolized transcatheter aortic valve occurring 6 years after implantation. The patient was successfully treated with a commercially available, off-the-shelf aortic endograft.

Novel Mechanism of Delayed Coronary Obstruction after Transcatheter Aortic Valve Replacement for Severe Aortic Stenosis: "Uppercut Phenomenon"

Delayed coronary obstruction is a rare complication after transcatheter aortic valve replacement (TAVR), and leads to a high in-hospital mortality rate. Here, we present a case of unpredictable delayed coronary obstruction in the left main trunk (LMT) after self-expandable device implantation because the left coronary height was enough over 15 mm. LMT obstruction was caused by a heavy calcification that was pushing up from the outside of the LMT, like an "uppercut" phenomenon. Stent-in-stent technique was a useful option for this type of LMT obstruction.