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Kindzelski B, Mick SL, Krishnaswamy A, Kapadia SR, Attia T, Hodges K, Siddiqi S, Lowry AM, Blackstone EH, Popovic Z, Svensson LG, Unai S, Yun JJ. Evolution of Alternative-access Transcatheter Aortic Valve Replacement. Ann Thorac Surg 2021; 112:1877-1885. [PMID: 33647251 DOI: 10.1016/j.athoracsur.2021.02.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 12/28/2020] [Accepted: 02/02/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Transfemoral access is the most common approach for transcatheter aortic valve replacement (TAVR). However, a subset of patients require alternative access. This study describes the evolution and outcomes of alternative-access TAVR at Cleveland Clinic. METHODS From January 2006 to January 2019, 2446 patients underwent TAVR, 414 (17%) through alternative access (247 transapical, 95 transaortic, 56 transaxillary, 2 transcarotid, 10 transiliac, 4 transcaval). Patients undergoing alternative-access TAVR had high preoperative risk. Propensity-matched comparisons were targeted at comparing transfemoral versus transaxillary approaches since 2012. RESULTS Over time, the favored alternative-access approach shifted from transapical and transaortic to transaxillary. Pacemaker requirement was similar for alternative-access and transfemoral approaches. Compared with transfemoral access, major vascular injuries were higher in the alternative-access group (12 [2.9%] vs 27 [1.3%], P = .02), but minor vascular injuries were lower (13 [3.1%] vs 198 [9.8%], P < .0001). Non-risk-adjusted 5-year survival was lower in the alternative-access group (45% vs 59%). Compared with intrathoracic approaches (transapical and transaortic), transaxillary access was associated with fewer blood transfusions (12 [21%] vs 176 [51%], P < .0001), less prolonged ventilation (1 [1.8%] vs 38 [11%], P = .03), and shorter length of stay (median, 5 vs 7.5 days, P < .0001). Survival and major morbidity were similar in matched comparisons of the transfemoral and transaxillary approaches. No brachial plexus injuries occurred with transaxillary access. CONCLUSIONS The transaxillary approach has emerged as our preferred alternative-access strategy for TAVR. It is associated with superior operative outcomes compared with transthoracic approaches, and results are comparable with those of the transfemoral approach.
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Affiliation(s)
- Bogdan Kindzelski
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Stephanie L Mick
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Amar Krishnaswamy
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Tamer Attia
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kevin Hodges
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shirin Siddiqi
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ashley M Lowry
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Zoran Popovic
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shinya Unai
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - James J Yun
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
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Zhan Y, Kawabori M, Lofftus S, Cobey F, Rastegar H, Weintraub A, Chen FY. Right Transaxillary Transcatheter Aortic Valve Replacement Using the "Flip-n-Flex" Technique. Ann Thorac Surg 2019; 109:57-62. [PMID: 31279789 DOI: 10.1016/j.athoracsur.2019.05.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 04/20/2019] [Accepted: 05/08/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Right transaxillary transcatheter aortic valve replacement (TAx-TAVR) is rarely performed due to challenging vascular tortuosity and unfavorable implantation angles. We explored this procedure using the newer-generation balloon-expandable SAPIEN 3 (Edwards Lifesciences, Irvine, CA) valve and our novel "flip-n-flex" technique. The safety and effectiveness of the procedure and the learning curve of our early experiences were investigated. METHODS The first 10 consecutive patients undergoing right TAx-TAVR performed at our center from June 2016 to May 2018 were included in the study. Patients' preoperative characteristics, procedural outcomes, and clinical outcomes were studied. Intraoperative fluoroscopy times were also reviewed to analyze the procedural learning curve. RESULTS The 10 patients were a mean age of 81.8 ± 8.7 years, and 5 patients (50%) were women. Mean Society of Thoracic Surgeons Predicted Risk of Mortality was 12.0% ± 9.5%. Procedural success was achieved in all cases without vascular complications. Paravalvular leak was absent or mild in all patients. Two patients (20%) required permanent pacemaker implantation. The median postoperative length of stay was 4 days (range, 2-13 days). The 30-day mortality was 0%. Mean transvalvular gradient improved from 38.4 ± 12.6 mm Hg to 9 ± 4.4 mm Hg postoperatively. New York Heart Association Functional Classification improved in all patients. The fluoroscopy time showed marked reduction from 44.1 ± 8.2 minutes to 17.4 ± 2.9 minutes with the use of the flip-n-flex technique. CONCLUSIONS Our early experience of right TAx-TAVR with the SAPIEN 3 valve demonstrated satisfactory outcomes and a quick learning as facilitated by the flip-n-flex technique. This could be a beneficial TAVR approach to suitable patients.
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Affiliation(s)
- Yong Zhan
- Division of Cardiac Surgery, Cardiovascular Center, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts.
| | - Masashi Kawabori
- Division of Cardiac Surgery, Cardiovascular Center, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | - Serena Lofftus
- Division of Cardiac Surgery, Cardiovascular Center, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | - Frederick Cobey
- Division of Cardiac Anesthesia, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | - Hassan Rastegar
- Division of Cardiac Surgery, Cardiovascular Center, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | - Andrew Weintraub
- Division of Cardiology, Cardiovascular Center, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | - Frederick Y Chen
- Division of Cardiac Surgery, Cardiovascular Center, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
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Hysi I, Gommeaux A, Pécheux M, Hochart P, Hannebicque G, Pâris M, Manchuelle A, Fabre O. Axillary Transcatheter Aortic Valve Replacement in Patients With Peripheral Vascular Disease. Semin Thorac Cardiovasc Surg 2018; 31:175-180. [PMID: 30291887 DOI: 10.1053/j.semtcvs.2018.09.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Accepted: 09/21/2018] [Indexed: 02/04/2023]
Abstract
The axillary artery seems an interesting alternative in nonfemoral transaortic valve replacement (TAVR) patients. This study describes our experience with this technique and its short-term follow-up results. This is a retrospective single center study. All axillary TAVR performed in our department between 2015 and 2017 were included in the study. Mean follow-up was 13.2 ± 9.5 months. All reporting was done according to the VARC-2 criteria. During the period covered, 43 patients had an axillary TAVR. Most patients were men (62.7%), had a mean age of 83.9 ± 5.3 years and presented with EuroSCORE I, II, and STS score of 27.9 ± 13.5%, 5.6 ± 4.9%, and 7.7 ± 4.05%, respectively. Vascular access was successful in all patients with a higher frequency of left approach (69.7%, n = 30). Both Medtronic CoreValve 37.2% (n = 16) and Edwards Sapien3 62.8% (n = 27) valves were used. An apical Certitude delivery system was preferentially used (24/27) in the latter group. There were no reported instances of valve migration or need for a second valve implantation. A single case (2.3%) of arterial vascular complication was reported. Central neurologic morbidity was 2.3%. No patient experienced brachial plexus injury. A pacemaker was implanted in 18.6% of cases (n = 8), with no significant difference between the 2 valves patient groups (S3 14.8% vs CV 25%, P 0.67). The 30-day mortality was 6.9% (n = 3) and 1-year survival was 86% [95% CI 72.6, 93.4]. Axillary TAVR is associated with acceptable morbidity, mortality, and leads to satisfactory short-term clinical outcomes. It has the potential to become the main alternative access route in nonfemoral TAVR patients.
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Affiliation(s)
- Ilir Hysi
- Departement of Cardiac Surgery of Artois, Centre Hospitalier de Lens et Hôpital Privé de Bois Bernard, Ramsay Générale de Santé, France.
| | - Antoine Gommeaux
- Departement of Cardiology, Hôpital Privé de Bois Bernard, Ramsay Générale de Santé, France
| | - Max Pécheux
- Deparetement of Cardiology, Centre Hospitalier de Lens, Lens, France
| | - Philippe Hochart
- Departement of Cardiology, Hôpital Privé de Bois Bernard, Ramsay Générale de Santé, France
| | - Géry Hannebicque
- Departement of Cardiology, Centre Hospitalier d'Arras, Lens, France
| | - Marc Pâris
- Departement of Cardiology, Hôpital Privé de Bois Bernard, Ramsay Générale de Santé, France
| | - Aurélie Manchuelle
- Departement of Cardiology, Hôpital Privé de Bois Bernard, Ramsay Générale de Santé, France
| | - Olivier Fabre
- Departement of Cardiac Surgery of Artois, Centre Hospitalier de Lens et Hôpital Privé de Bois Bernard, Ramsay Générale de Santé, France
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Transcatheter Aortic Valve Replacement: Comparing Transfemoral, Transcarotid, and Transcaval Access. Ann Thorac Surg 2018; 106:1105-1112. [DOI: 10.1016/j.athoracsur.2018.04.029] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 04/11/2018] [Accepted: 04/13/2018] [Indexed: 12/31/2022]
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Bavaria JE, Prager RL, Naunheim KS, Allen MS, Higgins RSD, Thourani VH, MacGillivray TE, Boden N, Sabik JF. Surgeon Involvement in Transcatheter Aortic Valve Replacement in the United States: A 2016 Society of Thoracic Surgeons Survey. Ann Thorac Surg 2017; 104:1088-1093. [PMID: 28408203 DOI: 10.1016/j.athoracsur.2017.03.055] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 03/31/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND The Society of Thoracic Surgeons (STS) surveyed cardiothoracic surgeon participants in its Adult Cardiac Surgery Database (ACSD) to learn the extent of surgeon involvement in transcatheter aortic valve replacement (TAVR) procedures. METHODS An electronic survey was delivered to 2,594 surgeons in June 2016. When the survey closed 2 weeks later, 487 completed surveys had been submitted for a response rate of 18.8%. RESULTS Among the 487 participants in the ACSD who responded to the survey, 410 (84.2%) reported that TAVR was performed at their institutions. Approximately three-quarters reported that they performed TAVR procedures as part of a heart team (77.5%; 313 of 404), cardiologists and cardiothoracic surgeons were jointly responsible for TAVR referrals (83.7%; 339 of 405), and TAVR programs were administered either jointly by the cardiology and cardiac surgery departments or exclusively by the cardiac surgery department (73.3%; 297 of 405). A majority were involved in the pre-, intra-, and postoperative care of patients undergoing TAVR, with 91.4% (370 of 405) reporting participation in multidisciplinary meetings, at least 50% regularly performing technical aspects in 10 of 11 conduct of operation categories, and 86.6% (266 of 307) caring for patients undergoing TAVR after the procedure. CONCLUSIONS Cardiac surgeons in the United States are active participants in the management of patients with aortic stenosis as part of the heart team. The STS survey found that not only were they actively involved in the treatment decision-making process but they also played a significant role in the valve procedure, including deployment and postprocedural care. The heart team model continues to evolve and should be expanded into other areas of structural heart disease.
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Affiliation(s)
- Joseph E Bavaria
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Richard L Prager
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan
| | - Keith S Naunheim
- Department of Surgery, Saint Louis University Medical Center, St. Louis, Missouri
| | - Mark S Allen
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Robert S D Higgins
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Vinod H Thourani
- Division of Cardiothoracic Surgery, Emory University, Atlanta, Georgia
| | | | | | - Joseph F Sabik
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
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Outcomes of a Less-Invasive Approach for Proximal Aortic Operations. Ann Thorac Surg 2017; 103:533-540. [DOI: 10.1016/j.athoracsur.2016.06.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 05/23/2016] [Accepted: 06/06/2016] [Indexed: 11/23/2022]
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Metaxa S, Ioannou A, Missouris CG. Transcatheter aortic valve implantation: new hope in the management of valvular heart disease. Postgrad Med J 2017; 93:280-288. [PMID: 28104807 DOI: 10.1136/postgradmedj-2016-134554] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Revised: 12/19/2016] [Accepted: 12/29/2016] [Indexed: 12/17/2022]
Abstract
Severe calcific aortic stenosis is relatively common, and unless treated with valve replacement it carries an adverse prognosis. A large number of patients, however, are denied surgery due to their advanced age or coexistent medical conditions that increase perioperative cardiovascular risks. Transcatheter aortic valve implantation (TAVI), a technique in which a bioprosthetic valve is inserted via a catheter and implanted within the diseased native aortic valve, is a new therapeutic modality for treatment of older patients with severe symptomatic aortic stenosis and other comorbidities, who have an inherently high surgical risk. This review will provide an overview of the pivotal trials in the development of TAVI; while also investigating important complications and limitations of the procedure and evaluating how new valves are being designed and clinically evaluated, with the ultimate goal of reducing potential complications and expanding the use of TAVI to lower-risk patient cohorts.
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Affiliation(s)
| | | | - Constantinos G Missouris
- Frimley Health NHS Foundation Trust, London, UK.,University of Cyprus Medical School, Nicosia, Cyprus
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Jones BM, Kapadia SR, Krishnaswamy A, Mick S, Tuzcu EM. Transfemoral Aortic Valve Implantation. Interv Cardiol 2016. [DOI: 10.1002/9781118983652.ch59] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Patel JS, Krishnaswamy A, Svensson LG, Tuzcu EM, Mick S, Kapadia SR. Access Options for Transcatheter Aortic Valve Replacement in Patients with Unfavorable Aortoiliofemoral Anatomy. Curr Cardiol Rep 2016; 18:110. [DOI: 10.1007/s11886-016-0788-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Suri RM, Minha S, Alli O, Waksman R, Rihal CS, Satler LP, Greason KL, Torguson R, Pichard AD, Mack M, Svensson LG, Rajeswaran J, Lowry AM, Ehrlinger J, Mick SL, Tuzcu EM, Thourani VH, Makkar R, Holmes D, Leon MB, Blackstone EH. Learning curves for transapical transcatheter aortic valve replacement in the PARTNER-I trial: Technical performance, success, and safety. J Thorac Cardiovasc Surg 2016; 152:773-780.e14. [PMID: 27215927 DOI: 10.1016/j.jtcvs.2016.04.028] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 03/30/2016] [Accepted: 04/07/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Introduction of hybrid techniques, such as transapical transcatheter aortic valve replacement (TA-TAVR), requires skills that a heart team must master to achieve technical efficiency: the technical performance learning curve. To date, the learning curve for TA-TAVR remains unknown. We therefore evaluated the rate at which technical performance improved, assessed change in occurrence of adverse events in relation to technical performance, and determined whether adverse events after TA-TAVR were linked to acquiring technical performance efficiency (the learning curve). METHODS From April 2007 to February 2012, 1100 patients, average age 85.0 ± 6.4 years, underwent TA-TAVR in the PARTNER-I trial. Learning curves were defined by institution-specific patient sequence number using nonlinear mixed modeling. RESULTS Mean procedure time decreased from 131 to 116 minutes within 30 cases (P = .06) and device success increased to 90% by case 45 (P = .0007). Within 30 days, 354 patients experienced a major adverse event (stroke in 29, death in 96), with possibly decreased complications over time (P ∼ .08). Although longer procedure time was associated with more adverse events (P < .0001), these events were associated with change in patient risk profile, not the technical performance learning curve (P = .8). CONCLUSIONS The learning curve for TA-TAVR was 30 to 45 procedures performed, and technical efficiency was achieved without compromising patient safety. Although fewer patients are now undergoing TAVR via nontransfemoral access, understanding TA-TAVR learning curves and their relationship with outcomes is important as the field moves toward next-generation devices, such as those to replace the mitral valve, delivered via the left ventricular apex.
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Affiliation(s)
| | - Sa'ar Minha
- Assaf-Harofeh Medical Center, Zerifin, Israel
| | | | - Ron Waksman
- MedStar Washington Hospital Center, Washington, DC
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Raj Makkar
- Cedars Sinai Medical Center, Los Angeles, Calif
| | | | - Martin B Leon
- Columbia University Medical Center/New York-Presbyterian Hospital, New York, NY
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Zhan Y, Wimmer NJ, Shah PB, Davidson MJ. Abdominal aorta as an alternative access route for transcatheter aortic valve replacement. J Card Surg 2015; 30:510-2. [PMID: 25873004 DOI: 10.1111/jocs.12550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A variety of access routes have been employed for transcatheter aortic valve replacement (TAVR). We report a TAVR case using the abdominal aorta as the direct access route when other approaches are not feasible.
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Affiliation(s)
- Yong Zhan
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Neil J Wimmer
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Pinak B Shah
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michael J Davidson
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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Aguirre J, Waskowski R, Poddar K, Kapadia S, Krishnaswamy A, McCullough R, Mick S, Navia JL, Roselli EE, Tuzcu ME, Sabik JF, Lytle BW, Svensson LG. Transcatheter aortic valve replacement: Experience with the transapical approach, alternate access sites, and concomitant cardiac repairs. J Thorac Cardiovasc Surg 2014; 148:1417-22. [DOI: 10.1016/j.jtcvs.2014.05.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 04/21/2014] [Accepted: 05/08/2014] [Indexed: 11/28/2022]
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Desai CS, Roselli EE, Svensson LG, Bonow RO. Transcatheter aortic valve replacement: current status and future directions. Semin Thorac Cardiovasc Surg 2014; 25:193-6. [PMID: 24331140 DOI: 10.1053/j.semtcvs.2013.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2013] [Indexed: 11/11/2022]
Abstract
Transcatheter aortic valve replacement (TAVR) is a revolutionary therapy for patients with aortic stenosis. Large registries and randomized controlled trials have demonstrated that TAVR is safe and effective in patients considered inoperable because of severe comorbidities and those who are high-risk surgical candidates. As TAVR evolves for lower-risk patients, attention will need to focus on reducing the rates of vascular injury, stroke, and paravalvular regurgitation. In this review, we discuss the status of TAVR in clinical practice, including patient selection, preoperative evaluation, techniques, and complications.
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Affiliation(s)
- Chintan S Desai
- Department of Preventive Medicine, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Eric E Roselli
- Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Lars G Svensson
- Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Robert O Bonow
- Department of Medicine, Northwestern University, Feinberg School of Medicine, Chicago, Illinois.
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