The development and testing of a smart sensorized guide wire for catheterization in a "blood" vessel phantom to support aortic valve implementation

PURPOSE

Heart valve disease is commonly treated by minimally invasive procedures with guide wires and catheterization. The main purpose of this study is to find out whether an extension of the guide wire with a sensor can support the surgeon within the blood vessel to reduce X-ray necessity.

METHODS

A smart guide wire is developed by an extension with a flex-bending sensor to evaluate the sensor signal with and without "blood" flow at a constant compression force. Various surgically relevant investigations are performed. For assessment, the mean temporal average of the moving averaged filtered ADC signal and a subsequent FFT are carried out.

RESULTS

Results show that there is a smaller sensor signal when the applied force or bending at the sensor is higher. In all investigations, there was a different sensor signal. The flex-bending sensor can detect the effect of pulsatile flow. The smallest temporal averaged signal difference between reference and clamp in the front wire's tip is 1.09%. For example, the mean temporal average of the filtered ADC signal for different clinically relevant scenarios is between 2550 and 2900.

CONCLUSIONS

The results show that the sensorized guide wire developed for catheterization can support aortic valve implementation. The sensor sensitivity is sufficient to detect even very small variations within the blood vessel and therefore is promising to support catheterization heart valve surgeries in future.

New Intercostal Transcatheter Aortic Valve Replacement Access: No Touch

Transcatheter aortic valve replacement (TAVR) is routinely performed via the transfemoral or transapical route. Subclavian, transcarotid, and transaortic access are described as alternative routes for TAVR. The small intercostal approach can be used for a safe TAVR without touching the ribs and sternum.

Minireview: Transaortic Transcatheter Aortic Valve Implantation: Is There Still an Indication?

Transaortic (TAo) transcatheter aortic valve implantation has become a valid alternative access route in patients with unsuitable femoral arteries. The current literature does not allow to clearly favor one of the alternative access routes. Every approach has its specific advantages. Transaortic (TAo) access is of particular importance in the case of calcifications of the supra-aortic branches and the aortic arch, as under these circumstances other alternative access routes, such as transaxillary or transcarotid, are not feasible. The purpose of this minireview is to give an overview and update on TAo transcatheter aortic valve implantation focusing on indication, technical aspects, and recent clinical data.

Budget impact analysis of transcatheter aortic valve replacement in low, intermediate, and high-risk patients with severe aortic stenosis in Saudi Arabia

AIMS

A budget impact analysis (BIA) comparing transcatheter aortic valve replacement (TAVR) with SAPIEN 3 and surgical aortic valve replacement (SAVR) for severe, symptomatic aortic stenosis among patients of low, intermediate, and high surgical risk from the perspective of the public and private sectors in Saudi Arabia.

MATERIALS AND METHODS

A Markov model was developed with six states to calculate the budget impact from time of either TAVR or SAVR intervention up to 5 years. We compared the budget effects of new permanent pacemaker implantation (PPI), new onset atrial fibrillation (AF), major/disabling stroke (MDS), and surgical site infections (SSI). One-way sensitivity analyses (OWSA) were performed on cost and probability inputs.

RESULTS

Analysis of the base case parameters suggests TAVR vs. SAVR is budget saving among intermediate- and high-risk patients at 5 years. TAVR vs. SAVR for low surgical risk reaches budget neutrality at 5 years. TAVR is associated with higher costs for PPI and budget savings for MDS, AF, and SSI. TAVR also results in savings for non-device costs due to fewer human resource uses and shorter procedure durations. Similarly, TAVR is associated with cost savings due to shorter hospital intensive care unit (ICU) and non-ICU stays. The OWSA consistently revealed that SAVR non-device theater costs were the leading cost driver across all surgical risk levels.

LIMITATIONS

This is the first budget impact analysis of its kind in Saudi Arabia and future research is needed on costing TAVR and SAVR procedures, the economic impact of SSI, and corroborating estimates for the public and private sectors.

CONCLUSIONS

Payers, providers, and policymakers increasingly turn to results of BIA to inform technologies affordability decisions. TAVR with SAPIEN 3 appears to generate savings vs. SAVR from a budget impact perspective across various surgical risk levels in Saudi Arabia.

Midterm outcomes of transaortic and transapical TAVI in patients with unsuitable vascular anatomy for femoral access: A propensity score inverse probability weight study

AIMS

Transaortic (TAo) and transapical (TA) implantation can be used in transcatheter aortic valve implantation (TAVI) when the transfemoral (TF) approach is precluded. We compare the safety and efficacy of these alternative techniques.

METHODS

From October 2007 to February 2016, TAo and TA patients' data were collected. Propensity score inverse probability of treatment weight (IPTW) method was employed to minimize the impact of no-randomization bias.

RESULTS

From our single-center non-TF-TAVI registry, 282 patients were included: 235 (83.3%) underwent TAo and 47 (16.7%) TA. Differences in baseline characteristics were statistically significant in age, sex, risk profile according to logistic-EuroSCORE, and previous cardiac surgery. No difference in hospital morbidity and mortality, but lower stroke-rate in TAo (1.27% vs. 8.5% p < .01) was observed. This was confirmed at logistic regression after IPTW adjustment (odds ratio [OR]: 0.16, 95% CI 0.03-0.71, p = .01), together with reduced risk of the paravalvular leak (PVL) (OR: 0.14, 95% confidence interval [CI]: 0.02-0.81, p = .02). Kaplan-Meier estimates did not demonstrate differences in long-term mortality among access routes (logrank test p = .13). At the IPTW-Cox regression model, long-term mortality was related to New York Heart Association III-IV (hazard ratio [HR]: 2.92, 95% CI: 1.15-7.40, p = .026), chronic renal failure (HR: 3.25; 95% CI: 1.02-10.32 p = .046), previous transient ischemic attack/stroke (HR: 2.29, 95% CI: 1.25-4.20 p = .007). Sapien-3 device resulted to be a protective factor, reducing long-term mortality (HR: 0.18, 95% CI 0.04- 0.90 p = .03).

CONCLUSIONS

TAo is safe and feasible in case of contraindication to femoral approach demonstrating comparable midterm outcomes to TA, thus representing a central access alternative, to increase the overall safety of high-risk TAVI procedures.

Transcatheter aortic valve implantation via surgical subclavian versus direct aortic access: A United Kingdom analysis

BACKGROUND

Surgical subclavian (SC) and direct aortic (DA) access are established alternatives to the default transfemoral route for transcatheter aortic valve implantation (TAVI). We sought to find differences in survival and procedure-related outcomes after SC- versus DA-TAVI.

METHODS

We performed an observational cohort analysis of cases prospectively uploaded to the UK TAVI registry. To ensure the most contemporaneous comparison, the analysis focused on SC and DA procedures performed from 2013 to 2015.

RESULTS

Between January 2013 and July 2015, 82 (37%) SC and 142 (63%) DA cases were performed that had validated 1-year life status. Multivariable regression analysis showed procedure duration was longer for SC cases (SC 193.5 ± 65.8 vs. DA 138.4 ± 57.7 min; p < .01) but length of hospital stay was shorter (SC 8.6 ± 9.5 vs. DA 11.9 ± 10.8 days; p = .03). Acute kidney injury was observed less frequently after SC cases (odds ratio [OR] 0.35, 95% confidence interval [CI 0.12-0.96]; p = .042) but vascular access site-related complications were more common (OR 9.75 [3.07-30.93]; p < .01). Procedure-related bleeding (OR 0.54 [0.24-1.25]; p = .15) and in-hospital stroke rate (SC 3.7% vs. DA 2.1%; p = .67) were similar. There were no significant differences in in-hospital (SC 2.4% vs. DA 4.9%; p = .49), 30-day (SC 2.4% vs. DA 4.2%; p = .71) or 1-year (SC 14.5% vs. DA 21.9%; p = .344) mortality.

CONCLUSIONS

Surgical subclavian and direct aortic approaches can offer favourable outcomes in appropriate patients. Neither access modality conferred a survival advantage but there were significant differences in procedural metrics that might influence which approach is selected.

Direct aortic route versus transaxillary route for transcatheter aortic valve replacement: a systematic review and meta-analysis

Background

The transfemoral route is contraindicated in nearly 10% of transcatheter aortic valve replacement (TAVR) candidates because of unsuitable iliofemoral vessels. Transaxillary (TAx) and direct aortic (DAo) routes are the principal nonfemoral TAVR routes; however, few studies have compared their outcomes.

Methods

We performed a systematic review and meta-analysis to compare the rates of mortality, stroke, and other adverse events of TAx and DAo TAVR. The study was prospectively registered with PROSPERO (registration number: CRD42017069788). We searched Medline, PubMed, Embase, and Cochrane databases for studies reporting the outcomes of DAo or TAx TAVR in at least 10 patients. Studies that did not use the Valve Academic Research Consortium definitions were excluded. We included studies that did not directly compare the two approaches and then pooled rates of events from the included studies for comparison.

Results

In total, 31 studies were included in the quantitative meta-analysis, with 2,883 and 2,172 patients in the DAo and TAx TAVR groups, respectively. Compared with TAx TAVR, DAo TAVR had a lower Society of Thoracic Surgery (STS) score, shorter fluoroscopic time, and less contrast volume use. The 30-day mortality rates were significantly higher in the DAo TAVR group (9.6%, 95% confidence interval (CI) = [8.4–10.9]) than in the TAx TAVR group (5.7%, 95% CI = [4.8–6.8]; P for heterogeneity <0.001). DAo TAVR was associated with a significantly lower risk of stroke in the overall study population (2.6% vs. 5.8%, P for heterogeneity <0.001) and in the subgroup of studies with a mean STS score of ≥8 (1.6% vs. 6.2%, P for heterogeneity = 0.005). DAo TAVR was also associated with lower risks of permanent pacemaker implantation (12.3% vs. 20.1%, P for heterogeneity = 0.009) and valve malposition (2.0% vs. 10.2%, P for heterogeneity = 0.023) than was TAx TAVR.

Conclusions

DAo TAVR increased 30-day mortality rate compared with TAx TAVR; by contrast, TAx TAVR increased postoperative stroke, permanent pacemaker implantation, and valve malposition risks compared with DAo TAVR.

Imaging of transcatheter aortic valve replacement complications

Aortic stenosis is increasing in incidence and is now commonly managed with transcatheter aortic valve replacement (TAVR) in intermediate and high-risk patients. Radiologists are likely to encounter patients undergoing this procedure both pre- and postoperatively, and therefore, an understanding of procedural complications is essential. Complications may relate to the access site or approach, or the valve itself. This article will review the most common complications described in literature and focuses on the role of multidetector computed tomography (CT) in their evaluation either exclusively, or complementary to other imaging methods.

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.