Avoiding the Learning Curve for Transcatheter Aortic Valve Replacement

Magnetic resonance imaging-guided focused ultrasound thalamotomy launch with remote telemedicine international proctorship

Background

COVID-19 limitations have hindered the implementation of new technologies by preventing proctors from coming to the site. We share our first experience of magnetic resonance imaging (MRI)-guided focused ultrasound (MRgFUS) treatment with an international remote online proctorship, and develop and evaluate the methodology of remote MRgFUS proctorship.

Methods

This single-center, nonrandomized controlled prospective study included 94 patients: 27 with essential tremor (ET) and 67 with tremor-dominant Parkinson's disease (PD). The coming of proctors was impossible, so we arranged for the remote participation of proctors from the United Kingdom, Spain, and Israel. A total of 38 patients (40.4%) received telemedicine-proctored treatment (proctor group) and 56 received their treatment independently (solo group). We used the Clinical Rating Scale for Tremor (CRST) for ET patients and the Unified Parkinson's Disease Rating Scale (UPDRS) Part III for PD patients.

Results

In patients with ET, success rates were 81.8% (proctor group) and 100% (solo group) (p = 0.22). CRST reduction on the treated side was 71.43% [65.83%; 80.56%] (proctor group) versus 60.87% [53.99; 79.58] (solo group) (p = 0.19). None of the patients showed worsening of tremors within 1 year. In patients with PD, the success rates were 92.6% (proctor group) and 100% (solo group) (p = 0.08). The UPDRS Part III improvement was 30.1% (proctor group) versus 39.9% (solo group) (p = 0.003). The 1-year recurrence rate was 40% (proctor group) and 17.5% (solo group) (p = 0.04). No complications were observed at 6 months.

Conclusions

We developed a feasible and safe methodology for telemedicine remote online-proctored MRgFUS treatment. No significant difference was observed between the solo and developed remote proctor protocols in terms of complication rate, effect, and long-term results; however, UPDRS Part III improvement was better in the PD solo group. This study demonstrated that the MRgFUS international proctorship can be performed successfully remotely.

The learning curve in transcatheter aortic valve implantation clinical studies: A systematic review

Background

Transcatheter aortic-valve implantation (TAVI) has become an essential alternative to surgical aortic-valve replacement in the treatment of symptomatic severe aortic stenosis, and this procedure requires technical expertise. The aim of this study was to identify prospective studies on TAVI from the past 10 years, and then to analyze the quality of information reported about the learning curve.

Materials and methods

A systematic review of articles published between 2007 and 2017 was performed using PubMed and the EMBASE database. Prospective studies regarding TAVI were included. The quality of information reported about the learning curve was evaluated using the following criteria: mention of the learning curve, the description of a roll-in phase, the involvement of a proctor, and the number of patients suggested to maintain skills.

Results

A total of sixty-eight studies met the selection criteria and were suitable for analysis. The learning curve was addressed in approximately half of the articles (n = 37, 54 percent). However, the roll-in period was mentioned by only eight studies (12 percent) and with very few details. Furthermore, a proctorship was disclosed in three articles (4 percent) whereas twenty-five studies (37 percent) included authors that were proctors for manufacturers of TAVI.

Conclusion

Many prospective studies on TAVI over the past 10 years mention learning curves as a core component of successful TAVI procedures. However, the quality of information reported about the learning curve is relatively poor, and uniform guidance on how to properly assess the learning curve is still missing.

TAVR Procedural Volumes and Patient Outcomes: Analysis of Recent Data

In less than 15 years, transcatheter aortic valve replacement (TAVR) has progressed from a procedure of last resort in patients at prohibitively high perioperative risk for major morbidity and mortality from surgical valve replacement to a viable alternative option to surgery in most patients with native (non-bicuspid) aortic valve stenosis. The number of medical centers offering TAVR has rapidly proliferated. There is mounting evidence that there are variations in patient outcomes associated with the yearly number of TAVR cases performed at each respective center. This review outlines the evolution of TAVR indications, common complications, the current literature addressing the association between procedural volumes and patient outcomes in TAVR, and offers a synopsis of risk factor assessment for patients considered for TAVR.

Trans-catheter aortic valve replacement program in a community hospital - Comparison with US national data

Symptomatic aortic stenosis remains a surgical disease, with aortic valve replacement resulting in symptom reduction and improvement in survival. For patients who are deemed a higher surgical risk, Transcatheter aortic-valve replacement (TAVR) is a viable, less invasive and increasingly common alternative. The study compares early outcomes in patients treated within one year of the commencement of TAVR program in a community hospital against outcomes of TAVR patients from nationwide reported data (Society of Thoracic Surgeons/ American College of Cardiology TVT registry). Preoperative characteristics and standardized procedural outcomes of all patients who underwent TAVR in Cape Cod Hospital between June 2015 and May 2016 (n = 62, CCH group) were compared using standardized data format to those of TAVR patients operated during the same time period in other centers within the United States participating in the STS/ACC TVT Registry (n = 24,497, USA group). Most preoperative patient characteristics were similar between groups. However, CCH patients were older (age≥80 years: 77.4% versus 64.3%, p = 0.032) and more likely to be non-elective cases (37.1% versus 9.7%, p<0.001). All 62 TAVR procedures in CCH were performed in the catheterization laboratory unlike most (89.7%) of the procedures in the USA group that were performed in hybrid rooms. A larger proportion of patients in the USA registry underwent TAVR under general anesthesia (78.2% vs.37.1%, P<0.001). Early aortic valve re- intervention rate was 0/62 (0%) in the CCH group VS. 74/ 24,497 (0.3%) in the USA group. In hospital mortality, which was defined as death of any cause during thirty days from date of operation, (CCH: 0% vs. USA: 2.5%, p = 0.410) and occurrence of early adverse events (including postoperative para-valvular leaks, conduction defects requiring pacemakers, neurologic and renal complications) were similar in the two groups. The study concludes that with specific team training and co-ordination, and with active support of experienced personnel, high risk patients with severe aortic valve stenosis can be managed safely with a TAVR procedure in a community hospital.

Outcomes of intermediate-risk patients treated with transcatheter and surgical aortic valve replacement in the Veterans Affairs Healthcare System: A single center 20-year experience

BACKGROUND

Transfemoral transcatheter aortic valve replacement (TAVR) was superior to surgical aortic valve replacement (SAVR) in the placement of aortic transcatheter valves (PARTNER) 2A trial (P2). The generalizability of the trial results to the broader population of patients with intermediate surgical risk remains unknown.

OBJECTIVE

To compare the outcomes of SAVR and TAVR among patients with intermediate surgical risk treated in the VA Healthcare System.

METHODS

We retrospectively analyzed the clinical characteristics and outcomes on all SAVR (1987-2014) and TAVR procedures (2015-2017) performed at the Minneapolis VA Healthcare System. Patients were divided into three groups based on their estimated 30-day mortality risk. The primary outcome was a composite of death or stroke at 30-days.

RESULTS

A total of 1,049 patients underwent SAVR with (n = 468, 45%) or without CABG (n = 581, 55%) and 110 underwent TAVR during the study period. Intermediate-risk patients represented 29.4% and 40% of patients undergoing SAVR and TAVR, respectively. The predicted 30-day mortality risk of intermediate-risk patients was 5.5% for the SAVR group and 5.2% for the TAVR group (P = 0.54). The observed combined rate of stroke or death at 30-days for intermediate-risk patients treated with SAVR and TAVR was 11% and 2.2%, respectively (P = 0.05). The results for SAVR and TAVR at the VA were comparable to the P2 trial and STS database (all P = NS). The results did not change when the analysis was restricted to a more contemporary (2005-2014) surgical cohort or isolated SAVR. The number needed to treat to prevent one death/stroke with TAVR was 10.

CONCLUSIONS

Adoption of TAVR as the preferred treatment modality in intermediate-risk patients may result in significant improvements in morbidity and mortality.

Routine use of anticoagulation after transcatheter aortic valve replacement: Initial safety outcomes from a single-center experience

BACKGROUND

Subclinical leaflet thrombosis (SCLT) can be seen in up to 12% of patients after transcatheter aortic valve replacement (TAVR). Anticoagulation appears to prevent and reverse SCLT but concerns exist about bleeding risk.

METHODS

Our program adopted a strategy of routine anticoagulation after TAVR, starting warfarin on post-procedure day 0 and continuing for 3months in 10/2015. We report the initial safety and efficacy outcomes of this approach. Bleeding events were assessed using Valve Academic Research Consortium (VARC) and Bleeding Academic Research Consortium (BARC) definitions.

RESULTS

The median (IQR) age of the population (n=191) was 82years (72-87) and the median (IQR) STS score was 5.6% (3-8). A total of 101 (53%) patients were discharged on anticoagulation (warfarin 97%) while 90 (47%) received antiplatelet therapy alone. The mean duration of anticoagulation therapy was 81±17 days. During follow-up 7 patients (4%) had a stroke or TIA, 3 (3%) in the anticoagulation group and 4 (4%) in the antiplatelet group (p=0.71). A total of 8 patients (4.2%) had BARC bleeding events during follow-up, 3 patients in the anticoagulation group (2.9%) and 5 in the antiplatelet group (5.5%, p=0.48). All bleeding events (VARC and BARC) were numerically lower in the anticoagulation group (8% versus 13%, p=0.20).

CONCLUSIONS

A strategy of routine anticoagulation for 3-months after TAVR is well tolerated and associated with similar or lower bleeding risk compared to antiplatelet therapy.