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Gregory AJ, Kent WDT, Adams C, Arora RC. Closing the care gap: combining enhanced recovery with minimally invasive valve surgery. Curr Opin Cardiol 2024; 39:380-387. [PMID: 38606679 DOI: 10.1097/hco.0000000000001147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
PURPOSE OF REVIEW Patients with advanced age and frailty require interventions for structural heart disease at an increasing rate. These patients typically experience higher rates of postoperative morbidity, mortality and prolonged hospital length of stay, loss of independence as well as associated increased costs to the healthcare system. Therefore, it is becoming critically important to raise awareness and develop strategies to improve clinical outcomes in the contemporary, high-risk patient population undergoing cardiacprocedures. RECENT FINDINGS Percutaneous options for structural heart disease have dramatically improved the therapeutic options for some older, frail, high-risk patients; however, others may still require cardiac surgery. Minimally invasive techniques can reduce some of the physiologic burden experienced by patients undergoing surgery and improve recovery. Enhanced Recovery After Cardiac Surgery (ERAS Cardiac) is a comprehensive, interdisciplinary, evidence-based approach to perioperative care. It has been shown to improve recovery and patient satisfaction while reducing complications and length of stay. SUMMARY Combining minimally invasive cardiac surgery with enhanced recovery protocols may result in improved patient outcomes for a patient population at high risk of morbidity and mortality following cardiac surgery.
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Affiliation(s)
- Alexander J Gregory
- Department of Anesthesiology, Perioperative and Pain Medicine, Cumming School of Medicine
- Libin Cardiovascular Institute, Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - William D T Kent
- Libin Cardiovascular Institute, Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Corey Adams
- Libin Cardiovascular Institute, Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Rakesh C Arora
- Harrington Heart and Vascular Institute - University Hospitals, Cleveland, Ohio, USA
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Damluji AA, Bernacki G, Afilalo J, Lyubarova R, Orkaby AR, Kwak MJ, Hummel S, Kirkpatrick JN, Maurer MS, Wenger N, Rich MW, Kim DH, Wang RY, Forman DE, Krishnaswami A. TAVR in Older Adults: Moving Toward a Comprehensive Geriatric Assessment and Away From Chronological Age: JACC Family Series. JACC. ADVANCES 2024; 3:100877. [PMID: 38694996 PMCID: PMC11062620 DOI: 10.1016/j.jacadv.2024.100877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 01/15/2024] [Accepted: 01/29/2024] [Indexed: 05/04/2024]
Abstract
Calcific aortic stenosis can be considered a model for geriatric cardiovascular conditions due to a confluence of factors. The remarkable technological development of transcatheter aortic valve replacement was studied initially on older adult populations with prohibitive or high-risk for surgical valve replacement. Through these trials, the cardiovascular community has recognized that stratification of these chronologically older adults can be improved incrementally by invoking the concept of frailty and other geriatric risks. Given the complexity of the aging process, stratification by chronological age should only be the initial step but is no longer sufficient to optimally quantify cardiovascular and noncardiovascular risk. In this review, we employ a geriatric cardiology lens to focus on the diagnosis and the comprehensive management of aortic stenosis in older adults to enhance shared decision-making with patients and their families and optimize patient-centered outcomes. Finally, we highlight knowledge gaps that are critical for future areas of study.
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Affiliation(s)
- Abdulla A. Damluji
- Inova Heart and Vascular Institute, Inova Center of Outcomes Research, Falls Church, Virginia, USA
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Gwen Bernacki
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
- Hospital and Specialty Medicine Service, Veterans Administration (VA) Puget Sound Health Care System, Seattle, Washington, USA
- Geriatric Research, Education and Clinical Center (GRECC), Veterans Administration (VA) Puget Sound Health Care System, Seattle, Washington, USA
| | - Jonathan Afilalo
- Department of Medicine/Cardiology, McGill University, Montreal, Canada
| | - Radmila Lyubarova
- Department of Medicine/Cardiology, Albany Medical College, Albany, New York, USA
| | - Ariela R. Orkaby
- New England GRECC, VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Medicine, Brigham & Women’s Hospital, Boston, Massachusetts, USA
| | - Min Ji Kwak
- Division of Geriatric and Palliative Medicine, McGovern Medical School, University of Texas Health Science Center, Houston, Texas, USA
| | - Scott Hummel
- Division of Cardiology, University of Michigan, Ann Arbor, Michigan, USA
- Geriatric Research Education and Clinical Center, VA Ann Arbor Health Care System, Ann Arbor, Michigan, USA
| | - James N. Kirkpatrick
- Division of Cardiology and Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, Washington, USA
| | - Mathew S. Maurer
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Nanette Wenger
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Michael W. Rich
- Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Dae Hyun Kim
- Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts, USA
| | - Roberta Y. Wang
- Department of Physical Medicine & Rehabilitation, Santa Clara Valley Medical Center, San Jose, California, USA
| | - Daniel E. Forman
- Department of Medicine (Divisions of Cardiology and Geriatrics) and Pittsburgh GRECC, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ashok Krishnaswami
- Division of Cardiology, Kaiser Permanente, San Jose Medical Center, San Jose, California, USA
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Šolc AJ, Línková H, Toušek P. Transcatheter aortic valve durability, predictors of bioprosthetic valve dysfunction, longer-term outcomes - a review. Expert Rev Med Devices 2024; 21:15-26. [PMID: 38032186 DOI: 10.1080/17434440.2023.2288275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 11/22/2023] [Indexed: 12/01/2023]
Abstract
INTRODUCTION Transcatheter aortic valve implantation (TAVI) is one of the most significant inventions in cardiology, as it provides a viable minimally invasive treatment option for patients with aortic stenosis, the most common valvular disease in the developed world and one with a poor prognosis when left untreated. Using data available to date, this review aims to discuss and identify possible predictors of TAVI valve durability - an essential requirement for the device's wide-spread use, especially in younger patients. AREAS COVERED This article explores the main causes of bioprosthetic valve dysfunction (BVD) based on pathophysiology and available data, and reviews possible predictors of BVD including prosthesis-related, procedure-related, and patient-related factors. An emphasis is made on affectable predictors, which could potentially be targeted with prevention management and improve valve durability. A literature search of online medical databases was conducted using relevant key words and dates; significant clinical trials were identified. A brief overview of important randomized controlled trials with mid to long-term follow-up is included in this article. EXPERT OPINION Identifying modifiable predictors of valve dysfunction presents an opportunity to enhance and predict valve durability - a necessity as patients with longer life-expectancies are being considered for the procedure.
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Affiliation(s)
- Abigail Johanna Šolc
- Third Faculty of Medicine, Charles University, Prague, Czech Republic
- Department of Cardiology, University Hospital Kralovské Vinohrady, Prague, Czech Republic
| | - Hana Línková
- Third Faculty of Medicine, Charles University, Prague, Czech Republic
- Department of Cardiology, University Hospital Kralovské Vinohrady, Prague, Czech Republic
| | - Petr Toušek
- Department of Cardiology, Third Faculty of Medicine, University Hospital Královské Vinohrady, Charles University, Prague, Czech Republic
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Cormican DS. The Economic Impact of Transcatheter Aortic Valve Replacement in Low-Surgical-Risk Patients Over 2 Years: The Start of the Conversation, Not the Final Word. J Cardiothorac Vasc Anesth 2023; 37:2425-2427. [PMID: 37709609 DOI: 10.1053/j.jvca.2023.08.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 08/09/2023] [Indexed: 09/16/2023]
Affiliation(s)
- Daniel S Cormican
- Division of Cardiothoracic Anesthesiology, Division of Surgical Critical Care, Anesthesiology Institute, Allegheny Health Network, Pittsburgh, PA
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Halim J, den Heijer P, van den Branden B, Meuwissen M, Vos J, Schölzel B, IJsselmuiden A. Short-term outcome after transcatheter aortic valve replacement with a novel balloon-expandable valve. Neth Heart J 2023; 31:500-505. [PMID: 36480146 PMCID: PMC10667167 DOI: 10.1007/s12471-022-01738-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2022] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Transcatheter aortic valve replacement (TAVR) has been expanding rapidly with numerous transcatheter heart valve (THV) systems currently available. The Myval balloon-expandable (BE) valve (Meril Life Sciences Pvt. Ltd., India) is a novel THV system indicated for the treatment of patients with severe aortic stenosis. The primary objective of this study is to assess the safety and performance of the Myval BE valve. METHODS In this prospective single-centre study, 120 consecutive patients who underwent TAVR with the Myval BE valve were included. Clinical outcomes were evaluated at 30 days and 6 months using Valve Academic Research Consortium‑2 criteria. All-cause mortality, stroke, acute kidney injury, major vascular complications, moderate or severe paravalvular leakage (PVL) and need for a permanent pacemaker implantation (PPI) were investigated. RESULTS At 6‑month follow-up, all-cause death and cardiac death were seen in 5.8% and 0.8% of the patients respectively. Periprocedural stroke and need for PPI were both seen in 3.3% of the patients. Access-site-related vascular and bleeding complications were absent. Improved valve haemodynamics and no moderate to severe PVL could be seen at 30 days. An intermediate valve size was selected in 51% of the patients. CONCLUSIONS The Myval BE valve demonstrates improved valve haemodynamics, absence of moderate to severe PVL and good safety outcomes at 6‑month follow-up with low cardiac death rate and acceptable rates of permanent pacemaker implantation and periprocedural stroke. Future randomised controlled trials will further establish the clinical utility of the Myval BE valve.
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Affiliation(s)
- J Halim
- Department of Cardiology, Amphia Hospital Breda, Breda, The Netherlands.
| | - P den Heijer
- Department of Cardiology, Amphia Hospital Breda, Breda, The Netherlands
| | - B van den Branden
- Department of Cardiology, Amphia Hospital Breda, Breda, The Netherlands
| | - M Meuwissen
- Department of Cardiology, Amphia Hospital Breda, Breda, The Netherlands
| | - J Vos
- Department of Cardiology, Amphia Hospital Breda, Breda, The Netherlands
| | - B Schölzel
- Department of Cardiology, Amphia Hospital Breda, Breda, The Netherlands
| | - A IJsselmuiden
- Department of Cardiology, Amphia Hospital Breda, Breda, The Netherlands
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Nübel J, Hauptmann M, Schön J, Fritz G, Butter C, Haase-Fielitz A. App-based assessment of memory functions in patients after transfemoral aortic valve replacement. J Geriatr Cardiol 2023; 20:664-672. [PMID: 37840630 PMCID: PMC10568551 DOI: 10.26599/1671-5411.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023] Open
Abstract
BACKGROUND Transfemoral aortic valve replacement (TAVR) is the standard treatment for elderly patients with aortic valve stenosis. Although safe and well-established, there is a risk of intraprocedural hemodynamic instability and silent cerebral embolism, which can lead to a decline in neurocognitive function and dementia. In clinical practice, comprehensive cognitive testing is difficult to perform. AI-assisted digital applications may help to optimize diagnosis and monitoring. METHODS Neurocognitive function was assessed by validated psychometric tests using "∆elta -App", which uses artificial intelligence and computational linguistic methods for extraction and analysis. Memory function was assessed using the 'Consortium to Establish a Registry for Alzheimer's Disease' (CERAD) word list and digit span task (DST) before TAVR and before hospital discharge. The study is registered in the German Register of Clinical Trials (https://drks.de/search/de/trial/DRKS00020813). RESULTS From October 2020 until March 2022, 141 patients were enrolled at University Hospital Heart Centre Brandenburg. Mean age was 81 ± 6 years, 42.6% were women. Time between the pre- and post-interventional test was on average 6 ± 3 days. Memory function before TAVR was found to be below average in relation to age and educational level. The pre-post TAVR comparison showed significant improvements in the wordlist repeat, P < 0.001 and wordlist recall test of CERAD, P < 0.001. There were no changes in the digital span test. CONCLUSIONS Despite impaired preoperative memory function before TAVR, no global negative effect on memory function after TVAR was detected. The improvements shown in the word list test should be interpreted as usual learning effects in this task.
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Affiliation(s)
- Jonathan Nübel
- Department of Cardiology, University Hospital Heart Centre Brandenburg, Brandenburg Medical School (MHB) Theodor Fontane, Bernau, Germany
| | - Michael Hauptmann
- Institute of Biostatistics and Registry Research, Brandenburg Medical School Theodor Fontane, Neuruppin, Germany
- Faculty of Health Sciences (FGW), Joint Faculty of the University of Potsdam, the Brandenburg Medical School Theodor Fontane and the Brandenburg Technical University Cottbus-Senftenberg, Cottbus, Germany
| | - Julika Schön
- Anesthesia and Intensive Care, University Hospital Ruppin Brandenburg (ukrb), Brandenburg Medical School (MHB) Theodor Fontane, Neuruppin, Germany
| | - Georg Fritz
- Department of Anesthesiology, Intensive Care and Pain Therapy, University Hospital Heart Centre Brandenburg, Brandenburg Medical School (MHB) Theodor Fontane, Bernau, Germany
| | - Christian Butter
- Department of Cardiology, University Hospital Heart Centre Brandenburg, Brandenburg Medical School (MHB) Theodor Fontane, Bernau, Germany
- Faculty of Health Sciences (FGW), Joint Faculty of the University of Potsdam, the Brandenburg Medical School Theodor Fontane and the Brandenburg Technical University Cottbus-Senftenberg, Cottbus, Germany
| | - Anja Haase-Fielitz
- Department of Cardiology, University Hospital Heart Centre Brandenburg, Brandenburg Medical School (MHB) Theodor Fontane, Bernau, Germany
- Faculty of Health Sciences (FGW), Joint Faculty of the University of Potsdam, the Brandenburg Medical School Theodor Fontane and the Brandenburg Technical University Cottbus-Senftenberg, Cottbus, Germany
- Institute of Social Medicine and Health System Research, Otto von Guericke University Magdeburg, Germany
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Kirmani BH, Akowuah E. Minimal Access Aortic Valve Surgery. J Cardiovasc Dev Dis 2023; 10:281. [PMID: 37504537 PMCID: PMC10380690 DOI: 10.3390/jcdd10070281] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 06/24/2023] [Accepted: 06/26/2023] [Indexed: 07/29/2023] Open
Abstract
Minimally invasive approaches to the aortic valve have been described since 1993, with great hopes that they would become universal and facilitate day-case cardiac surgery. The literature has shown that these procedures can be undertaken with equivalent mortality rates, similar operative times, comparable costs, and some benefits regarding hospital length of stay. The competing efforts of transcatheter aortic valve implantation for these same outcomes have provided an excellent range of treatment options for patients from cardiology teams. We describe the current state of the art, including technical considerations, caveats, and complications of minimal access aortic surgery and predict future directions in this space.
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Affiliation(s)
- Bilal H Kirmani
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK
| | - Enoch Akowuah
- Cardiac Surgery, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
- Academic Cardiovascular Unit, South Tees NHS Foundation Trust, Middlesbrough TS4 3BW, UK
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Halim J, Rooijakkers M, den Heijer P, El Haddad M, van den Branden B, Vos J, Schölzel B, Meuwissen M, van Gameren M, El Messaoudi S, van Royen N, IJsselmuiden S. Assessing the Novel Myval Balloon-Expandable Valve with the Evolut Valve: A Propensity-Matched Study. J Clin Med 2023; 12:4213. [PMID: 37445248 DOI: 10.3390/jcm12134213] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/08/2023] [Accepted: 06/20/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND The Myval balloon-expandable (BE) valve has shown encouraging early clinical data in terms of safety and efficacy. Comparative data with other well-established contemporary valves are nonetheless still scarce. This study aims to compare the performance of the Myval BE valve with the Evolut self-expanding (SE) valve. METHODS In this retrospective single-center study, 223 patients with symptomatic severe aortic stenosis (AS) were included and treated with the Myval BE valve (n = 120) or with the Evolut SE valve (n = 103). Then, 91 pairs were compared after matching. Clinical outcomes were evaluated at 30 days and 1 year. Echocardiographic follow-up was performed at 30 days. RESULTS Procedural complications were rare in both groups. At the 30-day follow-up, no significant difference in cardiac death (Myval: 1% vs. Evolut: 2%, p = 0.56), stroke (2% vs. 4%, p = 0.41) and myocardial infarction (1% vs. 3%, p = 0.31) was observed. A permanent pacemaker implantation (PPI) was significantly less needed in the Myval group (4% vs. 15%, p = 0.01). At 1 year, cardiac death (2% vs. 4%, p = 0.41) and the stroke rate (7% vs. 5%, p = 0.76) were similar. Moderate-severe paravalvular leakage (PVL) was also comparable in both groups (1% vs. 4%, p = 0.17). CONCLUSION Safety and efficacy outcomes were comparable between the two valves, except for a higher PPI rate for the Evolut SE valve. Up to 1-year follow-up, clinical outcomes showed acceptable rates of stroke and cardiac death with both valves. Valve hemodynamics were excellent with a low rate of moderate-severe PVL in both groups.
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Affiliation(s)
- Jonathan Halim
- Department of Cardiology, Amphia Hospital Breda, Molengracht 21, 4818 CK Breda, The Netherlands
| | - Maxim Rooijakkers
- Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Peter den Heijer
- Department of Cardiology, Amphia Hospital Breda, Molengracht 21, 4818 CK Breda, The Netherlands
| | - Milad El Haddad
- Department of Cardiology, AZ Sint-Jan Brugge, Ruddershove 10, 8000 Bruges, Belgium
| | - Ben van den Branden
- Department of Cardiology, Amphia Hospital Breda, Molengracht 21, 4818 CK Breda, The Netherlands
| | - Jeroen Vos
- Department of Cardiology, Amphia Hospital Breda, Molengracht 21, 4818 CK Breda, The Netherlands
| | - Bas Schölzel
- Department of Cardiology, Amphia Hospital Breda, Molengracht 21, 4818 CK Breda, The Netherlands
| | - Martijn Meuwissen
- Department of Cardiology, Amphia Hospital Breda, Molengracht 21, 4818 CK Breda, The Netherlands
| | - Menno van Gameren
- Department of Cardiology, Amphia Hospital Breda, Molengracht 21, 4818 CK Breda, The Netherlands
| | - Saloua El Messaoudi
- Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Sander IJsselmuiden
- Department of Cardiology, Amphia Hospital Breda, Molengracht 21, 4818 CK Breda, The Netherlands
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Garber L, Khodaei S, Maftoon N, Keshavarz-Motamed Z. Impact of TAVR on coronary artery hemodynamics using clinical measurements and image-based patient-specific in silico modeling. Sci Rep 2023; 13:8948. [PMID: 37268642 DOI: 10.1038/s41598-023-31987-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/21/2023] [Indexed: 06/04/2023] Open
Abstract
In recent years, transcatheter aortic valve replacement (TAVR) has become the leading method for treating aortic stenosis. While the procedure has improved dramatically in the past decade, there are still uncertainties about the impact of TAVR on coronary blood flow. Recent research has indicated that negative coronary events after TAVR may be partially driven by impaired coronary blood flow dynamics. Furthermore, the current technologies to rapidly obtain non-invasive coronary blood flow data are relatively limited. Herein, we present a lumped parameter computational model to simulate coronary blood flow in the main arteries as well as a series of cardiovascular hemodynamic metrics. The model was designed to only use a few inputs parameters from echocardiography, computed tomography and a sphygmomanometer. The novel computational model was then validated and applied to 19 patients undergoing TAVR to examine the impact of the procedure on coronary blood flow in the left anterior descending (LAD) artery, left circumflex (LCX) artery and right coronary artery (RCA) and various global hemodynamics metrics. Based on our findings, the changes in coronary blood flow after TAVR varied and were subject specific (37% had increased flow in all three coronary arteries, 32% had decreased flow in all coronary arteries, and 31% had both increased and decreased flow in different coronary arteries). Additionally, valvular pressure gradient, left ventricle (LV) workload and maximum LV pressure decreased by 61.5%, 4.5% and 13.0% respectively, while mean arterial pressure and cardiac output increased by 6.9% and 9.9% after TAVR. By applying this proof-of-concept computational model, a series of hemodynamic metrics were generated non-invasively which can help to better understand the individual relationships between TAVR and mean and peak coronary flow rates. In the future, tools such as these may play a vital role by providing clinicians with rapid insight into various cardiac and coronary metrics, rendering the planning for TAVR and other cardiovascular procedures more personalized.
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Affiliation(s)
- Louis Garber
- School of Biomedical Engineering, McMaster University, Hamilton, ON, Canada
| | - Seyedvahid Khodaei
- Department of Mechanical Engineering (Mail to JHE-310), McMaster University, Hamilton, ON, L8S 4L7, Canada
| | - Nima Maftoon
- Department of Systems Design Engineering, University of Waterloo, Waterloo, ON, Canada
- Centre for Bioengineering and Biotechnology, University of Waterloo, Waterloo, ON, Canada
| | - Zahra Keshavarz-Motamed
- School of Biomedical Engineering, McMaster University, Hamilton, ON, Canada.
- Department of Mechanical Engineering (Mail to JHE-310), McMaster University, Hamilton, ON, L8S 4L7, Canada.
- School of Computational Science and Engineering, McMaster University, Hamilton, ON, Canada.
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10
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Teramoto M, Yamagishi K, Cui R, Shirai K, Tamakoshi A, Iso H. Body Mass Index and Mortality from Nonrheumatic Aortic Valve Disease among Japanese Men and Women. J Atheroscler Thromb 2023; 30:150-159. [PMID: 35418541 PMCID: PMC9925207 DOI: 10.5551/jat.63452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
AIM We aimed to examine the impact of overweight and obesity on mortality from nonrheumatic aortic valve disease. METHODS In the Japan Collaborative Cohort Study, we analyzed data of 98,378 participants aged 40-79 years, with no history of coronary heart disease, stroke, or cancer at baseline (1988-1990) and who completed a lifestyle questionnaire including height and body weight; they were followed for mortality until the end of 2009. The Cox proportional hazards model was used to calculate the multivariable hazard ratios (HRs) with 95% confidence intervals (CIs) of nonrheumatic aortic valve disease mortality according to body mass index (BMI) after adjusting for potential confounding factors. RESULTS During the median 19.2 years follow-up, 60 deaths from nonrheumatic aortic valve disease were reported. BMI was positively associated with the risk of mortality from nonrheumatic aortic valve disease; the multivariable HRs (95% CIs) were 0.90 (0.40-2.06) for persons with BMI <21 kg/m2, 1.71 (0.81-3.58) for BMI 23-24.9 kg/m2, 1.65 (0.69-3.94) for BMI 25-26.9 kg/m2, and 2.83 (1.20-6.65) for BMI ≥ 27 kg/m2 (p for trend=0.006), compared with persons with BMI 21-22.9 kg/m2. Similar associations were observed between men and women (p for interaction=0.56). Excluding those who died during the first ten years of follow-up or a competing risk analysis with other causes of death as competing risk events did not change the association materially. CONCLUSIONS Overweight and obesity may be independent risk factors for nonrheumatic aortic valve disease mortality in Asian populations.
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Affiliation(s)
- Masayuki Teramoto
- Public Health, Department of Social Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kazumasa Yamagishi
- Department of Public Health Medicine, Faculty of Medicine, and Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
| | - Renzhe Cui
- Public Health, Department of Social Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kokoro Shirai
- Public Health, Department of Social Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Akiko Tamakoshi
- Department of Preventive Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hiroyasu Iso
- Public Health, Department of Social Medicine, Osaka University Graduate School of Medicine, Osaka, Japan,Department of Public Health Medicine, Faculty of Medicine, and Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
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Guichard L, Bhatia M. Con: General Anesthesia Should No Longer Routinely Be Used for Transfemoral Transcatheter Aortic Valve Replacement. J Cardiothorac Vasc Anesth 2022; 37:829-831. [PMID: 36641306 DOI: 10.1053/j.jvca.2022.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Lauriane Guichard
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Meena Bhatia
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
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12
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Kopanczyk R, Kumar N, Bhatt AM. A Brief History of Cardiothoracic Surgical Critical Care Medicine in the United States. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58121856. [PMID: 36557057 PMCID: PMC9788562 DOI: 10.3390/medicina58121856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/14/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022]
Abstract
Cardiothoracic surgical intensive care has developed in response to advances in cardiothoracic surgery. The invention of the cardiopulmonary bypass machine facilitated a motionless and bloodless surgical field and made operations of increasing complexity feasible. By the mid-1950s, the first successful procedures utilizing cardiopulmonary bypass took place. This was soon followed by the establishment of postoperative recovery units, the precursors to current cardiothoracic surgical intensive care units. These developments fostered the emergence of a new medical specialty: the discipline of critical care medicine. Together, surgeons and intensivists transformed the landscape of acute, in-hospital care. It is important to celebrate these achievements by remembering the individuals responsible for their conception. This article describes the early days of cardiothoracic surgery and cardiothoracic intensive care medicine.
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Affiliation(s)
- Rafal Kopanczyk
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
- Correspondence:
| | - Nicolas Kumar
- Department of Anesthesiology, Pain Medicine and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Amar M. Bhatt
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
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13
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Almas T, Haider R, Malik J, Mehmood A, Alvi A, Naz H, Satti DI, Zaidi SMJ, AlSubai AK, AlNajdi S, Alsufyani R, Ramtohul RK, Almesri A, Alsufyani M, H. Al-Bunnia A, Alghamdi HAS, Sattar Y, Alraies MC, Raina S. Nanotechnology in interventional cardiology: A state-of-the-art review. IJC HEART & VASCULATURE 2022; 43:101149. [DOI: 10.1016/j.ijcha.2022.101149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 11/03/2022] [Accepted: 11/14/2022] [Indexed: 11/19/2022]
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14
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Xenofontos P, Zamani R, Akrami M. The application of 3D printing in preoperative planning for transcatheter aortic valve replacement: a systematic review. Biomed Eng Online 2022; 21:59. [PMID: 36050722 PMCID: PMC9434927 DOI: 10.1186/s12938-022-01029-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 08/24/2022] [Indexed: 11/10/2022] Open
Abstract
Background Recently, transcatheter aortic valve replacement (TAVR) has been suggested as a less invasive treatment compared to surgical aortic valve replacement, for patients with severe aortic stenosis. Despite the attention, persisting evidence suggests that several procedural complications are more prevalent with the transcatheter approach. Consequently, a systematic review was undertaken to evaluate the application of three-dimensional (3D) printing in preoperative planning for TAVR, as a means of predicting and subsequently, reducing the incidence of adverse events. Methods MEDLINE, Web of Science and Embase were searched to identify studies that utilised patient-specific 3D printed models to predict or mitigate the risk of procedural complications. Results 13 of 219 papers met the inclusion criteria of this review. The eligible studies have shown that 3D printing has most commonly been used to predict the occurrence and severity of paravalvular regurgitation, with relatively high accuracy. Studies have also explored the usefulness of 3D printed anatomical models in reducing the incidence of coronary artery obstruction, new-onset conduction disturbance and aortic annular rapture. Conclusion Patient-specific 3D models can be used in pre-procedural planning for challenging cases, to help deliver personalised treatment. However, the application of 3D printing is not recommended for routine clinical practice, due to practicality issues.
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Affiliation(s)
| | - Reza Zamani
- Medical School, College of Medicine and Health, Exeter, UK
| | - Mohammad Akrami
- Department of Engineering, College of Engineering, Mathematics, and Physical Sciences, University of Exeter, Exeter, UK.
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15
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Butany J, Schoen FJ. Cardiac valve replacement and related interventions. Cardiovasc Pathol 2022. [DOI: 10.1016/b978-0-12-822224-9.00010-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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16
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Bodmer NJ, Fielding-Singh V, Vanneman MW. Transcatheter Aortic Valve Dissemination: The More the Merrier or Too Much of a Good Thing? J Cardiothorac Vasc Anesth 2021; 36:925-928. [PMID: 34974961 DOI: 10.1053/j.jvca.2021.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 11/15/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Natalie J Bodmer
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Vikram Fielding-Singh
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Matthew W Vanneman
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA.
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17
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Sturm RC, Harrison J, Tandar A. Frailty and TAVR-Is this the hard-to-define glass ceiling? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 34:61-62. [PMID: 34810114 DOI: 10.1016/j.carrev.2021.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 10/27/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Robert C Sturm
- Division Cardiovascular Medicine, University of Utah School of Medicine, United States of America
| | - Jonathan Harrison
- Division Cardiovascular Medicine, University of Utah School of Medicine, United States of America
| | - Anwar Tandar
- Division Cardiovascular Medicine, University of Utah School of Medicine, United States of America.
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18
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Bui HT, Khair N, Yeats B, Gooden S, James SP, Dasi LP. Transcatheter Heart Valves: A Biomaterials Perspective. Adv Healthc Mater 2021; 10:e2100115. [PMID: 34038627 DOI: 10.1002/adhm.202100115] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 04/23/2021] [Indexed: 11/11/2022]
Abstract
Heart valve disease is prevalent throughout the world, and the number of heart valve replacements is expected to increase rapidly in the coming years. Transcatheter heart valve replacement (THVR) provides a safe and minimally invasive means for heart valve replacement in high-risk patients. The latest clinical data demonstrates that THVR is a practical solution for low-risk patients. Despite these promising results, there is no long-term (>20 years) durability data on transcatheter heart valves (THVs), raising concerns about material degeneration and long-term performance. This review presents a detailed account of the materials development for THVRs. It provides a brief overview of THVR, the native valve properties, the criteria for an ideal THV, and how these devices are tested. A comprehensive review of materials and their applications in THVR, including how these materials are fabricated, prepared, and assembled into THVs is presented, followed by a discussion of current and future THVR biomaterial trends. The field of THVR is proliferating, and this review serves as a guide for understanding the development of THVs from a materials science and engineering perspective.
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Affiliation(s)
- Hieu T. Bui
- Department of Biomedical Engineering Georgia Institute of Technology 387 Technology Cir NW Atlanta GA 30313 USA
| | - Nipa Khair
- School of Advanced Materials Discovery Colorado State University 700 Meridian Ave Fort Collins CO 80523 USA
| | - Breandan Yeats
- Department of Biomedical Engineering Georgia Institute of Technology 387 Technology Cir NW Atlanta GA 30313 USA
| | - Shelley Gooden
- Department of Biomedical Engineering Georgia Institute of Technology 387 Technology Cir NW Atlanta GA 30313 USA
| | - Susan P. James
- School of Advanced Materials Discovery Colorado State University 700 Meridian Ave Fort Collins CO 80523 USA
| | - Lakshmi Prasad Dasi
- Department of Biomedical Engineering Georgia Institute of Technology 387 Technology Cir NW Atlanta GA 30313 USA
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19
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Carney JP, Schappa Faustich J, Lahti MT, Ashworth PE, Dalmasso AP, Moklyak Y, Bianco RW. New Model for the Assessment of Transcatheter Aortic Valve Replacement Devices in Sheep. J INVEST SURG 2020; 35:371-377. [PMID: 33371759 DOI: 10.1080/08941939.2020.1864796] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) is an effective therapy in treating high-risk patients suffering from aortic stenosis. Animal models used to evaluate safety and efficacy of TAVR devices prior to clinical use lack a stenotic aortic annulus, a critical impediment to long-term TAVR device evaluation. We sought to create a reproducible model of aortic stenosis using a modified aortic annuloplasty (MAA) procedure in sheep, followed by deployment and long-term evaluation of TAVR devices using this model. METHODS Twelve sheep underwent the MAA procedure and were recovered. Transthoracic echocardiography (TTE) was used to monitor changes in the aortic annulus in the postoperative period. At 60 days post-MAA, Test group animals were anesthetized for TAVR insertion and Control animals underwent a necropsy. Test animals were recovered following TAVR insertion and observed for a postoperative period of 140 days. RESULTS Twelve sheep survived the annuloplasty procedure and the 60-day recovery period. Gross examination of seven Control group animals revealed the implanted annuloplasty ring segments formed hard protrusions into the aortic annulus. Five sheep in the Test group underwent successful deployment of Abbott's experimental TAVR device without evidence of migration. Examination at 140 days post-TAVR insertion showed all devices tightly anchored within the modified aortic annulus. CONCLUSIONS The MAA procedure creates stenotic segments in the aortic annulus with adequate rigidity for anchorage and long-term evaluation of TAVR devices. This represents the first model that successfully mimics human aortic stenosis and provides a clinically relevant TAVR deployment platform for long-term evaluation in sheep.
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Affiliation(s)
- John P Carney
- Experimental Surgical Services Laboratory, Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jill Schappa Faustich
- Experimental Surgical Services Laboratory, Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Matthew T Lahti
- Experimental Surgical Services Laboratory, Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Agustin P Dalmasso
- Experimental Surgical Services Laboratory, Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Yuriy Moklyak
- Experimental Surgical Services Laboratory, Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Richard W Bianco
- Experimental Surgical Services Laboratory, Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
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20
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Evolution of outcome and complications in TAVR: a meta-analysis of observational and randomized studies. Sci Rep 2020; 10:15568. [PMID: 32968104 PMCID: PMC7511292 DOI: 10.1038/s41598-020-72453-1] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 06/17/2020] [Indexed: 11/22/2022] Open
Abstract
Aim of the present analysis was to collect and pool all available data currently in the literature regarding outcomes and complications of all approved TAVR prosthesis and to assess the transition from first to next generation TAVR devices by directly comparing both in regard of procedure related complications. Transcatheter aortic valve replacement is a well established treatment modality in patients with severe aortic stenosis deemed to be inoperable or at unacceptable risk for open heart surgery. First generation prostheses were associated with a high rate of peri-procedural complications like paravalvular regurgitation, valve malpositioning, vascular complications and conduction disorders. Refinement of the available devices incorporate features to address the limitations of the first-generation devices. A PRISMA checklist-guided systematic review and meta-analysis of prospective observational studies, national and device specific registries or randomized clinical trials was conducted. Studies were identified by searching PUBMED, SCOPUS, Cochrane Central Register of Controlled Trials and LILACs from January 2000 to October 2017. We extracted and pooled data on both mortality and complications from 273 studies for twelve different valves prostheses in a total of 68,193 patients. In second generation prostheses as compared to first generation devices, we observed a significant decrease in mortality (1.47 ± 1.73% vs. 5.41 ± 4.35%; p < 0.001), paravalvular regurgitation (1.75 ± 2.43vs. 12.39 ± 9.38, p < 0.001) and MACE. TAVR with contemporary next generation devices has led to an impressive improvement in TAVR safety driven by refined case selection, improved procedural techniques and increased site experience.
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21
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Sharma SK, Rao RS, Chopra M, Sonawane A, Jose J, Sengottuvelu G. Myval transcatheter heart valve system in the treatment of severe symptomatic aortic stenosis. Future Cardiol 2020; 17:73-80. [PMID: 32628046 DOI: 10.2217/fca-2020-0020] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The transcatheter aortic valve replacement (TAVR) is an established treatment for patients with severe symptomatic aortic stenosis (AS) at prohibitive risk for surgery. It is an alternative treatment to surgical aortic valve replacement in patients with AS at intermediate- and high-surgical risk. Although regulatory authorities extend the indications of TAVR to treat patients at low-surgical risk, the limitations of earlier-generation transcatheter heart valve (THV) systems accelerate the development of improved newer generation of THV systems. Myval™ THV (Meril Life Sciences Pvt. Ltd., Vapi, Gujarat, India) is a newer-generation, balloon-expandable TAVR system with features that facilitate accurate positioning of the bioprosthetic valve and favorable procedural and clinical outcomes. This review summarizes existing preclinical and clinical data on Myval THV for the intervention of symptomatic native AS and lays out the plan for future research program.
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Affiliation(s)
- Samin K Sharma
- Director of Clinical and Interventional Cardiology and Dean of International Clinical Affiliations, Mount Sinai Health System, NY, USA
| | - Ravinder S Rao
- Department of Cardiology, Eternal Heart Care Centre & Research Institute Pvt. Ltd., Jaipur, Rajasthan 302017, India
| | - Manik Chopra
- Department of Cardiology, Narayana Multispeciality Hospital, Ahmedabad, Gujarat 380023, India
| | - Anmol Sonawane
- Department of Cardiology, Breach Candy Hospital, Mumbai, Maharashtra 400026, India
| | - John Jose
- Department of Cardiology, Christian Medical College & Hospital, Vellore, Tamil Nadu 632002, India
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22
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Elbadawi A, Naqvi SY, Saad M, Elgendy IY, Mahmoud AA, Zainal A, Megaly M, Almahmoud MF, Altaweel A, Kleiman N, Abbott JD. In-Hospital Outcomes with Transfemoral Versus Transapical Access for Transcatheter Aortic Valve Replacement in Patients with Peripheral Arterial Disease. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 21:604-609. [DOI: 10.1016/j.carrev.2019.09.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 08/01/2019] [Accepted: 09/06/2019] [Indexed: 01/19/2023]
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23
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Boskovski MT, Nguyen TC, McCabe JM, Kaneko T. Outcomes of Transcatheter Aortic Valve Replacement in Patients With Severe Aortic Stenosis. JAMA Surg 2020; 155:69-77. [DOI: 10.1001/jamasurg.2019.4449] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Marko T. Boskovski
- Division of Cardiac Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Tom C. Nguyen
- Department of Cardiothoracic and Vascular Surgery, University of Texas at Houston
| | | | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
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24
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Zimmerman J, Birgenheier N. Appropriate Use Criteria for the Treatment of Patients with Severe Aortic Stenosis: A Review of the 2017 American College of Cardiology Guideline for the Cardiac Anesthesiologist. J Cardiothorac Vasc Anesth 2019; 33:3127-3142. [PMID: 31076302 DOI: 10.1053/j.jvca.2019.03.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 03/11/2019] [Accepted: 03/30/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Josh Zimmerman
- Division of Perioperative Echocardiography, Department of Anesthesiology, University of Utah, Salt Lake City, UT.
| | - Nate Birgenheier
- Department of Anesthesiology, University of Utah, Salt Lake City, UT
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25
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Mantha A, Juo YY, Morchi R, Ebrahimi R, Ziaeian B, Shemin RJ, Benharash P. Evolution of Surgical Aortic Valve Replacement in the Era of Transcatheter Valve Technology. JAMA Surg 2019; 152:1080-1083. [PMID: 28724144 DOI: 10.1001/jamasurg.2017.2344] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Aditya Mantha
- Division of Cardiothoracic Surgery, University of California, Irvine
| | - Yen-Yi Juo
- Division of Cardiac Surgery, University of California, Los Angeles
| | - Ravi Morchi
- Division of Cardiothoracic Surgery, University of California, Irvine
| | - Ramin Ebrahimi
- Division of Cardiology, Veteran Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Boback Ziaeian
- Division of Cardiology, Veteran Affairs Greater Los Angeles Healthcare System, Los Angeles, California.,Division of Cardiology, University of California, Los Angeles
| | - Richard J Shemin
- Division of Cardiac Surgery, University of California, Los Angeles
| | - Peyman Benharash
- Division of Cardiac Surgery, University of California, Los Angeles
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26
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Bourantas CV, Modolo R, Baumbach A, Søndergaard L, Prendergast BD, Ozkor M, Kennon S, Mathur A, Mullen MJ, Serruys PW. The evolution of device technology in transcatheter aortic valve implantation. EUROINTERVENTION 2019; 14:e1826-e1833. [PMID: 30719977 DOI: 10.4244/eij-d-18-01048] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Transcatheter aortic valve implantation (TAVI) has rapidly evolved and changed the landscape of structural interventional cardiology. Advances in transcatheter heart valve (THV) prostheses and TAVI-enabling devices have simplified the procedure, reduced the risk of complications, improved short- and long-term outcomes and broadened the applications of TAVI, not only in challenging patients and complex anatomies but also in intermediate-risk or even in low-risk patients, where surgical valve replacement constitutes an effective and well-established therapy. In this review article, we provide an overview of the developments in TAVI devices which have played a vital role in TAVI evolution: we describe the prostheses that failed to reach clinical practice, we present the characteristics of the first valves that were tested in the clinical arena, we summarise the evidence from the first studies that highlighted the potential but also the limitations of TAVI, and we present the advanced next-generation THV prostheses that have an improved performance and safety profile.
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Affiliation(s)
- Christos V Bourantas
- Department of Cardiology, Barts Heart Center, Barts Health NHS Trust, London, United Kingdom
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27
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Correlation Between Aortic Angulation and Outcomes of Transcatheter Aortic Valve Replacement With New-Generation Valves. Curr Probl Cardiol 2019; 46:100415. [PMID: 30975449 DOI: 10.1016/j.cpcardiol.2019.03.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 03/09/2019] [Indexed: 02/07/2023]
Abstract
The aim of this study was to assess the correlation of aortic angulation (AA) on immediate postprocedural and long-term outcomes following transcatheter aortic valve replacement (TAVR) with new-generation valves. There is limited and conflicting data on the impact of AA on short- and long-term outcomes in patients undergoing TAVR. Available studies to date were done with first-generation valves. We assessed 179 patients who underwent TAVR with either a balloon-expandable or self-expandable valve at our institute from May 2014 to June 2017 and had multislice computed tomography scans available for AA evaluation. All included patients received a second- or third-generation valve. TAVR endpoints, device success, and adverse events were defined according to the Valve Academic Research Consortium-2 criteria. The mean AA of the study population was 49.05 ± 10.07. Patients were divided into 2 groups: AA <49 and AA ≥49, and then further subdivided by valve type. There were no difference in mean age, The Society for Thoracic Surgery (STS) score, or race distribution between the AA <49 and AA ≥49 groups. The preimplantation balloon valvuloplasty rate was higher in patients with AA ≥ 49 compared to patients with AA <49, (70% vs 55.1%, P = 0.04). There was no difference in re-hospitalization, pacemaker implantation, postprocedural aortic regurgitation or mortality between patients with AA <49 and AA ≥49 irrespective of valve type (P < 0.05). AA does not significantly affect short- or long-term outcomes in patients who undergo TAVR with new-generation balloon-expandable or self-expandable valves.
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28
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Meng S, Mao J, Rouse EN, Le-Bel G, Bourget JM, Reed RR, Philippe E, How D, Zhang Z, Germain L, Guidoin R. The Red Kangaroo pericardium as a material source for the manufacture of percutaneous heart valves. Morphologie 2019; 103:37-47. [PMID: 30638803 DOI: 10.1016/j.morpho.2018.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 12/06/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND The kangaroo pericardium might be considered to be a good candidate material for use in the manufacture of the leaflets of percutaneous heart valves based upon the unique lifestyle. The diet consists of herbs, forbs and strubs. The kangaroo pericardium holds an undulated structure of collagen. MATERIAL AND METHOD A Red Kangaroo was obtained after a traffic fatality and the pericardium was dissected. Four compasses were cut from four different sites: auricular (AUR), atrial (ATR), sternoperitoneal (SPL) and phrenopericardial (PPL). They were investigated by means of scanning electron microscopy, light microscopy and transmission electron microscopy. RESULTS All the samples showed dense and wavy collagen bundles without vascularisation from both the epicardium and the parietal pericardium. The AUR and the ATR were 150±25μm thick whereas the SPL and the PPL were thinner at 120±20μm. The surface of the epicardium was smooth and glistening. The filaments of collagen were well individualized without any aggregation, but the banding was poorly defined and somewhat blurry. CONCLUSION This detailed morphological analysis of the kangaroo pericardium illustrated a surface resistant to thrombosis and physical characteristics resistant to fatigue. The morphological characteristics of the kangaroo pericardium indicate that it represents an outstanding alternative to the current sources e.g., bovine and porcine. However, procurement of tissues from the wild raises supply and sanitary issues. Health concerns based upon sanitary uncertainty and reliability of supply of wild animals remain real problems.
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Affiliation(s)
- S Meng
- Chongqing Key Lab of Catalysis and Functional Organic Molecules; College of Environment and Biotechnology, Chongqing Technology and Business University, Chongqing, PR China
| | - J Mao
- Axe Médecine Régénératrice, Centre de Recherche du CHU and Département de Chirurgie, Faculté de Médecine, Université Laval, Québec Canada
| | - E N Rouse
- Department of Comparative Medicine, College of Veterinary of Tennessee, Knoxville, TN, USA
| | - G Le-Bel
- Axe Médecine Régénératrice, Centre de Recherche du CHU and Département de Chirurgie, Faculté de Médecine, Université Laval, Québec Canada
| | - J M Bourget
- Axe Médecine Régénératrice, Centre de Recherche du CHU and Département de Chirurgie, Faculté de Médecine, Université Laval, Québec Canada
| | - R R Reed
- Department of Comparative Medicine, College of Veterinary of Tennessee, Knoxville, TN, USA
| | - E Philippe
- Axe Médecine Régénératrice, Centre de Recherche du CHU and Département de Chirurgie, Faculté de Médecine, Université Laval, Québec Canada
| | - D How
- Peninsula College of Medicine and Dentistry (PCMD), Plymouth, Devon, UK
| | - Z Zhang
- Axe Médecine Régénératrice, Centre de Recherche du CHU and Département de Chirurgie, Faculté de Médecine, Université Laval, Québec Canada
| | - L Germain
- Axe Médecine Régénératrice, Centre de Recherche du CHU and Département de Chirurgie, Faculté de Médecine, Université Laval, Québec Canada
| | - R Guidoin
- Axe Médecine Régénératrice, Centre de Recherche du CHU and Département de Chirurgie, Faculté de Médecine, Université Laval, Québec Canada.
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29
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Marino M, Lilie CJ, Culp WC, Schepel SR, Tippett JC. The Evolution of Echocardiographic Type and Anesthetic Technique for Transcatheter Aortic Valve Replacement at a High-Volume Transcatheter Aortic Valve Replacement Center. J Cardiothorac Vasc Anesth 2019; 33:29-35. [DOI: 10.1053/j.jvca.2018.06.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Indexed: 11/11/2022]
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30
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Hachinohe D, Latib A, Laricchia A, Demir OM, Agricola E, Romano V, Del Sole PA, Leone PP, Ancona MB, Mangieri A, Regazzoli D, Giannini F, Mitomo S, Monaco F, Buzzatti N, Montorfano M, Colombo A. Anatomic and procedural associations of transcatheter heart valve displacement following Evolut R implantation. Catheter Cardiovasc Interv 2018; 93:522-529. [PMID: 30286515 DOI: 10.1002/ccd.27827] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 07/16/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVES This study aimed to predict the displacement of self-expanding transcatheter heart valves (THV) during final deployment. BACKGROUND Accurate device positioning during transcatheter aortic valve implantation (TAVI) is crucial for optimal results. METHODS At our institution, 103 patients who underwent transfemoral TAVI with Evolut R were retrospectively identified. Multiple linear regression models were created, and a predictor equation was built to quantify the factors that may affect THV behavior. RESULTS Multiple linear regression analysis for THV displacement on the left coronary cusp (LCC) identified the angle between the THV and the ascending aorta (ATA), predilation, and less operator experience as independent predictors of upward displacement, whereas estimated glomerular filtration rate (eGFR) was inversely related with THV behavior (95% confidence interval: 0.219 to 0.340, 0.447 to 2.092, 0.165 to 1.757, and -0.053 to -0.011, respectively). Predictors of THV displacement on the noncoronary cusp side could not be identified using this model. CONCLUSIONS The ATA at the point of recapture, predilation, and less operator experience were independent predictors of upward displacement of THV on the LCC side. eGFR was an independent predictor of THV downward displacement on the LCC side. Of them, the ATA was the strongest predictor. Physicians may need to adjust this angle adequately before deployment to achieve the appropriate position.
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Affiliation(s)
- Daisuke Hachinohe
- Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy.,Interventional Cardiology Unit, EMO-GVM Centro Cuore Columbus, Milan, Italy.,Department of Cardiology, Sapporo Heart Center, Sapporo Cardio Vascular Clinic, Sapporo, Japan
| | - Azeem Latib
- Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy.,Interventional Cardiology Unit, EMO-GVM Centro Cuore Columbus, Milan, Italy.,Division of Cardiology, University of Cape Town, Cape Town, South Africa.,Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Ozan M Demir
- Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy.,Interventional Cardiology Unit, EMO-GVM Centro Cuore Columbus, Milan, Italy.,Department of Cardiology, Hammersmith Hospital, Imperial College Hospital Healthcare NHS Trust, London, United Kingdom
| | - Eustachio Agricola
- Non-invasive Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Vittorio Romano
- Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy
| | | | - Pier Pasquale Leone
- Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Marco B Ancona
- Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Antonio Mangieri
- Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Damiano Regazzoli
- Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Giannini
- Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Satoru Mitomo
- Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy.,Interventional Cardiology Unit, EMO-GVM Centro Cuore Columbus, Milan, Italy
| | - Fabrizio Monaco
- Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy
| | - Nicola Buzzatti
- Cardiac Surgery Unit, Cardiology and Cardiothoracic Surgery Department, San Raffaele Scientific Institute, Milan, Italy
| | - Matteo Montorfano
- Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Antonio Colombo
- Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy.,Interventional Cardiology Unit, EMO-GVM Centro Cuore Columbus, Milan, Italy
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Pre-procedural fit-testing of TAVR valves using parametric modeling and 3D printing. J Cardiovasc Comput Tomogr 2018; 13:21-30. [PMID: 30322772 DOI: 10.1016/j.jcct.2018.09.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 09/02/2018] [Accepted: 09/29/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Successful transcatheter aortic valve replacement (TAVR) requires an understanding of how a prosthetic valve will interact with a patient's anatomy in advance of surgical deployment. To improve this understanding, we developed a benchtop workflow that allows for testing of physical interactions between prosthetic valves and patient-specific aortic root anatomy, including calcified leaflets, prior to actual prosthetic valve placement. METHODS This was a retrospective study of 30 patients who underwent TAVR at a single high volume center. By design, the dataset contained 15 patients with a successful annular seal (defined by an absence of paravalvular leaks) and 15 patients with a sub-optimal seal (presence of paravalvular leaks) on post-procedure transthoracic echocardiogram (TTE). Patients received either a balloon-expandable (Edwards Sapien or Sapien XT, n = 15), or a self-expanding (Medtronic CoreValve or Core Evolut, n = 14, St. Jude Portico, n = 1) valve. Pre-procedural computed tomography (CT) angiograms, parametric geometry modeling, and multi-material 3D printing were utilized to create flexible aortic root physical models, including displaceable calcified valve leaflets. A 3D printed adjustable sizing device was then positioned in the aortic root models and sequentially opened to larger valve sizes, progressively flattening the calcified leaflets against the aortic wall. Optimal valve size and fit were determined by visual inspection and quantitative pressure mapping of interactions between the sizer and models. RESULTS Benchtop-predicted "best fit" valve size showed a statistically significant correlation with gold standard CT measurements of the average annulus diameter (n = 30, p < 0.0001 Wilcoxon matched-pairs signed rank test). Adequateness of seal (presence or absence of paravalvular leak) was correctly predicted in 11/15 (73.3%) patients who received a balloon-expandable valve, and in 9/15 (60%) patients who received a self-expanding valve. Pressure testing provided a physical map of areas with an inadequate seal; these corresponded to areas of paravalvular leak documented by post-procedural transthoracic echocardiography. CONCLUSION We present and demonstrate the potential of a workflow for determining optimal prosthetic valve size that accounts for aortic annular dimensions as well as the active displacement of calcified valve leaflets during prosthetic valve deployment. The workflow's open source framework offers a platform for providing predictive insights into the design and testing of future prosthetic valves.
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Transcatheter Aortic Valve Replacement: Efficiency and Safety Improvements With Progressive Experience and Improved Technology. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2018; 13:120-124. [PMID: 29668502 DOI: 10.1097/imi.0000000000000480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Transcatheter aortic valve replacement is now commercially available for intermediate-risk, high-risk, or inoperable patients with severe aortic stenosis. In this study, we investigated change in the safety and efficiency of the transcatheter aortic valve replacement procedure at our institution and patient outcomes comparing our first 100, second 100, and last 100 patients. METHODS From March 2012 to June 2016, 544 patients underwent transcatheter aortic valve replacement at our center. Three hundred patients were selected for this study and were categorized in the following three groups: group A, first to 100th patient; group B, 101st to 200th patient; and group C, 444th to 544th patient. Preoperative, intraoperative, and postoperative data were collected. RESULTS Three hundred patients, 162 male (54%) male and 138 female (46%) with a mean ± SD age of 79.10 ± 8.93 years and mean ± SD society of thoracic surgeons' risk score of 7.47 ± 0.76 were included. Fluoroscopy time, operation time, and incision time significantly decreased form group A to group C (all P < 0.05). Mean of contrast volume was also the highest in group A and the lowest in group C (P < 0.001). Acute kidney injury rate was 26% (n = 26) in group A versus 23% (n = 23) in group B (P = 0.743), and only one patient in group C (group C vs. group B, P < 0.001). Strokes declined over time: five (5%) stroke in group A; two (2%) stroke in group B, and no patient in group C (group C vs. group B, P = 0.1, and group C vs. group A, P = 0.059). In-hospital mortality was 5% (n = 5) in group A, 4% (n = 4) in group B, and 1% in group C (P = 0.21). CONCLUSIONS Progressive experience and technology advances with transcatheter aortic valve replacement procedures improved operators' expertise, making the transcatheter aortic valve replacement more efficient and safer over time.
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Aalaei-Andabili SH, Anderson RD, Bavry AA, Lee TC, Wayangankar S, Arnaoutakis GJ, Beaver TM. Transcatheter Aortic Valve Replacement. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2018. [DOI: 10.1177/155698451801300208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Seyed Hossein Aalaei-Andabili
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, FL USA
- Division of Cardiology, Department of Medicine, University of Florida, Gainesville, FL USA
| | - R. David Anderson
- Division of Cardiology, Department of Medicine, University of Florida, Gainesville, FL USA
| | - Anthony A. Bavry
- Division of Cardiology, Department of Medicine, University of Florida, Gainesville, FL USA
- North Florida/South Georgia Veterans Health System, Gainesville, FL USA
| | - Teng C. Lee
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, FL USA
| | - Siddharth Wayangankar
- Division of Cardiology, Department of Medicine, University of Florida, Gainesville, FL USA
| | - George J. Arnaoutakis
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, FL USA
| | - Thomas M. Beaver
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, FL USA
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Transcatheter heart valve for aortic valve implantation: republication of the article published in the Japanese Journal of Artificial Organs. J Artif Organs 2018; 21:125-131. [PMID: 29426997 DOI: 10.1007/s10047-017-1015-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 12/27/2017] [Indexed: 10/18/2022]
Abstract
This review was created based on a translation of the Japanese review first reported in the Japanese Journal of Artificial Organs in 2015 (vol. 44, no. 3, pp. 136-140), with some modifications.
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Gregory SH, Zoller JK, Shahanavaz S, Chilson KL, Ridley CH. Anesthetic Considerations for Transcatheter Pulmonary Valve Replacement. J Cardiothorac Vasc Anesth 2018; 32:402-411. [DOI: 10.1053/j.jvca.2017.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Indexed: 12/27/2022]
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Transcatheter aortic valve implantation at a high-volume center: the Bad Rothenfelde experience. POLISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2018; 14:215-224. [PMID: 29354172 PMCID: PMC5767770 DOI: 10.5114/kitp.2017.72224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 11/23/2017] [Indexed: 11/20/2022]
Abstract
Introduction The “transfemoral (TF) first” approach to access route selection in transcatheter aortic valve implantation (TAVI) is popular; however, the risk of major vascular complications is substantial. The “best for TF” approach identifies only the patients with ideal anatomy for TF-TAVI, potentially minimizing complications. Aim To characterize the outcomes of patients undergoing TAVI at a large-volume site that employs this approach. Material and methods Patients who underwent TAVI at the Bad Rothenfelde Heart Centre between 2008 and 2016 were consecutively enrolled. Findings were compared to those from large, multicenter registries. Results Of the 1,644 patients enrolled, 1,140 underwent TA- and 504 TF-TAVI. Comorbidities were more frequent in TA patients, who also had higher risk scores (EuroSCORE: 25.5% vs. 21.2%; STS score: 11.0% vs. 7.5%; p < 0.001 for both). Rates of conversion to open surgery, major vascular complications and intra-procedural mortality did not differ between groups. At 30 days, mortality rates were higher in the TA group (3.9% vs. 1.9%, p = 0.036). Stroke/transient ischemic attack and permanent pacemaker implantation rates did not differ significantly between groups (2.0% and 9.1% overall, respectively). Compared to multicenter registries, trends in mortality and complication rates were similar, though magnitudes were lower in the present study. In contrast with the present study, major vascular complication rates in multicenter registries are significantly higher for TF compared to TA patients. Conclusions At this high-volume center, the use of a “best for TF” approach to TAVI resulted in low mortality and complication rates.
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Kalich BA, Allender JE, Hollis IB. Medication Management of Patients Undergoing Transcatheter Aortic Valve Replacement. Pharmacotherapy 2017; 38:122-138. [DOI: 10.1002/phar.2056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Bethany A. Kalich
- University of the Incarnate Word Feik School of Pharmacy; San Antonio Texas
- University of Texas Health at San Antonio; San Antonio Texas
| | | | - Ian B. Hollis
- University of North Carolina Hospitals; Chapel Hill North Carolina
- UNC Eshelman School of Pharmacy; Chapel Hill North Carolina
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Neuburger PJ, Patel PA. Anesthetic Techniques in Transcatheter Aortic Valve Replacement and the Evolving Role of the Anesthesiologist. J Cardiothorac Vasc Anesth 2017; 31:2175-2182. [DOI: 10.1053/j.jvca.2017.03.033] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Indexed: 11/11/2022]
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Bourget JM, Zegdi R, Lin J, Wawryko P, Merhi Y, Convelbo C, Mao J, Fu Y, Xu T, Merkel NO, Wang L, Germain L, Zhang Z, Guidoin R. Correlation between structural changes and acute thrombogenicity in transcatheter pericardium valves after crimping and balloon deployment. Morphologie 2017; 101:19-32. [PMID: 27423215 DOI: 10.1016/j.morpho.2016.06.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 06/15/2016] [Accepted: 06/16/2016] [Indexed: 06/06/2023]
Abstract
INTRODUCTION Transcathether heart valve replacement has gained considerable acceptance during the last decades. It is now part of the armamentarium for aortic valve replacement. The procedure proved to be highly efficient. However the issues of the blood compatibility and tissue durability were not raised and the adverse events were probably under-reported, according to observations of thrombosis after deployment. MATERIAL AND METHOD Bovine pericardium leaflets were sewn inside a 26mm diameter stainless steel stent to manufacture these valves (one control and two experimental). The correlation between the trauma and the acute thombogenicity of bovine pericardium leaflets, after crimping and ballooning, was investigated via an in vitro blood flow with labeled platelets. These leaflets were processed for histology: scanning electron microscopy, light microscopy, and transmission electron microscopy. RESULTS The control specimens showed a regular pericardium structure with some blood cells deposited on the collagen fibrous surface (inflow) and scarce blood cells deposited on the serous surface (outflow). After crimping and ballooning, the structure of the pericardium was severely injured, eventually with delaminations and ruptures. The blood cell uptake was considerably increased compared to the control. CONCLUSION It would therefore be appropriate to pay more attention to the design of the valves. Specifically, the incorporation of a buffer tissue or fabric between the pericardium and the metallic stent is suggested. The issue of ballooning deserves detailed and in depth investigation regarding the lifetime of the device.
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Affiliation(s)
- J-M Bourget
- Department of Surgery, Faculty of Medicine, Vandry Building, Laval University, Axe médecine régénératrice, centre de recherche du CHU de Québec, Québec, Canada
| | - R Zegdi
- Inserm, U97O, université René-Descartes, service de chirurgie cardiovasculaire, hôpital européen Georges-Pompidou, 75015 Paris, France
| | - J Lin
- Key Laboratory of Textile Science and Technology of Ministry of Education and College of Textile, Donghua University, Shanghai, China
| | - P Wawryko
- Department of Pathology, University of Manitoba, Winnipeg, MB, Canada
| | - Y Merhi
- Laboratoire de thrombose et hémostase, centre de recherche, institut de cardiologie, université de Montréal, Montréal, QC, Canada
| | - C Convelbo
- Inserm, U97O, université René-Descartes, service de chirurgie cardiovasculaire, hôpital européen Georges-Pompidou, 75015 Paris, France
| | - J Mao
- Department of Surgery, Faculty of Medicine, Vandry Building, Laval University, Axe médecine régénératrice, centre de recherche du CHU de Québec, Québec, Canada
| | - Y Fu
- Key Laboratory of Textile Science and Technology of Ministry of Education and College of Textile, Donghua University, Shanghai, China
| | - T Xu
- Department of Surgery, Faculty of Medicine, Vandry Building, Laval University, Axe médecine régénératrice, centre de recherche du CHU de Québec, Québec, Canada
| | - N O Merkel
- Department of Surgery, Faculty of Medicine, Vandry Building, Laval University, Axe médecine régénératrice, centre de recherche du CHU de Québec, Québec, Canada
| | - L Wang
- Key Laboratory of Textile Science and Technology of Ministry of Education and College of Textile, Donghua University, Shanghai, China
| | - L Germain
- Department of Surgery, Faculty of Medicine, Vandry Building, Laval University, Axe médecine régénératrice, centre de recherche du CHU de Québec, Québec, Canada
| | - Z Zhang
- Department of Surgery, Faculty of Medicine, Vandry Building, Laval University, Axe médecine régénératrice, centre de recherche du CHU de Québec, Québec, Canada
| | - R Guidoin
- Department of Surgery, Faculty of Medicine, Vandry Building, Laval University, Axe médecine régénératrice, centre de recherche du CHU de Québec, Québec, Canada.
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Steinvil A, Bernardo N, Rogers T, Koifman E, Buchanan K, Alraies MC, Shults C, Torguson R, Okubagzi PG, Pichard AD, Satler LF, Ben-Dor I, Waksman R. Use of an ePTFE-covered nitinol self-expanding stent graft for the treatment off pre-closure device failure during transcatheter aortic valve replacement. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2017; 18:128-132. [DOI: 10.1016/j.carrev.2016.10.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 10/18/2016] [Indexed: 12/17/2022]
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Percutaneous Transcatheter Implantable Gadgets for De Novo Aortic Valve Regurgitation After Left Ventricular Assist Device Implant: Pushing the Limits or a Feasible Bailout? ASAIO J 2017; 63:115-116. [PMID: 28169845 DOI: 10.1097/mat.0000000000000537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Guidoin R, Zegdi R, Lin J, Mao J, Rochette-Drouin O, How D, Guan X, Bruneval P, Wang L, Germain L, Zhang Z. Transcatheter heart valve crimping and the protecting effects of a polyester cuff. Morphologie 2016; 100:234-244. [PMID: 27461102 DOI: 10.1016/j.morpho.2016.06.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 06/16/2016] [Accepted: 06/21/2016] [Indexed: 06/06/2023]
Abstract
INTRODUCTION Prior to deployment, the percutaneous heart valves must be crimped and loaded into sheaths of diameters that can be as low as 6mm for a 23mm diameter valve. However, as the valve leaflets are fragile, any damage caused during this crimping process may contribute to reducing its long-term durability in vivo. MATERIAL AND METHOD Bovine pericardium percutaneous valves were manufactured as follows. The leaflets were sutured on a nitinol frame. A polyester cuff fabric served as a buffer between the pericardium and the stent. Two valves were crimped and one valve was used as control. The valves were examined in gross observation and micro-CT scan and then the leaflets were processed for histology and analyzed in scanning electron microscopy, light microscopy and transmission electron microscopy. RESULT Crimping of the valves resulted in the increase thickness of the leaflets and there was no evidence of additional delamination. The heavy prints of the stents were irregularly distributed on the outflow surface in the crimped devices and were shallow and did not penetrate throughout the thickness of the leaflets. However, the wavy microscopy of collagen fiber bundles was well preserved. They were found to remain individualized without any agglutination as shown by the regular banding appearance. CONCLUSION Crimping of self-deployable valves per se caused only minor damages to the leaflets. However, the procedure could be refined in order to minimize areas of high pressure and swelling of the tissue that can be accompanied with flow surface disruption and increase of the hydraulic conductance. The incorporation of a polyester buffer serves to prevent the deleterious effects that may be caused if the pericardium tissue were in direct contact with the nitinol stent.
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Affiliation(s)
- R Guidoin
- Department of surgery, faculty of medicine, Laval university and axe médecine régénérative, centre de recherche, CHU, Vandry building, 2325, rue de l'Université, GIV OA6 Québec, Canada.
| | - R Zegdi
- Services de chirurgie cardiovasculaire et de pathologie, hôpital européen Georges-Pompidou, 75015 Paris, France
| | - J Lin
- Key laboratory of textile science and technology of Ministry of Education and College of Textile, Donghua university, Shanghai, China
| | - J Mao
- Department of surgery, faculty of medicine, Laval university and axe médecine régénérative, centre de recherche, CHU, Vandry building, 2325, rue de l'Université, GIV OA6 Québec, Canada
| | - O Rochette-Drouin
- Department of surgery, faculty of medicine, Laval university and axe médecine régénérative, centre de recherche, CHU, Vandry building, 2325, rue de l'Université, GIV OA6 Québec, Canada
| | - D How
- Peninsula school of medicine and dentistry, Plymouth, Devon, United Kingdom
| | - X Guan
- Key laboratory of textile science and technology of Ministry of Education and College of Textile, Donghua university, Shanghai, China
| | - P Bruneval
- Services de chirurgie cardiovasculaire et de pathologie, hôpital européen Georges-Pompidou, 75015 Paris, France
| | - L Wang
- Key laboratory of textile science and technology of Ministry of Education and College of Textile, Donghua university, Shanghai, China
| | - L Germain
- Department of surgery, faculty of medicine, Laval university and axe médecine régénérative, centre de recherche, CHU, Vandry building, 2325, rue de l'Université, GIV OA6 Québec, Canada
| | - Z Zhang
- Department of surgery, faculty of medicine, Laval university and axe médecine régénérative, centre de recherche, CHU, Vandry building, 2325, rue de l'Université, GIV OA6 Québec, Canada
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Schoen FJ. Morphology, Clinicopathologic Correlations, and Mechanisms in Heart Valve Health and Disease. Cardiovasc Eng Technol 2016; 9:126-140. [PMID: 27502286 DOI: 10.1007/s13239-016-0277-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 07/28/2016] [Indexed: 10/21/2022]
Abstract
The clinical and pathological features of the most frequent intrinsic structural diseases that affect the heart valves are well established, but heart valve disease mechanisms are poorly understood, and effective treatment options are evolving. Major advances in the understanding of the structure, function and biology of native valves and the pathobiology, biomaterials and biomedical engineering, and the clinical management of valvular heart disease have occurred over the past several decades. This communication reviews contemporary considerations relative to the pathology of valvular heart disease, including (1) clinical significance and epidemiology of valvular heart disease; (2) functional and dynamic valvular macro-, micro- and ultrastructure; (3) causes, morphology and mechanisms of human valvular heart disease; and (4) pathologic considerations in valve replacement, repair and, potentially, regeneration of the heart valves.
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Affiliation(s)
- Frederick J Schoen
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
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Abramowitz Y, Maeno Y, Chakravarty T, Kazuno Y, Takahashi N, Kawamori H, Mangat G, Cheng W, Jilaihawi H, Makkar RR. Aortic Angulation Attenuates Procedural Success Following Self-Expandable But Not Balloon-Expandable TAVR. JACC Cardiovasc Imaging 2016; 9:964-72. [PMID: 27424244 DOI: 10.1016/j.jcmg.2016.02.030] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 02/03/2016] [Accepted: 02/26/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the impact of increased aortic angulation (AA) on acute procedural success following transcatheter aortic valve replacement (TAVR). BACKGROUND The degree of angulation between the aorta and the heart can make accurate positioning of the bioprosthesis during TAVR more demanding, particularly in instances of an extremely angulated or horizontal aortic root. Nonetheless, there are limited data on the impact of AA on the acute success of TAVR. METHODS We assessed 582 patients who underwent TAVR at our institute and had contrast computed tomography available for AA evaluation. TAVR endpoints, device success, and adverse events were considered according to the Valve Academic Research Consortium-2 definitions. RESULTS The mean angulation of the aorta was 47.3 ± 8.7°. Patients were therefore divided into 2 groups: AA <48° and AA ≥48°. AA in the 480 patients who underwent balloon-expandable (BE) TAVR did not influence acute procedural success or short-term clinical outcome. In contrast, increased AA among the 102 patients who underwent self-expandable (SE) TAVR was found to significantly attenuate procedural success (area under the curve: 0.73; 95% confidence interval: 0.61 to 0.85; p = 0.008). The numerical cutoff for AA with the highest sum of sensitivity and specificity for device success was ≥48° (sensitivity 85%, specificity 61%). Moreover, patients whose AA was ≥48° were also associated with an increased need for a second valve and post-dilation, had increased fluoroscopy time and increased valve embolization, and had increased post-procedural paravalvular regurgitation greater than or equal to mild following SE TAVR. Major complications at 30 days, including mortality were similar between AA groups. Six-month mortality was also similar between both AA groups. CONCLUSIONS Increased aortic root angulation adversely influences acute procedural success following SE but not BE TAVR. Because of these data, BE valves may be preferred when evaluating patients with high AA before TAVR.
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Affiliation(s)
| | - Yoshio Maeno
- Cedars-Sinai Heart Institute, Los Angeles, California
| | | | - Yoshio Kazuno
- Cedars-Sinai Heart Institute, Los Angeles, California
| | | | | | | | - Wen Cheng
- Cedars-Sinai Heart Institute, Los Angeles, California
| | | | - Raj R Makkar
- Cedars-Sinai Heart Institute, Los Angeles, California.
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Schoen FJ, Gotlieb AI. Heart valve health, disease, replacement, and repair: a 25-year cardiovascular pathology perspective. Cardiovasc Pathol 2016; 25:341-352. [PMID: 27242130 DOI: 10.1016/j.carpath.2016.05.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 05/04/2016] [Accepted: 05/05/2016] [Indexed: 01/24/2023] Open
Abstract
The past several decades have witnessed major advances in the understanding of the structure, function, and biology of native valves and the pathobiology and clinical management of valvular heart disease. These improvements have enabled earlier and more precise diagnosis, assessment of the proper timing of surgical and interventional procedures, improved prosthetic and biologic valve replacements and repairs, recognition of postoperative complications and their management, and the introduction of minimally invasive approaches that have enabled definitive and durable treatment for patients who were previously considered inoperable. This review summarizes the current state of our understanding of the mechanisms of heart valve health and disease arrived at through innovative research on the cell and molecular biology of valves, clinical and pathological features of the most frequent intrinsic structural diseases that affect the valves, and the status and pathological considerations in the technological advances in valvular surgery and interventions. The contributions of many cardiovascular pathologists and other scientists, engineers, and clinicians are emphasized, and potentially fruitful areas for research are highlighted.
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Affiliation(s)
- Frederick J Schoen
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115; Pathology and Health Sciences and Technology (HST), Harvard Medical School, 75 Francis Street, Boston, MA 02115.
| | - Avrum I Gotlieb
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario M5S 1A8, Canada; Faculty of Medicine, University of Toronto, Toronto, Ontario M5S 1A8, Canada; Laboratory Medicine Program, University Health Network, Medical Sciences Building, 1 King's College Circle, Rm. 6275A, Toronto, Ontario M5S 1A8, Canada.
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Tokarek T, Siudak Z, Dziewierz A, Sobczyński R, Zasada W, Sorysz D, Olszewska-Wityńska K, Bryniarski K, Krawczyk-Ożóg A, Żabówka A, Sadowski J, Dudek D. Assessment of quality of life in patients after surgical and transcatheter aortic valve replacement. Catheter Cardiovasc Interv 2016; 88:E80-8. [PMID: 26800644 DOI: 10.1002/ccd.26400] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 09/29/2015] [Accepted: 12/21/2015] [Indexed: 11/10/2022]
Abstract
OBJECTIVES Transcatheter aortic valve implantation (TAVI) and minimally invasive aortic valve replacement (mini-thoracotomy, mini-sternotomy, MIAVR) have become an appealing alternative to conventional surgical (SAVR) treatment of severe aortic stenosis (AS) in high-risk patients. BACKGROUND Aim of the study was to evaluate the quality of life (QoL) in patients with AS and treated with transfemoral TAVI, SAVR, mini-thoracotomy and mini-sternotomy. METHODS One hundred and seventy-three patients with symptomatic AS were enrolled in 2011-2013. TAVI group consisted of 39 patients (22.5%), mini-sternotomy was performed in 44 patients (25.5%), mini-thoracotomy in 50 (29%), and AVR in 40 patients (23%). QoL was assessed perioperatively, 12 and 24 months after aortic valve replacement (AVR) by Minnesota Living with Heart Failure Questionnaire (MLHFQ) and EQ-5D-3L. RESULTS Median follow-up was 583.5 (IQR: 298-736) days. Improvement of health status after procedure in comparison with pre-operative period was significantly more often reported after TAVI in perioperative period (90.3%; P = 0.004) and 12 months after procedure (100%, P = 0.02). Global MLHFQ, physical and emotional dimension score at 30-day from AVR presented significant improvement after TAVI in comparison with surgical methods (respectively: 8.3(±8.6), P = 0.003; 4.1(±5.9), P = 0.01; 1.5(±2.6), P = 0.005). Total MLHFQ score was significantly lower (better outcome) in TAVI patients 1 year after procedure (4.8(±6.8), P = 0.004), no differences in somatic and emotional component were found. No differences were found in MLHFQ score 24 months after AVR. Data from EQ-D5-3L questionnaire demonstrated significant improvement of QoL at 30-day follow-up after TAVI in comparison with surgical methods (1.2(±1.7), P = 0.0008). CONCLUSIONS TAVI improves QoL in perioperative and 12 months observation in comparison with mini-thoracotomy, mini-sternotomy and SAVR. Improvement in QoL was obtained in both generic and disease specific questionnaires. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Tomasz Tokarek
- Department of Interventional Cardiology at University Hospital, Jagiellonian University Medical College in Krakow, Poland.
| | - Zbigniew Siudak
- Department of Interventional Cardiology at University Hospital, Jagiellonian University Medical College in Krakow, Poland
| | - Artur Dziewierz
- 2nd Department of Cardiology, Jagiellonian University Medical College in Krakow, Poland
| | - Robert Sobczyński
- Department of Cardiovascular Surgery and Transplantology at University Hospital, Jagiellonian University Medical College in Kraków, Poland
| | - Wojciech Zasada
- 2nd Department of Cardiology, Jagiellonian University Medical College in Krakow, Poland
| | - Danuta Sorysz
- 2nd Department of Cardiology, Jagiellonian University Medical College in Krakow, Poland
| | - Katarzyna Olszewska-Wityńska
- Department of Interventional Cardiology at University Hospital, Jagiellonian University Medical College in Krakow, Poland
| | - Krzysztof Bryniarski
- Department of Interventional Cardiology at University Hospital, Jagiellonian University Medical College in Krakow, Poland
| | - Agata Krawczyk-Ożóg
- Department of Interventional Cardiology at University Hospital, Jagiellonian University Medical College in Krakow, Poland
| | - Anna Żabówka
- Department of Interventional Cardiology at University Hospital, Jagiellonian University Medical College in Krakow, Poland
| | - Jerzy Sadowski
- Department of Cardiovascular Surgery and Transplantology at University Hospital, Jagiellonian University Medical College in Kraków, Poland
| | - Dariusz Dudek
- Department of Interventional Cardiology at University Hospital, Jagiellonian University Medical College in Krakow, Poland
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Leaflet stress and strain distributions following incomplete transcatheter aortic valve expansion. J Biomech 2015; 48:3663-71. [DOI: 10.1016/j.jbiomech.2015.08.012] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 07/29/2015] [Accepted: 08/13/2015] [Indexed: 11/18/2022]
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48
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Sterling LH, Windle SB, Filion KB, Eisenberg MJ. Pharmacological management strategies for stroke prevention following transcatheter aortic valve replacement: A systematic review. Int J Cardiol 2015; 191:303-11. [DOI: 10.1016/j.ijcard.2015.04.226] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 04/01/2015] [Accepted: 04/29/2015] [Indexed: 11/30/2022]
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49
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Byrom MJ, Sivakumaran Y, Vallely MP, Wilson MK, Bannon PG. How many sutures should a sutureless valve need? J Thorac Cardiovasc Surg 2015; 149:1058-9. [PMID: 25626952 DOI: 10.1016/j.jtcvs.2014.12.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 12/22/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Michael John Byrom
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia; The Baird Institute, Sydney, Australia
| | | | - Michael Patrick Vallely
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia; The Baird Institute, Sydney, Australia
| | - Michael Keith Wilson
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia; The Baird Institute, Sydney, Australia
| | - Paul Gerard Bannon
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia; The Baird Institute, Sydney, Australia; University of Sydney, Sydney, Australia.
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50
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He ZF, Zhang WM, Lutter G, Quaden R, Cremer J, Cai XJ. In vitro study of coronary flow occlusion in transcatheter aortic valve implantation. J Thorac Dis 2015; 6:1772-7. [PMID: 25589972 DOI: 10.3978/j.issn.2072-1439.2014.12.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 11/13/2014] [Indexed: 11/14/2022]
Abstract
BACKGROUND Transcatheter aortic valve implantation (TAVI) has been developed recently for patients with high morbidities and who are believed to be not tolerate standard surgical aortic valve replacement. Nevertheless, the TAVI is associated with complications such as potential obstruction of coronary ostia, mitral valve insufficiency, and stent migration although it seems promising. Impairment of the coronary blood flow after TAVI is catastrophic and it was believed to be associated with the close position of the coronary orifice and the aortic leaflets and valve stent. However, few data was available as to the anatomic relationship between valve stent and aortic root anatomic structures including the coronary arterial ostia, aortic leaflets. METHODS The aortic roots were observed in 40 hearts specimens. The width of aortic leaflet, height of aortic sinus annulus to the sinutubular junction (STJ), distance between aortic sinus annulus to its corresponding coronary ostia, and coronary arterial ostia to its corresponding STJ level were measured. Moreover, the relationships of valve stent, aortic leaflets and coronary ostia before/post stent implantation and after the open of aorta were evaluated respectively. RESULTS Approximate three quarters of the coronary ostia were located below the STJ level. The mean distances from left, right and posterior aortic sinus annulus to the related STJ level was comparable, which was 18.5±2.7, 18.9±2.6, 18.7±2.6 mm, respectively. Meanwhile, the height of left and right aortic sinus annulus to its corresponding coronary ostia was 16.6±2.8 and 17.2±3.1 mm for left and right side respectively. CONCLUSIONS Most of the coronary ostia were located below the STJ level and could be covered by the leaflets. This highlights the need of modified stents to prevent occlusion of coronary flow after TAVI.
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Affiliation(s)
- Zheng-Fu He
- 1 Department of Cardiothoracic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China ; 2 Department of Cardiovascular Surgery, School of Medicine, University Of Kiel, Kiel, Germany ; 3 Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Wei-Ming Zhang
- 1 Department of Cardiothoracic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China ; 2 Department of Cardiovascular Surgery, School of Medicine, University Of Kiel, Kiel, Germany ; 3 Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - George Lutter
- 1 Department of Cardiothoracic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China ; 2 Department of Cardiovascular Surgery, School of Medicine, University Of Kiel, Kiel, Germany ; 3 Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Rene Quaden
- 1 Department of Cardiothoracic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China ; 2 Department of Cardiovascular Surgery, School of Medicine, University Of Kiel, Kiel, Germany ; 3 Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Jochen Cremer
- 1 Department of Cardiothoracic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China ; 2 Department of Cardiovascular Surgery, School of Medicine, University Of Kiel, Kiel, Germany ; 3 Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Xiu-Jun Cai
- 1 Department of Cardiothoracic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China ; 2 Department of Cardiovascular Surgery, School of Medicine, University Of Kiel, Kiel, Germany ; 3 Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
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