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Yang Y, Richter R, Halfmann MC, Graafen D, Hell M, Vecsey-Nagy M, Laux G, Kavermann L, Jorg T, Geyer M, Varga-Szemes A, Emrich T. Prospective ECG-gated High-Pitch Photon-Counting CT Angiography: Evaluation of measurement accuracy for aortic annulus sizing in TAVR planning. Eur J Radiol 2024; 178:111604. [PMID: 38996738 DOI: 10.1016/j.ejrad.2024.111604] [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: 06/24/2024] [Accepted: 07/03/2024] [Indexed: 07/14/2024]
Abstract
PURPOSE In planning transcatheter aortic valve replacement (TAVR), retrospective cardiac spiral-CT is recommended to measure aortic annulus with subsequent CT-angiography (CTA) to evaluate access routes. Photon-counting detector (PCD)-CT enables to assess the aortic annulus in desired cardiac phases, using prospective ECG-gated high-pitch CTA. The aim of this study was to evaluate the measurement accuracy of aortic annulus using prospective ECG-gated high-pitch CTA against retrospective spiral-CT reference. METHOD Thirty patients underwent cardiac spiral-CT and prospective ECG-gated (30% R-R on aortic valve level) high-pitch CTA. Using propensity score matching, another 30 patients were identified whose CTA was performed using high-pitch mode without ECG-synchronization. Two investigators measured annular diameter, perimeter, and area on cardiac spiral-CT and high-pitch CTA. RESULTS The aortic valve was imaged in systole in 90 % of prospective ECG-gated CTA cases but only 50 % of non-ECG-gated CTA cases (p = 0.002). There was a strong correlation (r ≥ 0.94) without significant differences (p ≥ 0.09) between cardiac spiral-CT and prospective ECG-gated high-pitch CTA for all annulus measurements. In contrast, significant differences were found in annular short-axis diameter and area between cardiac spiral-CT and non-ECG-gated high-pitch CTA (p ≤ 0.03). Furthermore, prospective ECG-gated high-pitch CTA showed significantly reduced radiation exposure compared with cardiac spiral-CT (CTDI 4.52 vs. 24.10 mGy; p < 0.001). CONCLUSION PCD-CT-based prospective ECG-gated high-pitch scans with targeted systolic acquisition at the level of the aortic valve can simultaneously visualize TAVR access routes and accurately measure systolic annulus size. This approach could aid in optimizing protocols to achieve lower radiation doses in the growing population of younger, low-risk TAVR patients.
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Affiliation(s)
- Y Yang
- Department of Diagnostic and Interventional Radiology, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - R Richter
- Department of Diagnostic and Interventional Radiology, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - M C Halfmann
- Department of Diagnostic and Interventional Radiology, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - D Graafen
- Department of Diagnostic and Interventional Radiology, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - M Hell
- Department of Cardiology, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - M Vecsey-Nagy
- Department of Radiology and Radiological Science, Medical University of South Carolina, 25 Courtenay Dr, Charleston, SC 29425, United States; Heart and Vascular Center, Semmelweis University, 68. Varosmajor Street, Budapest 1122, Hungary
| | - G Laux
- Department of Cardiology, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - L Kavermann
- Department of Cardiology, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - T Jorg
- Department of Diagnostic and Interventional Radiology, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - M Geyer
- Department of Cardiology, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - A Varga-Szemes
- Department of Radiology and Radiological Science, Medical University of South Carolina, 25 Courtenay Dr, Charleston, SC 29425, United States
| | - T Emrich
- Department of Diagnostic and Interventional Radiology, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany; Department of Radiology and Radiological Science, Medical University of South Carolina, 25 Courtenay Dr, Charleston, SC 29425, United States.
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de Oliveira GC, Kessel J, Vavalle J, Caranasos T. Early outcomes of the suprasternal transcatheter aortic valve replacement technique. J Card Surg 2022; 37:2360-2364. [PMID: 35610545 DOI: 10.1111/jocs.16603] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 04/06/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) is now an established treatment option for patients with severe aortic stenosis. The most utilized approach remains transfemoral. In patients with difficult femoral access a variety of alternate approaches have been used. Recently, suprasternal access has emerged as a viable alternate approach in patients with very complex vascular access. We describe our 30-day outcomes of patients who underwent suprasternal transcatheter aortic valve replacement (suprasternal [SS]-TAVR), which constitutes the largest single-center cohort to date. METHODS From May 2016 to September 2021, 658 patients underwent TAVR at our institution. Of which 29 underwent SS-TAVR. We performed a retrospective analysis to evaluate early (30 days) outcomes of this procedure. Main outcomes evaluated included 30-day mortality, stroke and pacemaker rates, length of stay, readmission, and valvular function. RESULTS All patients were alive 30 days after the procedure. The median hospital length-of-stay was 2 days. Two patients (6.9%) had a stroke on the contra-lateral side of access. Two patients (6.90%) had significant cardiac arrhythmias requiring pacemaker placement. In 30 days, one patient was readmitted (3.45%). CONCLUSIONS Our data confirm the SS-TAVR as a feasible and safe alternative with comparable results to established approaches in patients who are unsuitable for femoral artery access and offers clinicians another access site in patients with very complex anatomy.
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Affiliation(s)
- Guilherme C de Oliveira
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Julia Kessel
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - John Vavalle
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Thomas Caranasos
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Qureshi WT, Malhotra R, Schmidlin EJ, Ahmed M, Kundu A, Hafiz AM, Walker J, Kakouros N. Evaluation of ECG-gated and Fast Low-Angle Shot (FLASH) Dual Source Computed Tomography Scanning Protocols for Transcatheter Aortic Valve Replacement. Acad Radiol 2021; 28:1669-1674. [PMID: 32972842 DOI: 10.1016/j.acra.2020.08.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 08/24/2020] [Accepted: 08/25/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) procedural success relies heavily on volumetric reconstruction imaging, particularly ECG-gated multi-detector row computed tomography. We postulated that single examination using fast low-angle shot (FLASH) dual source CT scanning (DS-CTA) could provide lower dose than ECG-gated CTA while maintaining the image quality. METHODS In this single-centre cohort study, all patients who underwent ECG-gated and FLASH DS-CTA were evaluated. Volumetric reconstructions were performed for both ECG-gated and FLASH DS-CTA to obtain nonsagittal views of the structures. ECG-gated cardiac CT was obtained to evaluate the aortic annular size while FLASH DS-CTA was obtained to examine the aortic and iliac vasculature as part of TAVR imaging protocol. We evaluated measures of aortic annulus, coronaries and sinus of Valsalva using ECG-gated and FLASH DS-CTA scanning protocols. Image quality assessments were performed using aortic root region-of-interest signal-to-noise ratio. RESULTS A total of 130 patients (mean age 81.5 ± 9.2 years, 46.2% female, and 99.2% white) underwent both ECG-gated CT and FLASH DS-CTA. There were excellent correlations between aortic annular area (R2 = 0.934) and aortic annular perimeter (R2 = 0.923) measured by the two protocols. Only 2 (1.5%) patients had >10% difference between aortic annular measurements by ECG-gated and FLASH DS-CTA, while none of the patients had a >10% difference between aortic annular perimeter measured by ECG-gated and FLASH DS-CT scans. There was no significant difference in signal-to-noise ratio between the two methods (mean difference 13.4; 95% CI -2.1-28.8, p = 0.09). There was significantly lower radiation dose for FLASH DS-CTA than ECG-gated CT scan (mean dose-length product difference 404.38; 95% CI 328.9-479.87, p <0.001). The measurements by the two scans led to the same transcatheter valve size selection in majority of the 128 (98.5%) patients by balloon expandable valve sizing recommendations and 130 (100%) of patients by self-expanding valve sizing recommendations. CONCLUSION Overall, FLASH DS-CTA and ECG-gated CT scans provided comparable image quality and aortic annular dimensions for pre-TAVR evaluation. DS-CTA additionally provided the necessary angiographic imaging of the aorta and peripheral access vessels while still maintaining a lower radiation dose. We propose that a single non-ECG gated FLASH DS-CTA could be utilized to provide all the necessary pre-TAVR imaging information without a gated CT scan.
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Ullah W, Zahid S, Zaidi SR, Sarvepalli D, Haq S, Roomi S, Mukhtar M, Khan MA, Gowda SN, Ruggiero N, Vishnevsky A, Fischman DL. Predictors of Permanent Pacemaker Implantation in Patients Undergoing Transcatheter Aortic Valve Replacement - A Systematic Review and Meta-Analysis. J Am Heart Assoc 2021; 10:e020906. [PMID: 34259045 PMCID: PMC8483489 DOI: 10.1161/jaha.121.020906] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background As transcatheter aortic valve replacement (TAVR) technology expands to healthy and lower‐risk populations, the burden and predictors of procedure‐related complications including the need for permanent pacemaker (PPM) implantation needs to be identified. Methods and Results Digital databases were systematically searched to identify studies reporting the incidence of PPM implantation after TAVR. A random‐ and fixed‐effects model was used to calculate unadjusted odds ratios (OR) for all predictors. A total of 78 studies, recruiting 31 261 patients were included in the final analysis. Overall, 6212 patients required a PPM, with a mean of 18.9% PPM per study and net rate ranging from 0.16% to 51%. The pooled estimates on a random‐effects model indicated significantly higher odds of post‐TAVR PPM implantation for men (OR, 1.16; 95% CI, 1.04–1.28); for patients with baseline mobitz type‐1 second‐degree atrioventricular block (OR, 3.13; 95% CI, 1.64–5.93), left anterior hemiblock (OR, 1.43; 95% CI, 1.09–1.86), bifascicular block (OR, 2.59; 95% CI, 1.52–4.42), right bundle‐branch block (OR, 2.48; 95% CI, 2.17–2.83), and for periprocedural atriorventricular block (OR, 4.17; 95% CI, 2.69–6.46). The mechanically expandable valves had 1.44 (95% CI, 1.18–1.76), while self‐expandable valves had 1.93 (95% CI, 1.42–2.63) fold higher odds of PPM requirement compared with self‐expandable and balloon‐expandable valves, respectively. Conclusions Male sex, baseline atrioventricular conduction delays, intraprocedural atrioventricular block, and use of mechanically expandable and self‐expanding prosthesis served as positive predictors of PPM implantation in patients undergoing TAVR.
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Affiliation(s)
- Waqas Ullah
- Thomas Jefferson University Hospitals Philadelphia PA
| | | | | | | | | | | | - Maryam Mukhtar
- University Hospitals of Leicester NHS Trust Leicester UK
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Catalano MA, Rutkin B, Kohn N, Hartman A, Yu PJ. Does Heart Valve Team Risk Assessment Predict Outcomes after Transcatheter Aortic Valve Replacement? Int J Angiol 2020; 29:39-44. [PMID: 32132815 DOI: 10.1055/s-0039-3401933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Consideration for transcatheter aortic valve replacement (TAVR) necessitates an integrated risk assessment by members of the Heart Valve Team. The utility of the integrated risk assessment for predicting TAVR outcomes is not established. This article aims to compare the utility of the integrated risk assessment to that of the Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) score for predicting patient outcomes after TAVR. A total of 274 patients who underwent TAVR from January 2016 to August 2017 were included in this study. Patients were deemed intermediate or high risk by two surgeons on the Heart Valve Team based on an integrated risk assessment that incorporates the STS-PROM score, fragility measures, end-organ dysfunction, and surgeon evaluation. Patients were also deemed low, intermediate, or high risk based solely on their STS-PROM scores of <3%, ≥3% to <8%, and ≥8%, respectively. Differences in postoperative outcomes between intermediate- and high-risk groups as categorized by the integrated risk assessment versus STS-PROM were compared. There were no statistically significant differences in postoperative outcomes between patients who were deemed high and intermediate risk by the Heart Valve Team risk assessment. In contrast, postoperative complication rates were significantly higher in patients deemed high risk as compared with intermediate risk by STS-PROM. Integrated risk assessment by the Heart Valve Team is not superior to STS-PROM in predicting postoperative outcomes in patients undergoing TAVR.
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Affiliation(s)
- Michael A Catalano
- Division of Cardiovascular and Thoracic Surgery, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Bruce Rutkin
- Division of Cardiovascular and Thoracic Surgery, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Nina Kohn
- The Feinstein Institute for Medical Research, Manhasset, New York
| | - Alan Hartman
- Division of Cardiovascular and Thoracic Surgery, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Pey-Jen Yu
- Division of Cardiovascular and Thoracic Surgery, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
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Camaj A, Claessen BE, Mehran R, Yudi MB, Power D, Baber U, Hengstenberg C, Lefevre T, Van Belle E, Giustino G, Guedeney P, Sorrentino S, Kupatt C, Webb JG, Hildick-Smith D, Hink HU, Deliargyris EN, Anthopoulos P, Sharma SK, Kini A, Sartori S, Chandrasekhar J, Dangas GD. The importance of the Heart Team evaluation before transcatheter aortic valve replacement: Results from the BRAVO-3 trial. Catheter Cardiovasc Interv 2020; 96:E688-E694. [PMID: 31943717 DOI: 10.1002/ccd.28717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 12/14/2019] [Accepted: 12/29/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND/OBJECTIVES Clinicians use validated scores to risk-stratify patients undergoing transcatheter aortic valve replacement (TAVR). However, evaluation by the Heart Team often deems patients to be at higher risk than their formal scores suggest. We sought to assess clinical outcomes of TAVR patients defined as high-risk by the Heart Team's assessment versus the patient's logistic EuroSCORE (LES). METHODS The BRAVO-3 trial randomized patients at high risk (LES ≥ 18, or deemed inoperable by the Heart Team) to TAVR with periprocedural anticoagulation with unfractionated heparin versus bivalirudin. Endpoints included net adverse cardiac events (NACE: the composite of all-cause mortality, MI, stroke, or bleeding), major adverse cardiovascular events (MACE: death, MI, or stroke), the individual components of MACE, major vascular complications, BARC ≥ 3b bleeding and VARC life-threatening bleeding at 30 days. We compared patients deemed high-risk based on LES ≥ 18 versus high-risk by the Heart Team despite lower LES. RESULTS A total of 467/800 (58.4%) patients were deemed high-risk by the Heart Team despite LES < 18. After multivariable analysis, there were no differences in the odds of endpoints between groups (NACE, ORLES≥18 : 1.32, 95% CI 0.86-2.02, p = .21; MACE, ORLES≥18 : 1.27, 95% CI 0.72-2.25, p = .41; major vascular complications, ORLES≥18 : 0.97, 95% CI 0.65-1.44, p = .88; BARC ≥3b, ORLES≥18 : 1.38, 95% CI 0.82-2.33, p = .23; and VARC life-threatening bleeding, ORLES≥18 : 0.99, 95% CI 0.69-1.41, p = .95). CONCLUSION Patients undergoing TAVR and labeled high-risk by LES ≥ 18 or Heart Team assessment despite LES < 18 have comparable short-term outcomes. Assignment of high-risk status to over 50% of patients is attributable to Heart Team's clinical assessment.
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Affiliation(s)
- Anton Camaj
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Bimmer E Claessen
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - David Power
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Usman Baber
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Christian Hengstenberg
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany, and Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Thierry Lefevre
- Institut Cardio Vasculaire Paris Sud, Hôpital Privé Jacques Cartier, Massy, France
| | - Eric Van Belle
- Department of Cardiology and INSERM UMR 1011, University Hospital, and CHRU Lille, Lille, France
| | - Gennaro Giustino
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Paul Guedeney
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166 Institut de cardiologie (AP-HP), Paris, France
| | - Sabato Sorrentino
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | | | - John G Webb
- St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - David Hildick-Smith
- Sussex Cardiac Centre-Brighton & Sussex University Hospitals NHS Trust, Brighton, East Sussex, UK
| | | | | | | | - Samin K Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Annapoorna Kini
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jaya Chandrasekhar
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - George D Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
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Martín Gutiérrez E, Martínez Comendador JM, Gualis Cardona J, Maiorano P, Castillo Pardo L, Cuellas Ramón C, Fernández Vázquez F, Castaño Ruiz M. Implante valvular aórtico transcatéter frente a sustitución valvular aórtica en pacientes de riesgo quirúrgico intermedio. Revisión bibliográfica y metaanálisis. CIRUGIA CARDIOVASCULAR 2018. [DOI: 10.1016/j.circv.2018.04.001] [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] Open
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Schymik G, Varsami C, Bramlage P, Conzelmann LO, Würth A, Luik A, Schröfel H, Tzamalis P. Two-Year Outcomes of Transcatheter Compared With Surgical Aortic Valve Replacement in "Minimal-Risk" Patients Lacking EuroSCORE Co-morbidities (from the TAVIK Registry). Am J Cardiol 2018; 122:149-155. [PMID: 29861048 DOI: 10.1016/j.amjcard.2018.02.053] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 02/16/2018] [Accepted: 02/26/2018] [Indexed: 12/20/2022]
Abstract
We aimed to compare the outcomes of transcatheter aortic valve implantation (TAVI) with surgical aortic valve replacement (SAVR) in an elderly but nonfrail, minimally co-morbid population. Although data comparing these 2 procedures in intermediate- and low-risk patients are mounting, no distinction has been made between co-morbidity and age/gender as driving forces for surgical risk. Patients undergoing isolated TAVI or SAVR between May 2008 and March 2015 were documented. Data for 225 patients (TAVI 132, SAVR 93) aged ≥75 and <86 years and fulfilling minimal-risk criteria were analyzed. Patients who underwent TAVI were older (80.7 vs 77.4 years, p <0.0001) and had a higher mean Society of Thoracic Surgeons score (2.16% vs 1.72%, p <0.0001). Mild prosthetic valve regurgitation (odds ratio [OR] 4.9, 95% confidence interval [CI] 3.34 to 7.20) was more likely after TAVI, as were renal complications (predominantly stage I acute kidney injury; OR 2.86, 95% CI 1.79 to 4.55) and new pacemaker implantation (OR 3.33, 95% CI 1.76 to 6.26) at 30 days; however, life-threatening bleeding (OR 0.58, 95% CI 0.36 to 0.93) and reintervention for bleeding (OR 0.03, 95% CI 0.01 to 0.13) were less likely. Survival was comparable between groups at 30 days (99.2% vs 100%, p = 1.0) and 1 year (96.2% vs 96.8%, OR 0.85, 95% CI 0.20 to 3.63, p = 0.823), but it was poorer for patients who underwent TAVI at 2 years (OR 0.31, 95% CI 0.16 to 0.61). In conclusion, the short-term outcomes of TAVI in elderly, low-risk, minimally co-morbid patients appear to be similar to those of SAVR, with access-specific complications. Although these results point toward the potential for more liberal use of TAVI in minimal-risk patients, poorer midterm survival remains a concern, requiring further exploration.
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Sičaja M. Transcatheter aortic valve implantation – fundamentals and a little bit more. CARDIOLOGIA CROATICA 2018; 13:198-198. [DOI: 10.15836/ccar2018.198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Siordia JA, Loera JM, Scanlon M, Evans J, Knight PA. Three-Year Survival Comparison between Transcatheter and Surgical Aortic Valve Replacement for Intermediate- and Low-Risk Patients. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2018. [DOI: 10.1177/155698451801300301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Juan A. Siordia
- Department of Cardiac Surgery, University of Rochester Medical Center, Rochester, NY USA
| | - Jackquelin M. Loera
- Department of Cardiac Surgery, University of Rochester Medical Center, Rochester, NY USA
| | - Matt Scanlon
- Department of Cardiac Surgery, University of Rochester Medical Center, Rochester, NY USA
| | - Jessie Evans
- Department of Cardiac Surgery, University of Rochester Medical Center, Rochester, NY USA
| | - Peter A. Knight
- Department of Cardiac Surgery, University of Rochester Medical Center, Rochester, NY USA
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Three-Year Survival Comparison between Transcatheter and Surgical Aortic Valve Replacement for Intermediate- and Low-Risk Patients. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2018; 13:153-162. [DOI: 10.1097/imi.0000000000000507] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Transcatheter aortic valve implantation is a suitable therapeutic intervention for patients deemed inoperable or high risk for surgical aortic valve replacement. Current investigations question whether it is a suitable alternative to surgery for intermediate- and low-risk patients. The following meta-analysis presents a comparison between transcatheter versus surgical aortic valve replacement in patients that are intermediate and low risk for surgery. Articles were collected via an electronic search using Google Scholar and PubMed. Articles of interest included studies comparing the survival of intermediate- and low-risk patients undergoing transcatheter aortic valve implantation to those undergoing surgical aortic valve replacement. Primary end points included 1-, 2-, and 3-year survival. Secondary end points included postintervention thromboembolic events, stroke, transient ischemic attacks, major vascular complications, permanent pacemaker implantation, life-threatening bleeding, acute kidney injury, atrial fibrillation, and moderate-to-severe aortic regurgitation. Six studies met the criteria for the meta-analysis. One- and two-year survival comparisons showed no difference between the two interventions. Surgical aortic valve replacement, however, presented with favorable 3-year survival compared with the transcatheter approach. Transcatheter aortic valve implantation had more major vascular complications, permanent pacemaker implantation, and moderate-to-severe aortic regurgitation rates compared with surgery. Surgical aortic valve replacement presented more life-threatening bleeding, acute kidney injury, and atrial fibrillation compared with a transcatheter approach. There was no statistical difference between the two approaches in terms of thromboembolic events, strokes, or transient ischemic attack rates. Surgical aortic valve replacement presents favorable 3-year survival rates compared with transcatheter aortic valve implantation.
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Nguyen TC, Terwelp MD, Thourani VH, Zhao Y, Ganim N, Hoffmann C, Justo M, Estrera AL, Smalling RW, Balan P, Lamelas J. Clinical trends in surgical, minimally invasive and transcatheter aortic valve replacement†. Eur J Cardiothorac Surg 2018; 51:1086-1092. [PMID: 28329200 DOI: 10.1093/ejcts/ezx008] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 12/20/2016] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Transcatheter aortic valve replacement (TAVR) and minimally invasive aortic valve replacement (MIAVR) have emerged as alternatives to surgical aortic valve replacement (SAVR) via traditional sternotomy. However, their effect on clinical practice remains unclear. The study's objective is to describe clinical trends between TAVR, MIAVR and SAVR in patients with severe aortic stenosis (AS). METHODS This retrospective observational study analyzed trends in isolated severe aortic valve replacement (AVR) among three high volume TAVR, MIAVR and SAVR centres in the United States. The cohort included 2571 patients from 2011 through 2014 undergoing SAVR ( n = 842), MIAVR ( n = 699) and TAVR ( n = 1030) further stratified into transapical (TA-TAVR) and trans-femoral (TF-TAVR). RESULTS Total AVR volume increased +107% with increases in TF-TAVR (+595%) and MIAVR (+57%). However, SAVR (-15%) and TA-TAVR (-49%) decreased from 2013 to 2014. In the final year, risk stratification by age ≥ 80, redo AVR, patients receiving dialysis and STS score >8% revealed increases in TF-TAVR and MIAVR, while SAVR decreased for all groups. CONCLUSIONS TF-TAVR and MIAVR increased while SAVR and TA-TAVR trended down in the latter periods, which underscore a paradigm shift in the treatment of severe AS and the importance of surgeon adoption of TF-TAVR and MIAVR techniques. As the demand for minimally invasive modalities increases, further studies comparing MIAVR versus TF-TAVR in low and intermediate risk patients are warranted.
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Affiliation(s)
- Tom C Nguyen
- Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School at Houston, Memorial Hermann Hospital - Heart and Vascular Institute, Houston, TX, USA
| | - Matthew D Terwelp
- Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School at Houston, Memorial Hermann Hospital - Heart and Vascular Institute, Houston, TX, USA
| | - Vinod H Thourani
- Structural Heart and Valve Center, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Yelin Zhao
- Department of Internal Medicine, Division of Cardiology, University of Texas Medical School at Houston, Memorial Hermann Hospital - Heart and Vascular Institute, Houston, TX, USA
| | - Nidal Ganim
- Department of Internal Medicine, Division of Cardiology, University of Texas Medical School at Houston, Memorial Hermann Hospital - Heart and Vascular Institute, Houston, TX, USA
| | - Carson Hoffmann
- Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School at Houston, Memorial Hermann Hospital - Heart and Vascular Institute, Houston, TX, USA
| | - Monica Justo
- Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School at Houston, Memorial Hermann Hospital - Heart and Vascular Institute, Houston, TX, USA
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School at Houston, Memorial Hermann Hospital - Heart and Vascular Institute, Houston, TX, USA
| | - Richard W Smalling
- Department of Internal Medicine, Division of Cardiology, University of Texas Medical School at Houston, Memorial Hermann Hospital - Heart and Vascular Institute, Houston, TX, USA
| | - Prakash Balan
- Department of Internal Medicine, Division of Cardiology, University of Texas Medical School at Houston, Memorial Hermann Hospital - Heart and Vascular Institute, Houston, TX, USA
| | - Joseph Lamelas
- Department of Cardiac Surgery, Mount Sinai Medical Center, Miami Beach, FL, USA
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13
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Hermans MC, Van Mourik MS, Hermens HJ, Baan J, Vis MM. Remote Monitoring of Patients Undergoing Transcatheter Aortic Valve Replacement: A Framework for Postprocedural Telemonitoring. JMIR Cardio 2018; 2:e9. [PMID: 31758782 PMCID: PMC6834331 DOI: 10.2196/cardio.9075] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 02/02/2018] [Accepted: 02/17/2018] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND The postprocedural trajectory of patients undergoing transcatheter aortic valve replacement (TAVR) involves in-hospital monitoring of potential cardiac rhythm or conduction disorders and other complications. Recent advances in telemonitoring technologies create opportunities to monitor electrocardiogram (ECG) and vital signs remotely, facilitating redesign of follow-up trajectories. OBJECTIVE This study aimed to outline a potential set-up of telemonitoring after TAVR. METHODS A multidisciplinary team systematically framed the envisioned telemonitoring scenario according to the intentions, People, Activities, Context, Technology (iPACT) and Functionality, Interaction, Content, Services (FICS) methods and identified corresponding technical requirements. RESULTS In this scenario, a wearable sensor system is used to continuously transmit ECG and contextual data to a central monitoring unit, allowing remote follow-up of ECG abnormalities and physical deteriorations. Telemonitoring is suggested as an alternative or supplement to current in-hospital monitoring after TAVR, enabling early hospital dismissal in eligible patients and accessible follow-up prolongation. Together, this approach aims to improve rehabilitation, enhance patient comfort, optimize hospital capacity usage, and reduce overall costs. Required technical components include continuous data acquisition, real-time data transfer, privacy-ensured storage, automatic event detection, and user-friendly interfaces. CONCLUSIONS The suggested telemonitoring set-up involves a new approach to patient follow-up that could bring durable solutions for the growing scarcities in health care and for improving health care quality. To further explore the potential and feasibility of post-TAVR telemonitoring, we recommend evaluation of the overall impact on patient outcomes and of the safety, social, ethical, legal, organizational, and financial factors.
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Affiliation(s)
- Mathilde C Hermans
- Heart Centre, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands.,Department of Technical Medicine, University of Twente, Enschede, Netherlands
| | - Martijn S Van Mourik
- Heart Centre, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Hermie J Hermens
- Biomedical Signals and Systems Group, University of Twente, Enschede, Netherlands
| | - Jan Baan
- Heart Centre, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Marije M Vis
- Heart Centre, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
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14
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Takagi H, Mitta S, Ando T. Long-term survival after transcatheter versus surgical aortic valve replacement for aortic stenosis: A meta-analysis of observational comparative studies with a propensity-score analysis. Catheter Cardiovasc Interv 2018; 92:419-430. [DOI: 10.1002/ccd.27521] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 12/24/2017] [Accepted: 01/08/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Hisato Takagi
- Department of Cardiovascular Surgery; Shizuoka Medical Center; Shizuoka Japan
| | - Shohei Mitta
- Department of Cardiovascular Surgery; Shizuoka Medical Center; Shizuoka Japan
| | - Tomo Ando
- Department of Cardiology; Detroit Medical Center; Detroit Michigan
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15
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Khan SU, Lone AN, Saleem MA, Kaluski E. Transcatheter vs surgical aortic-valve replacement in low- to intermediate-surgical-risk candidates: A meta-analysis and systematic review. Clin Cardiol 2017; 40:974-981. [PMID: 29168984 DOI: 10.1002/clc.22807] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 08/28/2017] [Accepted: 08/31/2017] [Indexed: 01/01/2023] Open
Abstract
The American and European expert documents recommend transcatheter aortic valve replacement (TAVR) for inoperable or high-surgical-risk patients with severe aortic stenosis. In comparison, efficacy of TAVR is relatively less studied in low- to intermediate-surgical-risk patients. We sought to discover whether TAVR can be as effective as surgical aortic valve replacement (SAVR) in low- to intermediate-surgical-risk candidates. Four randomized clinical trials (RCTs) and 8 prospective matched studies were selected using PubMed/MEDLINE, Embase, and Cochrane Library (inception: March 2017). Results were reported as random-effects odds ratio (OR) with 95% confidence interval (CI). Among 9851 patients, analyses of RCTs showed that all-cause mortality was comparable between TAVR and SAVR (short term, OR: 1.19, 95% CI: 0.86-1.64, P = 0.30; mid-term, OR: 0.97, 95% CI: 0.75-1.26, P = 0.84; and long term, OR: 0.97, 95% CI: 0.81-1.16, P = 0.76). The analysis restricted to matched studies showed similar outcomes. In the analysis stratified by study design, no significant differences were noted in the RCTs for stroke, whereas TAVR was better than SAVR in matched studies at short term only (OR: 0.46, 95% CI: 0.33-0.65, P < 0.001). TAVR is associated with reduced risk of acute kidney injury and new-onset atrial fibrillation (P < 0.05). However, increased incidence of permanent pacemaker implantation and paravalvular leaks was observed with TAVR. TAVR can provide similar mortality outcome compared with SAVR in low- to intermediate-surgical-risk patients with critical aortic stenosis. However, both procedures are associated with their own array of adverse events.
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Affiliation(s)
- Safi U Khan
- Department of Internal Medicine, Guthrie Clinic/Robert Packer Hospital, Sayre, Pennsylvania
| | - Ahmad N Lone
- Department of Internal Medicine, Guthrie Clinic/Robert Packer Hospital, Sayre, Pennsylvania
| | | | - Edo Kaluski
- Department of Internal Medicine, Guthrie Clinic/Robert Packer Hospital, Sayre, Pennsylvania
- Department of Cardiology, Rutgers Medical School, Newark, New Jersey, and The Commonwealth Medical College, Scranton, Pennsylvania
- Department of Cardiology, Guthrie Clinic/Robert Packer Hospital, Sayre, Pennsylvania
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16
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Arora S, Vavalle JP. Transcatheter aortic valve replacement in intermediate and low risk patients-clinical evidence. Ann Cardiothorac Surg 2017; 6:493-497. [PMID: 29062744 DOI: 10.21037/acs.2017.07.01] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The encouraging results of the PARTNER 2 (Placement of AoRtic TraNscathetER Valves 2) trial led to the approval of transcatheter aortic valve replacement (TAVR) in intermediate-surgical-risk patients. Recently, the SURTAVI (SUrgical Replacement and Transcatheter Aortic Valve Implantation) investigators demonstrated the feasibility of TAVR with self-expanding valves in intermediate-risk patients. The focus has now shifted to clinical trials comparing TAVR to surgery in low-surgical-risk populations with a goal to expand TAVR to all-risk patients. However, low-surgical-risk patients continue to be acceptable candidates for surgical aortic valve replacement, with proven outcomes over many decades. Although new data has emerged showing feasibility of TAVR in young patients with bicuspid valves, with newer generation TAVR valves there will be minimal tolerance for adverse outcomes in the low risk category. To expand the reach of TAVR into low-surgical-risk patients, important questions about valve durability, leaflet thrombosis, higher rates of paravalvular leak and permanent pacemakers (PPM) will need to be addressed. However, as TAVR technology continues to evolve, it seems to be just a matter of time before TAVR establishes itself as a modality for aortic valve replacement regardless of surgical risk.
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Affiliation(s)
- Sameer Arora
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - John P Vavalle
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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17
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Transcatheter versus surgical aortic valve replacement in patients with non-high surgical risk severe aortic stenosis: A systematic review. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2017; 18:S40-S48. [DOI: 10.1016/j.carrev.2017.02.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Revised: 02/13/2017] [Accepted: 02/15/2017] [Indexed: 11/22/2022]
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18
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Improved costs and outcomes with conscious sedation vs general anesthesia in TAVR patients: Time to wake up? PLoS One 2017; 12:e0173777. [PMID: 28379981 PMCID: PMC5381861 DOI: 10.1371/journal.pone.0173777] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 02/27/2017] [Indexed: 12/31/2022] Open
Abstract
Background Transcatheter aortic valve replacement (TAVR) has become a commonplace procedure for the treatment of aortic stenosis in higher risk surgical patients. With the high cost and steadily increasing number of patients receiving TAVR, emphasis has been placed on optimizing outcomes as well as resource utilization. Recently, studies have demonstrated the feasibility of conscious sedation in lieu of general anesthesia for TAVR. This study aimed to investigate the clinical as well as cost outcomes associated with conscious sedation in comparison to general anesthesia in TAVR. Methods Records for all adult patients undergoing TAVR at our institution between August 2012 and June 2016 were included using our institutional Society of Thoracic Surgeons (STS) and American College of Cardiology (ACC) registries. Cost data was gathered using the BIOME database. Patients were stratified into two groups according to whether they received general anesthesia (GA) or conscious sedation (CS) during the procedure. No-replacement propensity score matching was done using the validated STS predicted risk of mortality (PROM) as a propensity score. Primary outcome measure with survival to discharge and several secondary outcome measures were also included in analysis. According to our institution's data reporting guidelines, all cost data is presented as a percentage of the general anesthesia control group cost. Results Of the 231 patients initially identified, 225 (157 GA, 68 CS) were included for analysis. After no-replacement propensity score matching, 196 patients (147 GA, 49 CS) remained. Overall mortality was 1.5% in the matched population with a trend towards lower mortality in the CS group. Conscious sedation was associated with significantly fewer ICU hours (30 vs 96 hours, p = <0.001) and total hospital days (4.9 vs 10.4, p<0.001). Additionally, there was a 28% decrease in direct cost (p<0.001) as well as significant decreases in all individual all cost categories associated with the use of conscious sedation. There was no difference in composite major adverse events between groups. These trends remained on all subsequent subgroup analyses. Conclusion Conscious sedation is emerging as a safe and viable option for anesthesia in patients undergoing transcatheter aortic valve replacement. The use of conscious sedation was not only associated with similar rates of adverse events, but also shortened ICU and overall hospital stays. Finally, there were significant decreases in all cost categories when compared to a propensity matched cohort receiving general anesthesia.
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19
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Burrage M, Moore P, Cole C, Cox S, Lo WC, Rafter A, Garlick B, Garrahy P, Mundy J, Camuglia A. Transcatheter Aortic Valve Replacement is Associated with Comparable Clinical Outcomes to Open Aortic Valve Surgery but with a Reduced Length of In-Patient Hospital Stay: A Systematic Review and Meta-Analysis of Randomised Trials. Heart Lung Circ 2017; 26:285-295. [DOI: 10.1016/j.hlc.2016.07.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 07/21/2016] [Indexed: 11/27/2022]
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20
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Arora S, Misenheimer JA, Ramaraj R. Transcatheter Aortic Valve Replacement: Comprehensive Review and Present Status. Tex Heart Inst J 2017; 44:29-38. [PMID: 28265210 DOI: 10.14503/thij-16-5852] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Aortic stenosis is the most common valvular heart disease in the developed world. About 7% of the population over age 65 years suffers from degenerative aortic stenosis. The prognosis of patients with symptomatic severe aortic stenosis is dismal without valve replacement. Even though the American College of Cardiology recommends aortic valve replacement to treat this condition as a class I recommendation, approximately one third of these patients over the age of 75 years are not referred for surgery. Typically, this is from concern about prohibitive surgical risk associated with patient frailty, comorbidities, age, and severe left ventricular dysfunction. The advent in France of transcatheter aortic valve replacement has raised the hope in the United States for an alternative, less invasive treatment for aortic stenosis. Two recent trials-the Placement of AoRTic TraNscathetER Valve Trial Edwards SAPIEN Transcatheter Heart Valve (Partner) and the CoreValve US Pivotal-have established transcatheter aortic valve replacement as the preferred approach in patients who are at high or prohibitive surgical risk. The more recently published Partner 2 trial has shown the feasibility of transcatheter aortic valve replacement in intermediate-surgical-risk patients as well. With a profile that promises easier use and better valve performance and delivery, newer-generation valves have shown their potential for further improvement in safety profile and overall outcomes. We review the history and status of this topic.
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21
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Arora S, Ramm CJ, Misenheimer JA, Vavalle JP. Early transcatheter valve prosthesis degeneration and future ramifications. Cardiovasc Diagn Ther 2017; 7:1-3. [PMID: 28164006 DOI: 10.21037/cdt.2016.08.04] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Sameer Arora
- Division of Cardiology, University of North Carolina at Chapel Hill, NC, USA
| | - Cassandra J Ramm
- Division of Cardiology, University of North Carolina at Chapel Hill, NC, USA
| | - Jacob A Misenheimer
- Division of Cardiology, University of North Carolina at Chapel Hill, NC, USA;; Division of Cardiology, Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - John P Vavalle
- Division of Cardiology, University of North Carolina at Chapel Hill, NC, USA
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22
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Agarwal S, Kapadia S, Tuzcu EM, Krishnaswamy A. Safety and efficacy of transcatheter aortic valve replacement in intermediate risk patients sets the stage for contemporary trials in lower risk groups. Cardiovasc Diagn Ther 2016; 6:459-461. [PMID: 27747170 DOI: 10.21037/cdt.2016.05.01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Shikhar Agarwal
- Section of Interventional Cardiology, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Samir Kapadia
- Section of Interventional Cardiology, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH 44195, USA
| | - E Murat Tuzcu
- Section of Interventional Cardiology, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Amar Krishnaswamy
- Section of Interventional Cardiology, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH 44195, USA
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