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Sheng W, Dai H, Zheng R, Aihemaiti A, Liu X. An Updated Comprehensive Review of Existing Transcatheter Aortic Valve Replacement Access. J Cardiovasc Transl Res 2024:10.1007/s12265-024-10484-z. [PMID: 39186224 DOI: 10.1007/s12265-024-10484-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 01/18/2024] [Indexed: 08/27/2024]
Abstract
For the past 20 years, transcatheter aortic valve replacement (TAVR) has been the treatment of choice for symptomatic aortic stenosis. The transfemoral (TF) access is considered the gold standard approach for TAVR. However, TF-TAVR cannot be performed in some patients; thus, alternative accesses are required. Our review paper generalises the TAVR accesses currently available, including the transapical, transaortic, trans-subclavian/axillary, transcarotid, transcaval, and suprasternal approaches. Their advantages and disadvantages have been analysed. Since there is no standard recommendation for an alternative approach, access selection depends on the expertise of the local cardiac team, patient characteristics, and access properties. Each TAVR centre is recommended to master a minimum of one non-TF access alternative. Of note, more evidence is required to delve into the clinical outcomes of each approach, at both early and long-term (Figure 1).
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Affiliation(s)
- Wenjing Sheng
- Department of Cardiology, the Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, People's Republic of China, 310009
- Internal Medicine, Zhejiang University School of Medicine, Hangzhou, People's Republic of China, 310058
| | - Hanyi Dai
- Department of Cardiology, the Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, People's Republic of China, 310009
- Internal Medicine, Zhejiang University School of Medicine, Hangzhou, People's Republic of China, 310058
| | - Rongrong Zheng
- Department of Cardiology, the Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, People's Republic of China, 310009
- Internal Medicine, Zhejiang University School of Medicine, Hangzhou, People's Republic of China, 310058
| | - Ailifeire Aihemaiti
- Department of Cardiology, the Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, People's Republic of China, 310009
- Internal Medicine, Zhejiang University School of Medicine, Hangzhou, People's Republic of China, 310058
| | - Xianbao Liu
- Department of Cardiology, the Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, People's Republic of China, 310009.
- Internal Medicine, Zhejiang University School of Medicine, Hangzhou, People's Republic of China, 310058.
- Binjiang Institute of Zhejiang University, Hangzhou, 310052, Zhejiang, China.
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Abdelnour MW, Patel V, Patel PM, Kasel AM, Frangieh AH. Alternative access in transcatheter aortic valve replacement-an updated focused review. Front Cardiovasc Med 2024; 11:1437626. [PMID: 39175626 PMCID: PMC11338806 DOI: 10.3389/fcvm.2024.1437626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Accepted: 07/22/2024] [Indexed: 08/24/2024] Open
Abstract
Aortic Stenosis (AS) is a common condition with an estimated pooled prevalence of all AS in the elderly population at around 12.4%, with that of severe AS estimated to be around 3.4%. In the past, surgical aortic valve replacement was the primary treatment option for severe AS for decades. However, with the compelling evidence on the safety and efficacy of transcatheter aortic valve replacement (TAVR), it has become the gold standard treatment option for many patients with symptomatic severe AS. Transfemoral access has been the preferred method for transcatheter heart valve delivery. However, the prevalent use of TAVR on a diverse patient profile with different risk factors, such as peripheral artery disease, precluded the possibility of a transfemoral approach despite the improvement of valves and delivery systems technology. Therefore, alternative TAVR approaches have gained increasing utility in cases where transfemoral access is unfavorable. We review the journey, evolution, and techniques for different approaches of percutaneous TAVR, including transfemoral, transcarotid, transsubclavian/transaxillary, and transcaval approaches, in addition to the traditional "surgical" transaortic and transapical accesses. Consolidating these data highlights each approach's practicality and limitations, providing additional grounding for case-by-case utilization and future clinical research.
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Affiliation(s)
- Mark W. Abdelnour
- Division of Cardiology, Department of Medicine, University of California Irvine Medical Center, Orange, California, CA, United States
| | - Vishal Patel
- Division of Cardiology, Department of Medicine, University of California Irvine Medical Center, Orange, California, CA, United States
| | - Pranav M. Patel
- Division of Cardiology, Department of Medicine, University of California Irvine Medical Center, Orange, California, CA, United States
| | - A. M. Kasel
- Department of Cardiology, University Heart Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Antonio H. Frangieh
- Division of Cardiology, Department of Medicine, University of California Irvine Medical Center, Orange, California, CA, United States
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Taieb P, Barbash IM. Editorial: The carotid highway: Navigating towards safer TAVR access for patients. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 63:14-15. [PMID: 38485598 DOI: 10.1016/j.carrev.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 03/05/2024] [Indexed: 05/26/2024]
Affiliation(s)
- Philippe Taieb
- Interventional Cardiology Unit, Leviev Heart Center, Sheba Medical Center, Tel Aviv University, Ramat Gan, Israel
| | - Israel M Barbash
- Interventional Cardiology Unit, Leviev Heart Center, Sheba Medical Center, Tel Aviv University, Ramat Gan, Israel.
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Salihu A, Ferlay C, Kirsch M, Shah PB, Skali H, Fournier S, Meier D, Muller O, Hugelshofer S, Skalidis I, Tzimas G, Monney P, Eeckhout E, Arangalage D, Rancati V, Antiochos P, Lu H. Outcomes and Safety of Transcaval Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-analysis. Can J Cardiol 2024:S0828-282X(24)00407-0. [PMID: 38797283 DOI: 10.1016/j.cjca.2024.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 05/17/2024] [Accepted: 05/21/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND The transcaval (TCv) vascular approach is increasingly used in transcatheter aortic valve replacement (TAVR) in patients unsuitable for the gold-standard transfemoral approach. We aimed to evaluate the efficacy, safety, and clinical outcomes associated with TCv-TAVR. METHODS A systematic review and meta-analysis was conducted by searching PubMed/Medline, Embase, and the Cochrane Library for all articles assessing the TCv approach published through December 2023. Outcomes included 30-day and 1-year all-cause mortality (ACM), 30-day rehospitalisation, perioperative complications and postoperative complications at 30 days. The meta-analysis was registered on the PROSPERO database with the identifier CRD42024501921. RESULTS A total of 8 studies with 467 patients were included. TCv-TAVR procedures achieved a success rate of 98.5%. TCv-TAVR was associated with a 30-day ACM rate of 6.1% (95% confidence interval [CI]: 3.9%-8.2%), a 1-year ACM rate of 14.9% (95% CI 2.3%-27.6%) and a 30-day rehospitalisation rate of 4.2% (95% CI -2.2% to 10.6%). Postoperative stroke or transient ischemic attack, major vascular complications, and major or life-threatening bleeding occurred in 3.3%, 8.7%, and 7.5% of cases, respectively. Cumulative meta-analyses showed a temporal trend of decreasing rates of vascular complications. CONCLUSIONS The TCv approach in TAVR demonstrated a reassuring efficacy and safety profile, with mortality and postoperative complication rates similar to those reported for supra-aortic alternative TAVR access routes. The temporal decrease in vascular complications suggests potential improvements in procedural techniques and device technology. These findings further support the TCv approach as a viable option in patients ineligible for the transfemoral access. PROSPERO CRD42024501921.
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Affiliation(s)
- Adil Salihu
- Division of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Clémence Ferlay
- Division of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; Adult Intensive Care Unit, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; Division of Cardiac Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Matthias Kirsch
- Division of Cardiac Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Pinak B Shah
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hicham Skali
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Stephane Fournier
- Division of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - David Meier
- Division of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Olivier Muller
- Division of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Sarah Hugelshofer
- Division of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Ioannis Skalidis
- Division of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Georgios Tzimas
- Division of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Pierre Monney
- Division of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Eric Eeckhout
- Division of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Dimitri Arangalage
- Division of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; Cardiology Department, AP-HP, Bichat Hospital and Université de Paris, Paris, France
| | - Valentina Rancati
- Division of Anaesthesiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Panagiotis Antiochos
- Division of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Henri Lu
- Division of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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Bruce CG, Khan JM, Rogers T, Yildirim DK, Babaliaros VC, Greenbaum AB, Lederman RJ. Transcatheter Electrosurgery: A Narrative Review. Circ Cardiovasc Interv 2023; 16:e012019. [PMID: 36799217 PMCID: PMC10108249 DOI: 10.1161/circinterventions.122.012019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 01/04/2023] [Indexed: 02/18/2023]
Abstract
Transcatheter electrosurgery describes the ability to cut and traverse tissue, at a distance, without an open surgical field and is possible using either purpose-built or off-the-shelf devices. Tissue traversal requires focused delivery of radiofrequency energy to a guidewire tip. Initially employed to cross atretic pulmonary valves, tissue traversal has enabled transcaval aortic access, recanalization of arterial and venous occlusions, transseptal access, and many other techniques. To cut tissue, the selectively denuded inner curvature of a kinked guidewire (the Flying-V) or a single-loop snare is energized during traction. Adjunctive techniques may complement or enable contemporary transcatheter procedures, whereas myocardial slicing or excision of ectopic masses may offer definitive therapy. In this contemporary review we discuss the principles of transcatheter electrosurgery, and through exemplary clinical applications highlight the range of therapeutic options offered by this versatile family of procedures.
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Affiliation(s)
- Christopher G. Bruce
- Cardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Jaffar M. Khan
- Cardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Toby Rogers
- Cardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
- MedStar Washington Hospital Center, Washington, DC, USA
| | - D. Korel Yildirim
- Cardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | | | - Adam B. Greenbaum
- Structural Heart and Valve Center, Emory University Hospital, Atlanta, GA, USA
| | - Robert J. Lederman
- Cardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
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Transcaval Access and Closure Best Practices. JACC Cardiovasc Interv 2023; 16:371-395. [PMID: 36858658 PMCID: PMC9989507 DOI: 10.1016/j.jcin.2022.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 11/15/2022] [Accepted: 12/05/2022] [Indexed: 03/02/2023]
Abstract
Transcaval aortic access is a versatile electrosurgical technique for large-bore arterial access through the wall of the abdominal aorta from the adjoining inferior vena cava. Although counterintuitive, its relative safety derives from the recognition that interstitial hydraulic pressure exceeds venous pressure, so arterial bleeding harmlessly decompresses into the nearby caval venous hole. Transcaval access has been performed in thousands of patients for transcatheter aortic valve replacement and endovascular thoracic aneurysm repair and to avoid limb ischemia in percutaneous mechanical circulatory support. Transcaval access may have value compared with transaxillary or subclavian access and with surgical transcarotid access when standard transfemoral access is not optimal. The dissemination of transcaval access and closure techniques has been hampered by the unavailability of commercially marketed devices. This state-of-the-art review details exemplary transcaval technique, patient selection, computed tomographic planning, step-by-step access and closure, management of complications, and procedural troubleshooting in special situations. These contemporary best practices can help operators gain or maintain proficiency.
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Marmagkiolis K, Iliescu CA, Grines CL, Matar F, Cilingiroglu M. 2021. The year in review. Structural heart interventions. Int J Cardiol 2022; 359:99-104. [PMID: 35427702 PMCID: PMC9005217 DOI: 10.1016/j.ijcard.2022.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 04/04/2022] [Accepted: 04/08/2022] [Indexed: 11/23/2022]
Abstract
Since the beginning of 2020, the corona virus (COVID-19) pandemic redefined in many ways the practice of cardiology, research and cardiology conferences. Virtual conferences replaced most major in-person venues. The number of "elective" structural heart interventions declined and clinical research endured major setbacks in regards to academic and industry-sponsored clinical trials. In this review, we attempt to provide a broad overview of the field for general and interventional cardiologists with a specific interest in structural heart interventions.
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Affiliation(s)
- Konstantinos Marmagkiolis
- Cardiology, University of Texas, MD Anderson Cancer Center, Houston, TX, United States of America; Cardiology, Univeristy of South Florida, Tampa, FL, United States of America.
| | - Cezar A Iliescu
- Medicine, Interventional Cardiology, Medical Director MD Anderson Cardiac Catheterization Laboratory, Houston, TX, United States of America
| | - Cindy L Grines
- Northside Hospital, Atlanta, GA, United States of America
| | - Fadi Matar
- Cardiology, Univeristy of South Florida, Tampa, FL, United States of America
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Lederman RJ, Babaliaros VC, Lisko JC, Rogers T, Mahoney P, Foerst JR, Depta JP, Muhammad KI, McCabe JM, Pop A, Khan JM, Bruce CG, Medranda GA, Wei JW, Binongo JN, Greenbaum AB. Transcaval Versus Transaxillary TAVR in Contemporary Practice: A Propensity-Weighted Analysis. JACC Cardiovasc Interv 2022; 15:965-975. [PMID: 35512920 PMCID: PMC9138050 DOI: 10.1016/j.jcin.2022.03.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 03/06/2022] [Accepted: 03/07/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The aim of this study was to compare transcaval and transaxillary artery access for transcatheter aortic valve replacement (TAVR) at experienced medical centers in contemporary practice. BACKGROUND There are no systematic comparisons of transcaval and transaxillary TAVR access routes. METHODS Eight experienced centers contributed local data collected for the STS/ACC TVT Registry (Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry) between 2017 and 2020. Outcomes after transcaval and axillary/subclavian (transaxillary) access were adjusted for baseline imbalances using doubly robust (inverse propensity weighting plus regression) estimation and compared. RESULTS Transcaval access was used in 238 procedures and transaxillary access in 106; for comparison, transfemoral access was used in 7,132 procedures. Risk profiles were higher among patients selected for nonfemoral access but similar among patients requiring transcaval and transaxillary access. Stroke and transient ischemic attack were 5-fold less common after transcaval than transaxillary access (2.5% vs 13.2%; OR: 0.20; 95% CI: 0.06-0.72; P = 0.014) compared with transfemoral access (1.7%). Major and life-threatening bleeding (Valve Academic Research Consortium 3 ≥ type 2) were comparable (10.0% vs 13.2%; OR: 0.66; 95% CI: 0.26-1.66; P = 0.38) compared with transfemoral access (3.5%), as was blood transfusion (19.3% vs 21.7%; OR: 1.07; 95% CI: 0.49-2.33; P = 0.87) compared with transfemoral access (7.1%). Vascular complications, intensive care unit and hospital length of stay, and survival were similar between transcaval and transaxillary access. More patients were discharged directly home and without stroke or transient ischemic attack after transcaval than transaxillary access (87.8% vs 62.3%; OR: 5.19; 95% CI: 2.45-11.0; P < 0.001) compared with transfemoral access (90.3%). CONCLUSIONS Patients undergoing transcaval TAVR had lower rates of stroke and similar bleeding compared with transaxillary access in a contemporary experience from 8 US centers. Both approaches had more complications than transfemoral access. Transcaval TAVR access may offer an attractive option.
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Affiliation(s)
- Robert J Lederman
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA.
| | - Vasilis C Babaliaros
- Emory Structural Heart and Valve Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - John C Lisko
- Emory Structural Heart and Valve Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Toby Rogers
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA; Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Paul Mahoney
- Division of Cardiology, The Sentara Heart Center, Norfolk, Virginia, USA
| | - Jason R Foerst
- Carilion Clinic, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
| | - Jeremiah P Depta
- Department of Cardiology, Sands Constellation Heart Institute, Rochester Regional Health, Rochester, New York, USA
| | | | - James M McCabe
- Division of Cardiology, University of Washington Medical Center, Seattle, Washington, USA
| | - Andrei Pop
- AMITA Health Alexian Brothers Medical Center, Elk Grove Village, Illinois, USA
| | - Jaffar M Khan
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Christopher G Bruce
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Giorgio A Medranda
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Jane W Wei
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Jose N Binongo
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Adam B Greenbaum
- Emory Structural Heart and Valve Center, Emory University School of Medicine, Atlanta, Georgia, USA. https://twitter.com/AdamGreenbaumMD
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