Clinical Impact of Crossover Techniques for Primary Access Hemostasis in Transfemoral Transcatheter Aortic Valve Replacement Procedures

OBJECTIVES

To determine the occurrence of vascular complications (VCs) following transfemoral transcatheter aortic valve replacement (TAVR) with new-generation devices according to the use of a crossover technique (COT).

BACKGROUND

The use of a COT (with/without balloon) has been associated with a reduction of VCs in TAVR patients. However, scarce data support its use with second-generation devices. Also, its potential benefit in obese patients (at high-risk of VCs) has not been elucidated.

METHODS

A multicenter study including 2214 patients who underwent full percutaneous transfemoral TAVR (COT, 1522 patients; no COT, 692 patients). Thirty-day events were evaluated according to the use of a COT using a multivariate logistic regression model. A subanalysis was performed in obese patients.

RESULTS

Primary access major VCs (3.5% COT vs 3.9% no COT; P=.19), major/life-threatening bleeding (3.4% COT vs 2.0% no COT; P=.33), and mortality rates (2.4% COT vs 2.6% no COT; P=.23) were similar between groups. However, minor VCs (11.7% COT vs 5.9% no COT; P<.001) and postprocedural acute renal failure (8.9% COT vs 3.9% no COT; P<.001) were higher in patients undergoing the COT. In the overall cohort, percutaneous closure device failure was more frequent in obese patients (4.0% in the obese group vs 1.9% in the non-obese group; P<.01), but these differences were no longer significant in those undergoing a COT (3.4% in the obese group vs 2.0% in the non-obese group; P=.12). Indeed, in the subset of obese patients, the COT tended to be associated with fewer VCs (3.4% COT vs 5.9% no COT; P=.09).

CONCLUSIONS

The use of a COT was not associated with a reduction of major VCs or improved outcomes. However, some patient subsets, such as those with higher body mass index, may benefit from the use of a COT. These findings would suggest the application of a tailored strategy, following a risk-benefit assessment in each TAVR candidate.

Long-Term Outcomes After Transcatheter Aortic Valve-in-Valve Replacement

BACKGROUND

Data on long-term outcomes after valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) are scarce. The objective of this study was to determine the long-term clinical outcomes and structural valve degeneration (SVD) over time in patients undergoing ViV-TAVR.

METHODS AND RESULTS

Consecutive patients undergoing ViV-TAVR in 9 centers between 2009 and 2015 were included. Patients were followed yearly, and clinical and echocardiography data were collected prospectively. SVD was defined as subclinical (increase >10 mm Hg in mean transvalvular gradient+decrease >0.3 cm² in valve area or new-onset mild or moderate aortic regurgitation) and clinically relevant (increase >20 mm Hg in mean transvalvular gradient+decrease >0.6 cm² in valve area or new-onset moderate-to-severe aortic regurgitation). A total of 116 patients (mean age, 76±11 years; 64.7% male; mean Society of Thoracic Surgeons score, 8.0±5.1%) were included. Balloon- and self-expandable valves were used in 47.9% and 52.1% of patients, respectively, and 30-day mortality was 6.9%. At a median follow-up of 3 years (range, 2-7 years), 30 patients (25.9%) had died, 20 of them (17.2%) from cardiovascular causes. Average mean transvalvular gradients remained stable up to 5-year follow-up ( P=0.92), but clinically relevant SVD occurred in 3/99 patients (3.0%), and 15/99 patients (15.1%) had subclinical SVD. One patient with SVD had redo ViV-TAVR.

CONCLUSIONS

About one-fourth of ViV-TAVR recipients had died after a median follow-up of 3 years. Overall valve hemodynamics remained stable over time and clinically relevant SVD was infrequent, but 1 out of 10 patients exhibited some degree of SVD.

Disseminating information using an anesthesiology consultant report: impact on patient perceptions of quality of care

STUDY OBJECTIVE

To determine if providing an Anesthesiology Consultant Report (ACR) to patients would result in enhanced patients' perceptions of their knowledge about their care and improve their perception of the quality of their care.

DESIGN

Randomized, unblinded study.

SETTING

Outpatient center associated with tertiary care center.

PATIENTS

371 outpatients without adverse anesthetic events.

INTERVENTIONS

Patients were randomized to receive either routine discharge instructions or routine instructions and an anesthesia discharge summary (ACR).

MEASUREMENTS AND MAIN RESULTS

Short questionnaire with discharge packet regarding knowledge of anesthetic and questions regarding satisfaction and perceptions of quality of care was distributed. The patients in the group that received an ACR were more satisfied with the management of their pain and other symptoms (p < 0.05, by Wilcoxon rank sums) and were more satisfied overall with the quality of the anesthesia care (p < 0.01, by Wilcoxon rank sums). Taken another way, significantly more patients deemed the quality of their anesthetic care as excellent in the ACR group compared to control (83% vs. 67%, p < 0.01).

CONCLUSIONS

Providing patients, with uneventful anesthetic courses, with information regarding their anesthetic care, in the form of the ACR, results in improved perceptions of the quality of care.

The effect of substance P and its fragments on passive avoidance retention and brain monoamine activity

It has been shown that substance P(SP), as well as its carboxy and amino terminal fragments, affects a wide range of behaviors. In order to test the CNS activity of these fragments, we measured their effects on passive avoidance learning and monoamine activity. Following one-trial passive avoidance training, mice were injected intraventricularly with either a carboxy or amino terminal SP fragment (SP-C or SP-N), SP itself or phosphate-buffered saline (PBS). SP-N enhanced avoidance retention, which was tested 24 h after training. In a second experiment, monoamine activity was measured one hour after intraventricular injection of SP, PBS or SP fragments. SP-C decreased both nigral 5-hydroxyindoleacetic acid/5-hydroxytryptamine (5-HIAA/5-HT) and, to a lesser extent, 3,4-dihydroxyphenylacetic acid/dopamine, while SP-N increased nigral 5-HIAA/5-HT. It was concluded that SP-N and SP-C can exert behavioral and neurochemical effects that may be independent of the parent SP molecule.

Jaundice and breast-feeding among Alaskan Eskimo newborns

The course, incidence, and severity of neonatal jaundice was studied in 95 Alaskan Eskimo infants. Breast-fed infants had higher bilirubin concentrations than bottle-fed babies. Both groups experienced high bilirubin levels, similar to those previously reported in Navajo and Oriental infants but greater than those observed in whites and blacks. A marked capacity to inhibit hepatic glucuronyl transferase was observed in breast-milk specimens but only partly accounted for the bilirubin differences between breast-fed and bottle-fed Eskimo infants. These data suggest that in some racial groups predisposed to neonatal jaundice, feeding practices significantly alter the course and severity of hyperbilirubinemia.