Many patients have iliofemoral vessel anatomy unsuitable for conventional transfemoral (TF) transcatheter aortic valve implantation (TAVI). Safe and practical alternatives to the TF approach are, ...therefore, needed. This study compared outcomes of alternative nonfemoral routes, transapical (TA), direct aortic (DA), and subclavian (SC), with standard femoral access. In this retrospective study, data from 3,962 patients in the UK TAVI registry were analyzed. All patients who received TAVI through a femoral, subclavian, TA, or DA approach were eligible for inclusion. The primary outcome measure was survival up to 2 years. Median Logistic EuroSCORE was similar for SC, DA, and TA but significantly lower in the TF cohort (22.1% vs 20.3% vs 21.2% vs 17.0%, respectively, p <0.0001). Estimated 1-year survival rate was similar for TF (84.6 ± 0.7%) and SC (80.5 ± 3%, p = 0.27) but significantly worse for TA (74.7 ± 1.6%, p <0.001) and DA (75.2 ± 3.3%, p <0.001). A Cox proportional hazard model was used to analyze survival up to 2 years. Survival in the SC group was not significantly different from the TF group (hazard ratio HR 1.22, 95% confidence interval CI 0.88 to 1.70, p = 0.24). In contrast, survival in the TA (HR 1.74, 95% CI 1.43 to 2.11; p <0.001) and DA (HR 1.55, 95% CI 1.13 to 2.14; p <0.01) cohorts was significantly reduced compared with TF. In conclusion, TA and DA TAVI were associated with similar survival, both significantly worse than with the TF route. In contrast, subclavian access was not significantly different from TF and may represent the safest nonfemoral access route for TAVI.
Abstract Background Despite the wealth of data showing the positive effects on cardiac reverse remodelling in the long-term, the immediate effects of transcatheter aortic valve implantation (TAVI) on ...the left ventricle are yet to be comprehensively described using cardiovascular magnetic resonance imaging. Also, the link between myocardial fibrosis and acute left ventricular (LV) mass regression is unknown. Methods Fifty-seven patients with severe aortic stenosis awaiting TAVI underwent paired cardiovascular magnetic resonance scans before and early after the procedure (4 interquartile range, 3-5 days). LV mass, volume, and function were measured. Late gadolinium enhancement (LGE) imaging was performed to assess for the presence of and pattern of myocardial fibrosis. Results After the procedure, 53 (95%) patients experienced an immediate (10.1 ± 7.1%) reduction in indexed LV mass (LVMi) from 76 ± 15.5 to 68.4 ± 14.7 g/m2 ( P < 0.001). Those with no LGE experienced the greatest LVMi regression (13.9 ± 7.1%) compared with those with a midwall/focal fibrosis pattern LGE (7.4 ± 5.8%) and infarct pattern LGE (7.2 ± 7.0%; P = 0.005). There was no overall change in LV ejection fraction (LVEF; 55.1 ± 12.1% to 55.5 ± 10.9%; P = 0.867), however a significant improvement in LVEF was seen in those with abnormal (< 55%; n = 24; 42%) baseline LVEF (43.2 ± 8.9 to 46.7 ± 10.5%; P = 0.027). Baseline LVMi ( P = 0.005) and myocardial fibrosis ( P < 0.001) were strong independent predictors of early LVMi regression. Conclusions LV reverse remodelling occurs immediately after TAVI, with significant LV mass regression in the total population and an improvement in LVEF in those with preexisting LV impairment. Those without myocardial fibrosis at baseline experience greater LV mass regression than those with fibrosis.
We describe a patient who presented with heart failure 7 years post-transcatheter aortic valve implantation (TAVI) as a result of severe structural valve degeneration. Anatomic challenges, combined ...with the type of transcatheter heart valve used initially, meant that TAVI-in-TAVI risked obstructing the coronary arteries, even if preceded by bioprosthetic aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction. The patient was treated with balloon aortic valvuloplasty.
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We describe a patient who presented with heart failure 7 years post-transcatheter aortic valve implantation (TAVI) as a result of severe structural…
Abstract Significant paravalvular leak (PVL) after transcatheter aortic valve implantation (TAVI) is associated with poor outcome. We present the case of an 83-year-old female with severe aortic ...stenosis who underwent TAVI with an Evolut-R valve (Medtronic, Minneapolis, MN, USA). An aortogram post-procedure showed aortic regurgitation thought to be moderately severe after post-dilatation. She deteriorated 24 h after her procedure and required a further intervention. She was salvaged with a Lotus (Boston Scientific, Marlborough, MA, USA) ‘valve in valve’ that completely eliminated PVL. < Learning objective: Significant paravalvular leak is a potential complication of transcatheter aortic valve implantation. This can result in poor outcomes especially in patients who have a small non-compliant left ventricular cavity with limited ability to compensate for volume overload. Such complications can be identified early by performing aortography, transthoracic echocardiogram and assessing invasive hemodynamics. A ‘valve in valve’ procedure with the Lotus valve (Boston Scientific, Marlborough, MA, USA) has shown favorable results in these patients.>
We investigated human immunodeficiency virus (HIV) type 1 RNA, proviral DNA, and antiretroviral drug-resistant variants in cervicovaginal secretions of HIV-1-infected women receiving antiretroviral ...therapy. The prevalence of detectable HIV-1 RNA in genital secretions was inversely related to the number of antiretroviral drugs taken by the patients. Proviral DNA was detected in approximately half of all samples of cervicovaginal secretions from HIV-1-infected women, regardless of the presence or absence of HIV-1 RNAin cervicovaginal secretions and of the antiretroviral regimen. In cervicovaginal secretions of most women with persisting genital viral replication, HIV variants exhibiting mutations associated with drug resistance against protease and reverse-transcriptase pol genes were found. Our observations indicate that antiretroviral therapy is not effective in purging the female genital tract of cellassociated provirus and that antiretroviral drugs that penetrate the female genital tract at suboptimal concentrations exert a potent selective pressure on genital HIV variants when local replication of free HIV-1 RNA persists.
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