The time has come. Over the past few years, we have been living a constant increase in the number of patients with aortic stenosis who are treated with transcatheter aortic valve implantation (TAVI). ...Although the latest indications of the clinical practice guidelines from the European Society of Cardiology1 are somehow more restrictive than those of the American College of Cardiology2 regarding age cut-offs and surgical risk we’ve seen a growing demand for TAVI in low-risk patients and, progressively, in younger patients in almost all anatomical settings. Up until now, randomized clinical trials had mostly focused on comparing the TAVI technique to conventional aortic valve replacement surgery.3,4 And although these studies with different models of transcatheter aortic valves laid the foundation for the indications published by the guidelines, very few of them make head-to-head comparisons among the different TAVI models currently available. As a matter of fact, most are observational, non-randomized or non-inferiority clinical trials. On the other hand, the variability of the different models currently available has been growing with technological advances to perform easier, safer, and more durable transcatheter heart valves. However, can we assume that there will be some sort of class effect in all TAVI models currently available? In...
HOW WOULD I APPROACH IT? This is a a challenging case that combines severe coronary artery disease of trifurcated left main coronary artery and severe aortic stenosis in an elderly female patient ...with chronic kidney disease. According to the current clinical guidelines, this patient whose score in the Society of Thoracic Surgeons score is > 10% and with good femoral accesses has an I-B indication for a transcatheter aortic valve implantation (TAVI). No other factor supports performing surgery except for the existence of coronary artery disease, which could be considered eligible for coronary artery bypass graft given the complexity of the left main lesion and the presence of good distal beds. However, what makes this patient's surgical risk nearly unacceptable is the combination of a valve replacement procedure plus coronary bypasses, so if a better percutaneous option is available, and we believe there is, such an option should be pursued. After establishing the indication for TAVI, there is a II-A indication for percutaneous revascularization since the percent diameter stenosis is > 70% in proximal segments, the Syntax I score estimated using the data available is 27 points (29 if intense calcification is considered) and after adding clinical data tinto consideration, the Syntax II score shows a 4-year mortality rate after percutaneous coronary intervention (PCI) of 44.2% vs 33.6% after surgery. All this leaves the decision making process open since the risk involved in both strategies is high. In this case we might choose PCI plus TAVI.
Methods REPARA is a multicentre, prospective registry, designed to evaluate the efficacy and safety of the bioresorbable coronary device Absorb® in native coronary arteries in daily clinical ...practice. Primary objective is MACE at 12 months, including cardiac death, myocardial infarction, target lesion revascularization and stent thrombosis.
Abstract Background Transcatheter aortic valve implantation (TAVI) is the recommended therapy for patients with severe aortic stenosis who are not suitable candidates for surgery. The aim of this ...study was to describe early experience and long-term follow-up with the CoreValve self-expanding aortic prosthesis at 42 Ibero-American hospitals. Methods Multiple centre observational study including 1220 consecutive patients with symptomatic severe aortic stenosis who are not suitable candidates for surgery and underwent transcatheter aortic valve implantation with the self-expanding Medtronic CoreValve System between December 2007 and May 2012. Results The registry included 1220 consecutive patients with a mean age of 80.8 ± 6.3 years and a mean logistic euroSCORE of 17.8% ± 13%. The procedural success rate was 96.1%. Hospital mortality was 7.3% and combined end-point was 21.3%. Aortic regurgitation after TAVI was present in 24.5% (Sellers grade ≥ 2). The estimated 1-year and 2-year survival rates were 82.1% and 73.4% respectively. The following issues were significant independent risk factors for hospital mortality: acute kidney failure (odds ratio 3.55); stroke (odds ratio 5.72); major bleeding (odds ratio 2.64) and euroSCORE (odds ratio 1.02). Long-term predictors of mortality were diabetes mellitus (hazard ratio 1.59, 95% confidence interval 1.09–2.31), severe chronic obstructive pulmonary disease (hazard ratio 1.85, 95% confidence interval 1.85–2.88), and functional classes NYHA III–IV (hazard ratio 1.31, 95% confidence interval 1.01–1.70). Conclusions Transcatheter aortic valve implantation constitutes a safe and viable therapeutic option for high operative risk patients with severe aortic stenosis. Long-term prognosis is conditioned by associate comorbidities.
Transaxillary access (TXA) has become the most widely used alternative to transfemoral access (TFA) in patients undergoing transcatheter aortic valve implantation (TAVI). The aim of this study was to ...compare total in-hospital and 30-day mortality in patients included in the Spanish TAVI registry who were treated by TXA or TFA access.
We analyzed data from patients treated with TXA or TFA and who were included in the TAVI Spanish registry. In-hospital and 30-day events were defined according to the recommendations of the Valve Academic Research Consortium. The impact of the access route was evaluated by propensity score matching according to clinical and echocardiogram characteristics.
A total of 6603 patients were included; 191 (2.9%) were treated via TXA and 6412 via TFA access. After adjustment (n=113 TXA group and n=3035 TFA group) device success was similar between the 2 groups (94%, TXA vs 95%, TFA; P=.95). However, compared with the TFA group, the TXA group showed a higher rate of acute myocardial infarction (OR, 5.3; 95%CI, 2.0-13.8); P=.001), renal complications (OR, 2.3; 95%CI, 1.3-4.1; P=.003), and pacemaker implantation (OR, 1.6; 95%CI, 1.01-2.6; P=.03). The TXA group also had higher in-hospital and 30-day mortality rates (OR, 2.2; 95%CI, 1.04-4.6; P=.039 and OR, 2.3; 95%CI, 1.2-4.5; P=.01, respectively).
Compared with ATF, TXA is associated with higher total mortality, both in-hospital and at 30 days. Given these results, we believe that TXA should be considered only in those patients who are not suitable candidates for TFA.
El acceso transaxilar (ATx) se ha convertido en el acceso alternativo al transfemoral (ATF), más utilizado en pacientes sometidos a implante percutáneo de válvula aórtica (TAVI). El objetivo principal de este estudio es comparar la mortalidad total hospitalaria y a los 30 días de los pacientes incluidos en el registro español de TAVI a los que se trató por acceso ATx frente a ATF.
Se analizó a todos los pacientes incluidos en el registro español de TAVI tratados por ATx o ATF. Los eventos hospitalarios y a los 30 días de seguimiento se definieron según las recomendaciones de la Valve Academic Research Consortium. Se evaluó el impacto de la vía de acceso mediante emparejamiento por puntuación de propensión según las características clínicas y ecográficas.
Se incluyó a 6.603 pacientes, 191 (2,9%) tratados por ATx y 6.412 con ATF. Después del ajuste (grupo de ATx, n=113; grupo de ATF, n=3.035), el éxito del dispositivo fue similar entre ambos grupos (el 94% en el grupo de ATx frente al 95% en el de ATF; p=0,95); sin embargo, se observó un incremento en la tasa de infarto agudo de miocardio (OR=5,3; IC95%, 2,0-13,8; p=0,001), complicaciones renales (OR=2,3; IC95%, 1,3-4,1; p=0,003) e implante de marcapasos (OR=1,6; IC95%, 1,01-2,6; p=0,03) en el grupo de ATx comparado con el de ATF. De mismo modo, la mortalidad hospitalaria y a los 30 días fueron superiores en el grupo de ATx (respectivamente, OR=2,2; IC95%, 1,04-4,6; p=0,039; y OR=2,3; IC95%, 1,2-4,5; p=0,01).
El ATx se asocia con un aumento en la mortalidad total tanto hospitalaria como a los 30 días frente al ATF. Ante estos resultados, el ATx debe considerarse solo en caso de que el ATF no sea posible.
Background
Vasopressor test (VPT) might be useful in patients with functional mitral regurgitation (MR) and left ventricular dysfunction (MITRA‐FR‐like patients) during transcatheter edge‐to‐edge ...repair (TEER).
Aims
We aimed to evaluate the prognostic impact of VPT.
Methods
MR treated with TEER were included in a multicenter prospective registry. VPT was used intraprocedurally in patients with left ventricular dysfunction and/or hypotension. The 1‐year echocardiographic and clinical outcomes were compared according to the use of VPT. The primary endpoint was a combination of mortality + heart failure (HF) readmission at 1‐year.
Results
A total of 1115 patients were included, mean age was 72.8 ± 10.5 years and 30.4% were women. VPT was performed in 128 subjects (11.5%), more often in critically ill patients with biventricular dysfunction. Postprocedurally the VPT group had greater rate of MR ≥ 2+ (46.9% vs. 31.7%, p = 0.003) despite greater number of devices (≥2 clips, 52% vs. 40.6 p = 0.008) and device repositioning or new clip in 12.5%. At 1‐year, the primary endpoint occurred more often in the VPT group (27.3% vs. 16.9%, p = 0.002) as well as all‐cause mortality (21.9% vs. 8.1%, p ≤ 0.001) but no differences existed in HF readmission rate (14.8% vs. 13.2%, p = 0.610), cardiovascular mortality (4.4% vs. 3.9%, p = 0.713) or residual MR ≥ 2+ (51.1% vs 51.7%, p = 0.371).
Conclusions
Dynamic evaluation of MR during TEER procedure through VPT was performed in patients with worse baseline risk who also presented higher all‐cause mortality at 1‐year follow‐up. However, 1‐year residual MR, cardiovascular mortality and HF readmission rate remained comparable suggesting that VPT might help in the management of MITRA‐FR‐like patients.
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