Management of left main coronary artery obstruction after transcatheter aortic valve replacement utilizing a periscope approach.

Coronary obstruction is a rare but potentially fatal complication of transcatheter aortic valve replacement (TAVR). It can result from native leaflet or stent frame obstruction of the coronary ostia. There are reports detailing the difficulty of percutaneous coronary intervention following TAVR, but none that describe a periscope approach to access the left main ostia in the presence of a braided nitinol frame. This report describes an alternative approach to access a coronary artery when the valve stent struts are prohibitive to equipment delivery.

Physicians' perspectives and attitudes toward surgical bailout in transcatheter aortic valve replacement.

Objectives: The incidence of surgical bailout during transcatheter aortic valve replacement (TAVR) is ∼1%, with an associated 50% in-hospital mortality. We performed an exploratory qualitative study of TAVR team perceptions regarding routine surgical bailout planning with patients. Methods: We developed a semistructed interview guide to explore clinician perspectives on the TAVR consent process, managing intraoperative emergencies, and involving patients in surgical contingency planning. We interviewed surgeons, cardiologists, and anesthesiologists involved with TAVR in 4 hospitals. We performed qualitative thematic analysis via independent coding of salient quotations from the transcribed texts. Codes were categorized based on shared meaning and the final themes were derived by identifying key content, and examining its relational nature. Results: Thirteen interviews were conducted, identifying 4 major themes. Participants agreed that eliciting patient preference for bailout is crucial, particularly when surgical outcome is ambiguous. In those cases, participants offered criteria for determining which patients should be engaged in a more nuanced discussion. The ethos of specialty clinicians impacted anticipation and response to procedural emergencies. Finally, physician attitudes reflected strong emotional responses to patient death/morbidity, particularly in iatrogenic injury. Participants expressed anxiety with performing TAVR without surgical backup, while also demonstrating willingness to respect patients' wishes. Conclusions: The TAVR team supports engaging patients regarding potential surgical bailout and honoring their preferences in the event of complication. However, clinical judgment about the expected outcome of bailout would frame that discussion. Participants described the emotional weight of not pursuing bailout if indicated and the importance of good coping mechanisms.

Exposure to glucocorticoids prior to transcatheter aortic valve replacement is associated with reduced incidence of high-degree AV block and pacemaker.

BACKGROUND: Tissue edema and inflammation, which occur at the device landing zone during valve deployment, may contribute to the pathophysiology of conduction abnormalities after transcatheter aortic valve replacement (TAVR). We hypothesized that exposure to glucocorticoids prior to TAVR will reduce the incidence of conduction abnormalities requiring PPM implantation after TAVR. METHODS: We included 167 consecutive patients treated with TAVR at the Minneapolis VA Medical Center and University of Minnesota. Exposure to glucocorticoids was assessed by linking electronic medical and pharmacy records. The primary outcome was a new PPM within 30 days of the index TAVR procedure. RESULTS: Of the 167 patients included, 16 (9.5%) were exposed to glucocorticoids prior to TAVR. No differences in age, STS score, pre-existing right bundle branch block, implantation depth or valve type were seen among patients exposed to glucocorticoids versus those who were unexposed. Patients exposed to glucocorticoids were more likely to have moderate/severe COPD (43% versus 18%, p < 0.01). The cumulative incidence of PPM implantation at 30-days after TAVR was 18%. None of the patients exposed to glucocorticoids required a PPM while 30 (19%) of the unexposed patients did (p = 0.04). CONCLUSIONS: Exposure to glucocorticoids prior to TAVR may be associated with reduced incidence of PPM requirement though larger studies are needed to support these findings. Tissue edema and inflammation may be significant contributors to the pathophysiology of conduction abnormalities after TAVR and could represent a therapeutic target.

Avoiding the Learning Curve for Transcatheter Aortic Valve Replacement.

Objectives. To evaluate whether collaboration between existing and new transcatheter aortic valve replacement (TAVR) programs could help reduce the number of cases needed to achieve optimal efficiency. Background. There is a well-documented learning curve for achieving procedural efficiency and safety in TAVR procedures. Methods. A multidisciplinary collaboration was established between the Minneapolis VA Medical Center (new program) and the University of Minnesota (established program since 2012, n = 219) 1 year prior to launching the new program. Results. 269 patients treated with TAVR (50 treated in the first year at the new program). Mean age was 76 (±18) years and STS score was 6.8 (±6). Access included transfemoral (n = 35, 70%), transapical (n = 8, 16%), transaortic (n = 2, 4%), and subclavian (n = 5, 10%) types. Procedural efficiency (procedural time 158 ± 59 versus 148 ± 62, p = 0.27), device success (96% versus 87%, p = 0.08), length of stay (5 ± 3 versus 6 ± 7 days, p = 0.10), and safety (in hospital mortality 4% versus 6%, p = 0.75) were similar between programs. We found no difference in outcome measures between the first and last 25 patients treated during the first year of the new program. Conclusions. Establishing a partnership with an established program can help mitigate the learning curve associated with these complex procedures.

Early Access to the Cardiac Catheterization Laboratory for Patients Resuscitated From Cardiac Arrest Due to a Shockable Rhythm: The Minnesota Resuscitation Consortium Twin Cities Unified Protocol.

BACKGROUND: In 2013 the Minnesota Resuscitation Consortium developed an organized approach for the management of patients resuscitated from shockable rhythms to gain early access to the cardiac catheterization laboratory (CCL) in the metro area of Minneapolis-St. Paul. METHODS AND RESULTS: Eleven hospitals with 24/7 percutaneous coronary intervention capabilities agreed to provide early (within 6 hours of arrival at the Emergency Department) access to the CCL with the intention to perform coronary revascularization for outpatients who were successfully resuscitated from ventricular fibrillation/ventricular tachycardia arrest. Other inclusion criteria were age >18 and <76 and presumed cardiac etiology. Patients with other rhythms, known do not resuscitate/do not intubate, noncardiac etiology, significant bleeding, and terminal disease were excluded. The primary outcome was survival to hospital discharge with favorable neurological outcome. Patients (315 out of 331) who were resuscitated from VT/VF and transferred alive to the Emergency Department had complete medical records. Of those, 231 (73.3%) were taken to the CCL per the Minnesota Resuscitation Consortium protocol while 84 (26.6%) were not taken to the CCL (protocol deviations). Overall, 197 (63%) patients survived to hospital discharge with good neurological outcome (cerebral performance category of 1 or 2). Of the patients who followed the Minnesota Resuscitation Consortium protocol, 121 (52%) underwent percutaneous coronary intervention, and 15 (7%) underwent coronary artery bypass graft. In this group, 151 (65%) survived with good neurological outcome, whereas in the group that did not follow the Minnesota Resuscitation Consortium protocol, 46 (55%) survived with good neurological outcome (adjusted odds ratio: 1.99; [1.07-3.72], P=0.03). CONCLUSIONS: Early access to the CCL after cardiac arrest due to a shockable rhythm in a selected group of patients is feasible in a large metropolitan area in the United States and is associated with a 65% survival rate to hospital discharge with a good neurological outcome.