RESUMEN
BACKGROUND: Transcatheter aortic valve implantation (TAVI) is now a well-established therapeutic option in an elderly high-risk patient cohort with aortic valve disease. Although most commonly performed via a transfemoral route, alternative approaches for TAVI are constantly being improved. Instead of the classical mini-sternotomy, it is possible to achieve a transaortic access via a right anterior mini-thoracotomy in the second intercostal space. We describe our experience with this sternum- and rib-sparing technique in comparison to the classical transaortic approach. METHODS: Our retrospective study includes 173 patients who were treated in our institution between January 2017 and April 2020 with transaortic TAVI via either upper mini-sternotomy or intercostal thoracotomy. The primary endpoint was 30-day mortality, and secondary endpoints were defined as major postoperative complications that included admission to the intensive care unit and overall hospital stay, according to the Valve Academic Research Consortium 3. RESULTS: Eighty-two patients were treated with TAo-TAVI by upper mini-sternotomy, while 91 patients received the intercostal approach. Both groups were comparable in age (mean age: 82 years) and in the proportion of female patients. The intercostal group had a higher rate of peripheral artery disease (41% vs. 22%, p = 0.008) and coronary artery disease (71% vs. 40%, p < 0.001) with a history of percutaneous coronary intervention or coronary artery bypass grafting, resulting in significantly higher preinterventional risk evaluation (EuroScore II 8% in the intercostal vs. 4% in the TAo group, p = 0.005). Successful device implantation and a reduction of the transvalvular gradient were achieved in all cases with a significantly lower rate of trace to mild paravalvular leakage in the intercostal group (12% vs. 33%, p < 0.001). The intercostal group required significantly fewer blood transfusions (0 vs. 2 units, p = 0.001) and tended to require less reoperation (7% vs. 15%, p = 0.084). Hospital stays (9 vs. 12 d, p = 0.011) were also shorter in the intercostal group. Short- and long-term survival in the follow-up showed comparable results between the two approaches (30-day, 6-month- and 2-year mortality: 7%, 23% and 36% in the intercostal vs. 9%, 26% and 33% in the TAo group) with acute kidney injury (AKI) and reintubation being independent risk factors for mortality. CONCLUSIONS: Transaortic TAVI via an intercostal access offers a safe and effective treatment of aortic valve stenosis.
RESUMEN
INTRODUCTION: Renal sympathetic denervation (RDN) is a novel treatment option in patients with treatment-resistant arterial hypertension. A subset of recently published randomized and non-randomized trials indicates that RDN leads to sustained lowering of blood pressure (BP) under controlled study conditions. However, registry data that allow evaluation of safety and efficacy in a real-world setting are largely missing. METHODS: Sixty-three consecutive patients with treatment-resistant hypertension underwent RDN with the radiofrequency-based Symplicity™ catheter. As part of our prospective registry, treatment efficacy and safety were monitored after 3, 6, and 12 months. RESULTS: At 6 months follow-up, office systolic BP significantly improved by 19 + 23 mmHg as compared to baseline, while diastolic BP values reduced by 6 + 13 mmHg (p < 0.05). One year after RDN, office BP levels further improved (26 + 25 mmHg in systolic BP and 9 + 13 mmHg in diastolic BP, respectively), even though 19 patients had reduced the number and/or dosage of antihypertensive agents. The response rate, defined as reduction of office systolic BP of ≥ 10 mmHg, was 73% after 6 months. Baseline BP was the only significant predictor of blood pressure response, whereas no correlation was found between the number of ablation points and the individual changes in office blood pressure. Interestingly, patients with challenging renal anatomy profited somewhat less from the procedure than those with "normal" renal anatomy. Procedure related adverse events occurred in three patients (4.7%) and were limited to vascular access complications. CONCLUSIONS: RDN with the Symplicity™ system is safe and effective in patients with treatment-resistant hypertension also in a real-world setting.
