Meta-analysis of the impact of mitral regurgitation on outcomes after transcatheter aortic valve implantation.

Significant mitral regurgitation (MR) constitutes an important co-existing valvular heart disease burden in the setting of aortic valve stenosis. There are conflicting reports on the impact of significant MR on outcomes after transcatheter aortic valve implantation (TAVI). We evaluated the impact of MR on outcomes after TAVI by performing a meta-analysis of 8 studies involving 8,927 patients reporting TAVI outcomes based on the presence or absence of moderate-severe MR. Risk ratios (RRs) were calculated using the inverse variance random-effects model. None-mild MR was present in 77.8% and moderate-severe MR in 22.2% of the patients. The presence of moderate-severe MR at baseline was associated with increased mortality at 30 days (RR 1.35, 95% confidence interval [CI] 1.14 to 1.59, p = 0.003) and 1 year (RR 1.24, 95% CI 1.13 to 1.37, p <0.0001). The increased mortality associated with moderate-severe MR was not influenced by the cause of MR (functional or degenerative MR; RR 0.90, 95% CI 0.62 to 1.30, p = 0.56). The severity of MR improved in 61 ± 6.0% of patients after TAVI. Moderate-severe residual MR, compared with none-mild residual MR after TAVI, was associated with significantly increased 1-year mortality (RR 1.48, 95% CI 1.31 to 1.68, p <0.00001). In conclusion, baseline moderate-severe MR and significant residual MR after TAVI are associated with an increase in mortality after TAVI and represent an important group to target with medical or transcatheter therapies in the future.

Incidence and impact of prosthesis-patient mismatch after transcatheter aortic valve implantation.

BACKGROUND AND AIM OF THE STUDY: The study aim was to investigate the incidence of patient-prosthesis mismatch (PPM) with new catheter valves, and its influence on the patients' clinical state. At present, few echocardiographic data are available on the incidence and impact of PPM with the CoreValve and Sapien prostheses for transcatheter aortic valve implantation (TAVI). METHODS: The reliability of effective orifice area (EOA) measurements was assured by awaiting an interval of six months after TAVI. Of 256 survivors after TAVI, 149 complete echocardiographic data sets were available for the assessment of the indexed EOA (iEOA). In total, 106 CoreValve prostheses and 43 Sapien prostheses were implanted in this high-risk cohort (mean age 81 +/- 6 years, mean logistic EuroSCORE 20 +/- 13%). RESULTS: The overall incidence of PPM (iEOA < 0.85 cm2/m2) was 61%. Patients with a larger body surface area were more likely to develop PPM (p = 0.001), while the prosthesis type, native annulus diameter, preoperative EOA, gender and prosthesis size had no influence. The mean aortic gradient was significantly higher in patients with PPM. A reduction in the left ventricular end-diastolic diameter was seen in all patients, without significant differences between groups. There were no differences in postoperative NYHA class or self-assessed health state between patients with or without PPM. CONCLUSION: PPM was common after TAVI in the presented cohort, presumably because the native calcium masses narrow the outflow area available for blood flow. As expected for low gradients, there was no impairment of left ventricular dimension regression or clinical state of the patients, even if severe PPM was present. Based on the presented data, it is assumed that PPM might be less relevant in TAVI patients.

Transcatheter aortic valve implantation in patients with concomitant mitral and tricuspid regurgitation.

BACKGROUND: The impact of atrioventricular valve regurgitation in patients who undergo transcatheter aortic valve implantation (TAVI) is not known. We examined the clinical outcome after TAVI in patients with moderate or more severe concomitant mitral or tricuspid regurgitation (TR). METHODS: Two hundred sixty-eight consecutive patients who underwent TAVI at our institution since July 2007 were enrolled in this study. Patients had preoperative echocardiographic assessment of aortic stenosis and concomitant valve disease. At 6 months and 1 year, survival, New York Heart Association (NYHA) functional status, self-assessed state of health, and severity of mitral regurgitation (MR) and tricuspid regurgitation (TR) were assessed. RESULTS: Preoperatively, 22.4% of patients (60/268) had moderate or more severe MR, 20.1% (54/268) had moderate or more severe TR, and 9.3% (25/268) had moderate or more severe MR and TR. With moderate or more severe TR, 1 year all-cause mortality was significantly higher compared with that of mild or less severe TR (33.9% and 20.9%, respectively; log rank p = 0.028). With moderate or more severe MR, 1-year all-cause mortality was 30.2% compared with 21.2% in mild or less severe MR (log rank p = 0.068). Neither moderate or more severe MR nor TR emerged as an independent risk factor. At 6 months, heart failure symptoms were significantly reduced regardless of the extent of atrioventricular valve regurgitation. Sixty-seven percent of patients with moderate or more severe MR and 50% of patients with moderate or more severe TR had an improvement of valve regurgitation. CONCLUSIONS: Atrioventricular valve regurgitation is present in a subgroup of patients undergoing TAVI whose survival is impaired. The majority of surviving patients exhibit the clinical benefits of TAVI with amelioration of heart failure symptoms and a decrease in severity of atrioventricular valve regurgitation. At present, moderate or more severe atrioventricular valve regurgitation cannot be considered a contraindication for TAVI.

Wall shear stress and flow patterns in the ascending aorta in patients with bicuspid aortic valves differ significantly from tricuspid aortic valves: a prospective study.

AIMS: We compared flow and wall shear stress (WSS) patterns in the ascending aorta of individuals with either bicuspid aortic valve (BAV) or tricuspid aortic valve (TAV) using four-dimensional cardiovascular magnetic resonance (4D-CMR). BAV are known to be associated with dilation and dissection of the ascending aorta. However, the cause of vessel disease in patients with BAVs is unknown. Inborn connective tissue disease and also dilation secondary to increased WSS because of altered blood flow patterns in the ascending aorta are discussed as causes for dilation of the aorta. WSS can be estimated non-invasively by 4D-CMR. METHODS AND RESULTS: Eighteen, otherwise, healthy individuals with functionally normal BAVs were compared prospectively with an age- and sex-matched control group of healthy individuals with TAV. Blood flow data were obtained by 4D-CMR visualization and WSS was calculated with specific software tools. Eighty-five per cent of the individuals with BAVs showed a high-grade helical flow pattern in the ascending aorta compared with 6% of the individuals with TAV. WSS in the ascending aorta was significantly altered in individuals with BAVs compared with TAV. CONCLUSION: WSS and flow patterns in the ascending aorta in patients with BAVs without concomitant valve or vessel disease are significantly different compared with TAV. The significantly higher shear forces may have an impact on the development of aortic dilation in patients with BAVs.

Incidence and treatment of procedural cardiovascular complications associated with trans-arterial and trans-apical interventional aortic valve implantation in 412 consecutive patients.

OBJECTIVE: Trans-catheter aortic valve implantation (TAVI) technology is rapidly evolving, with 412 procedures having been performed at our institution. Herein, we report a complete, prospective analysis of complications occurring during transvascular and trans-apical implantations with two different prostheses. METHODS: Between June 2007 and June 2010, 412 patients (258 female, mean age 80.3±7.2 years, logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) 20.2%±13.0%) underwent TAVI through either a retrograde (n=252 transfemoral, n=28 transaxillary, and n=5 transaortic) or antegrade (n=127 trans-apical) approach at our institution. The trans-apical access was chosen only in cases where transvascular implantation was not possible. As many as 283 CoreValve and 129 Edwards Sapien prostheses were implanted. RESULTS: Thirty-day survival was 90.9%. Vascular complications occurred in 42 patients (10.2%). In four patients, lethal aortic root (n=3) or abdominal (n=1) aortic rupture occurred. Pericardial effusion developed in 53 patients (12.8%), which resulted in cardiac tamponade in 12 patients (2.9%). Twenty-three patients (5.6%) with valve malplacement were treated interventionally. In five patients (1.2%), emergency institution of cardiopulmonary bypass was required during the procedure for temporary support; all patients survived. Seventeen patients underwent re-intervention on the catheter valve (4.1%). CONCLUSIONS: With growing experience, complications with TAVI may be avoided by proper patient selection and skillful management. Other complications, when they occur, require a specific treatment algorithm to avoid delay in decision making. A considerable number of complications after TAVI require surgical treatment. Therefore, the ideal environment for TAVI procedures is a hybrid operating room, where a multidisciplinary team of surgeons, cardiologists, and anesthesiologists is best fitted to meet the current needs associated with TAVI technology. A reduction in complications was seen after 300 cases. This finding attests to the complexity of the procedure in addition to the experience required to reduce the incidence of complications.

Incidence and predictors of acute kidney injury in patients undergoing transcatheter aortic valve implantation.

BACKGROUND: Acute kidney injury (AKI) can occur in up to one third of patients after surgical aortic valve replacement and can be associated with increased mortality. Little data exist, however, about the incidence, predictors, and prognostic implications of AKI after transcatheter aortic valve implantation (TAVI). OBJECTIVES: The aim of this study was to examine the incidence, predictors, and prognostic implications of AKI after TAVI. METHODS: Between January 2007 and January 2010, we prospectively enrolled 234 consecutive patients who underwent TAVI with the Medtronic CoreValve System (Medtronic CoreValve, Minneapolis, Minnesota) or Edwards SAPIEN (Edwards Lifesciences, Inc, Irvine, CA) heart valve. Acute kidney injury was defined according to the risk, injury, failure, loss, end-stage criteria. Patients with preoperative end-stage renal failure requiring dialysis were excluded. Baseline characteristics and procedural-related factors were examined as predictors for AKI in a multivariable regression model. RESULTS: Acute kidney injury was identified in 46 (19.6%) of 234 patients, and 24 (10.3%) of 234 patients required renal replacement therapy. The unadjusted in-hospital mortality rate was 15.2% in those patients without AKI and 7.7% in those with AKI (P = .015). Univariable logistic regression analysis identified preoperative serum creatinine, preoperative blood urea nitrogen, peripheral vascular disease, and blood transfusion to be associated with AKI. Preoperative serum creatinine level remained as the only independent predictor of AKI (OR 3.7 95%, CI 1.24-11.3, P = .019). The amount of contrast used (in milliliters) was not associated with AKI (OR 1.8 95%, CI 0.94-3.5, P = .07). CONCLUSION: In this study, we observed that one fifth of patients developed AKI after TAVI and that AKI was associated with increased in-hospital mortality. Preoperative serum creatinine level was identified as the only predictor of AKI.

Are bicuspid aortic valves a limitation for aortic valve repair?

OBJECTIVE: To compare the mid-term results after aortic valve (AV) repair in bicuspid AVs with those in tricuspid AVs. METHODS: Between 2000 and 2010, 100 patients (mean age 47.2 years) underwent AV repair procedures for insufficient bicuspid AV (n=43) and tricuspid AV (n=57). Aortic regurgitation (AR) more than moderate was present in 31/43 and 21/57 patients in the bicuspid AV and the tricuspid AV group, respectively. Concomitant root replacement by either the reimplantation or the remodeling technique was performed in 42 patients (bicuspid AV 17/43, tricuspid AV 25/57). All patients were prospectively studied with postoperative and further annual clinical assessment and echocardiography. Follow-up was 99% complete with a mean follow-up time of 22 months. RESULTS: Three patients died during the initial hospitalization, all due to postoperative cardiac failure. Overall actuarial 3 years' survival was 93±4.2% without significant differences between the two groups. Overall actuarial 3 years' freedom from AV-related reoperation was 86±5.1% without significant differences between the groups (85±9.7% for bicuspid AV, 86±6.0% for tricuspid AV; log-rank test: p=0.98). Overall actuarial 3 years' freedom from recurrent AR≥moderate was 100% and AR>trace was 71.3±8.2% without significant differences between the groups (76.5±11.7% for bicuspid AV, 71.4±9.4 for tricuspid AV; log-rank test: p=0.97). CONCLUSIONS: The mid-term outcome in terms of survival, freedom from reoperation or recurrent AR is similar for both groups of patients after AV repair procedures. Therefore, we advocate valve repair also in patients presenting with an insufficient bicuspid AV.

Aortic annulus evaluation in transcatheter aortic valve implantation.

OBJECTIVES: We compared the annulus diameters measured by transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), and dual-source computed tomography (DSCT) before transcatheter aortic valve implantation (TAVI). BACKGROUND: In TAVI correct evaluation of the aortic annulus is mandatory to choose the correct prosthesis type and size and to prevent complications. There is no gold standard for the assessment of aortic annulus diameters. METHODS: Preoperative assessment of the aortic annulus with TTE, TEE, and DSCT was performed in 187 consecutive patients referred for TAVI between June 2007 and May 2009. RESULTS: The mean aortic annuli were 22.6 ± 2.0 mm measured with DSCT, 22.3 ± 2.5 mm with TTE, and 22.9 ± 2.2 mm with TEE. Despite a strong correlation between the measurement techniques, relevant statistical spread occurred with differences up to 3 mm in all measurement methods. Inter- and intraobserver variability was good for TEE and less satisfactory for DSCT measurements. TEE measurements taken as decisive parameter for the implantation changed the implantation strategy in 15.5% of patients and did not show an increased rate of procedural complications. CONCLUSION: Despite a strong correlation, the measurement techniques for the aortic annulus show relevant statistical spread, consequently one measurement technique cannot definitely predict another. TEE measurements show a more satisfactory intra- and interobserver variability than DSCT. Taking TEE annulus measurements as decisive parameter for the implantation has an impact on the implantation strategy and is safe with a low rate of procedural complications.

Predictors for new-onset complete heart block after transcatheter aortic valve implantation.

OBJECTIVES: The aim of this study was to identify risk factors for new-onset atrioventricular (AV) block requiring pacemaker (PM) implantation after transcatheter aortic valve implantation (TAVI). BACKGROUND: High-grade AV block and consecutive PM implantation are frequent complications following TAVI. METHODS: For logistic regression analysis, we included 159 patients (mean age: 81 +/- 6 years, EuroSCORE: 22 +/- 13%) who underwent TAVI (n = 116 transfemoral, n = 4 via subclavian artery, n = 37 transapical, n = 2 transaortic) between June 2007 and January 2009 and who had no previously implanted PM. RESULTS: Thirty-five patients (22%) developed new-onset post-operative AV block with the need of PM implantation. Logistic regression revealed a 2-fold increased risk for new-onset AV block in patients in whom a large valve is implanted in a small annulus (32% pacemaker implantations, odds ratio [OR]: 2.378, p = NS), a 4-fold increased risk with the implantation of the CoreValve (Medtronic, Minneapolis, Minnesota) versus the Edwards Sapien valve (Edwards Lifesciences, Irvine, California) (27% pacemaker implantations, OR: 3.781, p = NS), and a 5-fold increased risk for patients who exhibit an AV block episode instantly during the implantation procedure (49% pacemaker implantations, OR: 4.819, p = 0.001). Pre-existing ECG alterations were not identified as risk factors for AV block after transcatheter aortic valve implantation. CONCLUSIONS: We assume that conduction tissue impairment is provoked by mechanical compression with large prostheses in smaller annuli or in the larger area of the CoreValve covering the outflow tract and may appear instantly during the implantation procedure. Continuous post-operative electrocardiogram monitoring should be performed for at least 3 days in all patients after TAVI procedures and until discharge in patients with increased risk for this complication.

Intermittent regurgitation caused by incomplete leaflet closure of the Medtronic ADVANTAGE bileaflet heart valve: analysis of the underlying mechanism.

OBJECTIVE: Clinical echocardiographic assessments of the Medtronic ADVANTAGE (Medtronic Inc, Minneapolis, Minn) prosthesis in the aortic position revealed a phenomenon identified as "intermittent regurgitation." An in vitro investigation was initiated to identify the underlying mechanism. METHODS: In a pulse duplicator environment, 6 ADVANTAGE size 23 aortic valves were analyzed. Leaflet motion and flow through the valves were documented using echocardiography with color Doppler flow, digital high speed imaging, and flow meter assessment. RESULTS: Intermittent regurgitation could be reproduced in all 6 of the tested valves within limited ranges of flow, pressure, and valve orientation. By virtue of high-speed imaging, the mechanism underlying intermittent regurgitation was identified. During intermittent regurgitation, the leading edge of the second-to-close leaflet makes contact with the chamfer on the leading edge of the first-to-close leaflet. The fluid closing forces working on the first-to-close leaflet prevent it from shifting back so that the leading edge of the second-to-close leaflet remains positioned against the chamfer of the first-to-close leaflet. In this position, the major radius of the second-to-close leaflet does not reach the housing's major radius. Therefore, a crescent-shaped gap remains between the leaflet tip of the second-to-close leaflet and the housing major radius during all or part of diastole. The regurgitant fraction can increase from a normal range of 6% to 25% during an intermittent regurgitation beat. CONCLUSIONS: In vitro intermittent regurgitation can be induced in the size 23 aortic ADVANTAGE valve under a limited range of conditions. To avoid possible misinterpretations, the phenomenon must be known in detail by all physicians dealing with patients with an ADVANTAGE valve.

The complete supraannular concept: in vivo hemodynamics of bovine and porcine aortic bioprostheses.

BACKGROUND: Complete supraannular placement of an aortic bioprosthesis is one approach to optimize the hemodynamic result of an aortic valve replacement. It is achieved with the combination of a special valve design and the supraannular sewing technique with noneverted mattress sutures. We evaluated 5 bioprostheses designed for complete supraannular placement to assess potential hemodynamic differences caused by factors (eg, valve material) other than implantation position. METHODS AND RESULTS: In 336 patients (mean age, 72.0+/-7.1 years; 143 women), hemodynamics including mean pressure gradients, effective orifice areas, and indices and incidence of patient-prosthesis mismatch were evaluated 6 months after surgery. Annulus diameter was measured during surgery. Patients received the Carpentier Edwards Perimount Magna (Magna, n=169), the Medtronic Mosaic (Mosaic, n=46), the Mosaic Ultra (Ultra, n=17), the SJM Epic Supra (Epic, n=46), and the Sorin Soprano (Soprano, n=58). For small annulus sizes (<23 mm), the mean pressure gradients of the Magna (11.82+/-4.8 mm Hg) were significantly lower than the Mosaic (16.04+/-6.1 mm Hg) and the Ultra (22.0+/-4.1 mm Hg), and the Soprano (13.3+/-5.2 mm Hg) was hemodynamically superior to the Ultra. For medium (23 to 24 mm) and large (>24 mm) annulus sizes, the mean pressure gradients of the Magna were lower than the Epic (10.0+/-3.5 mm Hg versus 14.9+/-6.4 mm Hg; 9.9+/-4.0 mm Hg versus 18.6+/-12.7 mm Hg). Furthermore, in patients with large annulus size, the mean pressure gradients of the Soprano (11.4+/-3.8 mm Hg) were lower compared with the Epic (18.5+/-12.7 mm Hg). Severe patient-prosthesis mismatch was observed more frequently in patients with the Mosaic (12/46; 26.1%) and the Ultra (3/17; 17.6%) prostheses. CONCLUSIONS: Complete supraannular placement cannot prevent high pressure gradients or patient-prosthesis mismatch thoroughly, but the choice of a bovine prosthesis can optimize hemodynamic performance.

Survival after transapical and transfemoral aortic valve implantation: talking about two different patient populations.

OBJECTIVE: Recently, suspicion had been expressed that survival might be impaired after antegrade transapical as opposed to retrograde transfemoral valve implantation in high-risk patients with aortic stenosis. We analyzed survival in patients undergoing transcatheter aortic valve implantation with special emphasis on the access site for implantation. METHODS: Between June 2007 and February 2009, 203 high-risk patients (EuroSCORE, 22% +/- 14%; mean age, 81 +/- 7 years) underwent transcatheter aortic valve implantation via a transapical (n = 50) or transfemoral (n = 153) access. The transapical implantation technique was chosen only in patients who had no access through diseased femoral arteries. RESULTS: Thirty-day survival was 88.8% after transfemoral versus 91.7% after transapical implantation (P = .918). The transapical group had a significantly higher preoperative brain natriuretic peptide value and a significantly higher incidence of peripheral vessel, cerebrovascular, and coronary heart disease. Death within 30 days was valve related in 25% (transapical) and 31% (transfemoral), cardiac in 25% and 13%, and noncardiac in 50% and 56%, respectively (no significant difference). Complications specific to the access site (peripheral vessel injury or apex complications) occurred in both groups, whereas neurologic events did not occur in the transapical group (P = .041). CONCLUSIONS: Our patient and access site selection process, with the transfemoral technique considered the access site of first choice, results in comparable survival and morbidity for either transfemoral or transapical transcatheter aortic valve implantation. Both techniques are associated with certain access site-specific complications that require highly qualified management. The neurologic risk profile of the patients should be included in the decision-making process before transcatheter aortic valve implantation, inasmuch as neurologic events may be reduced with the transapical access.

[Transcatheter aortic valve implantation: surgeon's view]. / Kathetergestützte Aortenklappenimplantation aus chirurgischer Sicht.

BACKGROUND AND PURPOSE: The technology of catheter- based aortic valve implantation is a new, less invasive therapeutic option for patients with symptomatic high-grade aortic stenosis. The present paper aims to demonstrate that optimal therapy should be provided by a multidisciplinary team consisting of cardiac surgeons, cardiologists and cardioanesthesiologists in a hybrid suite. PATIENTS AND METHODS: From June 2007 to April 2009, 234 patients have been treated by transcatheter aortic valve implantation through different access sites (n = 168 femoral artery, n = 56 left ventricular apex, n = 7 subclavian artery, n = 3 ascending aorta) at the German Heart Center Munich, Germany. An algorithm for the choice of the most appropriate access site for the individual patient was established. RESULTS: The 30-day mortality was 11.2% in this high-risk patient cohort. A certain number of periprocedural complications required surgical management. There was a considerable clinical improvement of the patients 6 months after the procedure. CONCLUSION: Integrating the new methods of aortic valve implantation into a cardiac surgery program, all kinds of surgical and interventional treatment options may be offered to the patient with aortic stenosis by one multidisciplinary team. A qualified and safe performance of transcatheter aortic valve implantation and the management of potential complications require the presence of a hybrid suite.

Valve implantation on the beating heart: catheter-assisted surgery for aortic stenosis.

BACKGROUND: For an increasing number of patients with severe symptomatic aortic stenosis, advanced age and comorbidity make the risk of surgery unacceptably high. In such cases, catheter-based techniques for aortic valve implantation are a new therapeutic option. In this paper, we describe the initial results obtained at the German Heart Center, Munich, with a new technique of this kind. METHODS: From June 2007 to September 2008, 152 patients underwent transcatheter aortic valve implantation at the German Heart Center, Munich (121 transfemorally, 26 transapically, and 5 through other sites of access). In this technique, a stent-mounted valve is crimped onto a catheter and then positioned and deployed in the aortic annulus under fluoroscopic control. RESULTS: The 30-day mortality was 11.8% in this group of patients at high risk. The more common post-procedural complications were third-degree atrioventricular block leading to pacemaker implantation (31/152, 20%), vascular complications (25/152, 16%), and cerebrovascular events (8/152, 5%). Six months after the procedure, the patients had recovered clinically to a considerable extent, and the implanted prostheses exhibited good hemodynamic function. CONCLUSIONS: The technical feasibility of catheter-based aortic valve implantation has been demonstrated at multiple centers around the world. Its indications still need to be refined on the basis of the short- and long-term results of the randomized and observational studies that are currently in progress. It is already apparent that catheter-based aortic valve implantation can bring about clinical improvement in patients who are deemed ineligible for open surgery.

Transient global amnesia - not so rare after all.

QUESTION: Transient global amnesia (TGA) is characterised by the sudden occurrence of amnesia while lacking other neurological symptoms. Complete remission occurs within 24 hours. The pathogenesis remains unknown. The objective of this study was to evaluate the prevalence of TGA in a primary referral hospital in Uster, Switzerland and examine the accuracy of the diagnostic procedure and outcome. METHODS: We conducted a retrospective review of patients with TGA admitted to the Uster hospital, Switzerland between 1/2005 and 10/2007. Of 8166 patients, 20 consecutive cases fulfilled the diagnostic criteria and were further analysed. We included presenting symptoms, diagnostic tests performed, treatment and outcome. A questionnaire to investigate the treating doctor's knowledge of TGA was conducted. A follow up was conducted in all patients at 19.1 +/- 7.1 months after presentation. RESULTS: The incidence was 6.8/100 000/year. In all patients the symptoms resolved within 24 hours and all patients were seen by a consultant neurologist. Drug related causes were excluded. 25% episodes started after some form of exercise, 20% after emotional distress. All patients underwent cerebral imaging. 76% of the questionnaires sent to in-hospital physicians were returned. Diagnostic criteria of TGA were fully known in 75%. In 30% the diagnosis on admission was not TGA and had to be adjusted during the hospital stay. Follow up showed relapse in 10%. CONCLUSION: TGA is a syndrome of which emergency physicians should be aware. The diagnosis is made clinically and the prognosis is good, although relapses may occur. Missed diagnoses may lead to uncertainty in patients and their relatives.

Results of percutaneous and transapical transcatheter aortic valve implantation performed by a surgical team.

OBJECTIVE: Transcatheter aortic valve implantation has been performed by several groups, most of them either specializing on the transapical (surgeons) or the percutaneous femoral transarterial approach (cardiologists). We achieved both transapical and percutaneous transcatheter valve implantation by a surgical team in a hybrid suite. METHODS: Since June 2007, 137 patients (n=78 female, mean age 81+/-7 years) underwent transcatheter aortic valve implantation (n=109 transfemoral, n=3 via subclavian artery, n=2 directly through ascending aorta, n=23 transapical) with the CoreValve (n=114) or the Edwards Sapien (n=23) prosthesis. RESULTS: Thirty-day mortality was 12.4% in this patient cohort. One hundred and eight patients (78.8%) are alive at a mean follow-up of 97+/-82 days. Pacemaker implantation due to postoperative AV block was performed in 27 patients (19.7%), and 7 patients (5.1%) sustained neurological events. Patients improved in NYHA class (from 3.1+/-0.3 to 1.9+/-0.5, p<0.001) and in self-assessed health state (from 55+/-17% to 68+/-16%, p<0.001) at one-month follow-up. Echocardiographic assessment revealed excellent hemodynamic function of the prostheses with a mean aortic gradient (MAG) of 11.9+/-4.4 mmHg and an effective orifice area (EOA) of 1.6+/-0.4 cm(2) at discharge and a MAG of 11.0+/-4.2 mmHg and an EOA of 1.6+/-0.3 cm(2) at six months FU. CONCLUSIONS: Transcatheter aortic valve implantation has become an alternative technique for the treatment of aortic stenosis with reasonable short- and mid-term results at our institution. With the opportunity to treat aortic stenosis by conventional surgical valve replacement and transapical and percutaneous transcatheter procedures, the technique of lowest risk for the individual patient can be chosen and performed by one team.

Transcatheter aortic valve implantation through the ascending aorta: an alternative option for no-access patients.

Retrograde transcatheter aortic valve implantation (TAVI) was successfully performed in an 80-year-old woman who had critical aortic stenosis but had no conventional access available because of severe calcifications of the femoral, iliac, and subclavian arteries. The TAVI procedure was performed with the CoreValve ReValving System. The currently available results obtained with TAVI show that such approaches provide significant clinical improvement in patients with severe aortic stenosis and unacceptable risk or contraindications for surgery. The ascending aorta approach might help to expand the implantation possibilities for those patients for whom the typical access sites are not available.

First successful aortic valve implantation with the CoreValve ReValving System via right subclavian artery access: a case report.

We successfully implanted a bioprosthetic aortic valve via the right subclavian artery within the framework of the CoreValve transapical aortic valve replacement (TAVR) ReValving (CoreValve, Irvine, CA, USA) clinical trial on November 20, 2007, at the Clinic for Cardiovascular Surgery at the German Heart Center Munich, Technical University Munich. The self-expanding aortic valve prosthesis is primarily designed for retrograde delivery across the aortic valve. The described approach via the right subclavian artery was performed because of severe peripheral vascular disease of the femoral and iliac arteries, as well as the left subclavian artery, and because a transapical delivery system was not available at the time of surgery.