Procedural and clinical outcomes of the valve-in-valve technique for severe aortic insufficiency after balloon-expandable transcatheter aortic valve replacement.

OBJECTIVE: To describe the clinical and procedural outcomes of patients treated with the valve-in-valve technique for severe aortic insufficiency (AI) after balloon-expandable transcatheter aortic valve replacement (TAVR). BACKGROUND: Severe AI immediately after valve implantation is a notable complication of TAVR. It can be treated with a valve-in-valve technique which involves deploying a second valve within the first one to crush the leaflets of the first implant leaving a new functional valve. METHODS: We analyzed data on 142 consecutive patients at our institution undergoing TAVR with the Sapien valve between November of 2007 and April of 2011. Etiologies of acute AI, procedural and intermediate term clinical outcomes were reported for those in whom a valve-in-valve procedure was necessary. Post-hoc analysis of these cases with C-THV imaging (Paieon Medical Ltd.) was performed to elucidate the mechanism for successful AI treatment. RESULTS: A total of 5 of 142 (3.5%) patients were treated with the valve-in-valve technique. Etiologies of the aortic valve insufficiency included bioprosthesis malposition (n = 3), valve dysfunction (n = 1), and valve undersizing (n = 1). With placement of the second valve, the first valve dimensions increased to approach the nominal valve size while the second valve size remained less than nominal. CONCLUSIONS: The valve-in-valve technique is an appropriate bailout measure for patients with acute valvular AI after balloon-expandable TAVR.

Cerebral embolic exposure during transfemoral and transapical transcatheter aortic valve replacement.

AIM OF STUDY: To characterize the cerebral embolic exposure during transfemoral (TF) and transapical (TA) TAVR. METHODS: To detect cerebral embolic events during TAVR, intraoperative neuromonitoring using transcranial Doppler (TCD) was utilized in 28 patients (Edwards SAPIEN valve TF n = 18, TA n = 10). High intensity transient signals (HITS) reflective of embolic events were recorded. RESULTS: The mean age was 83.4 ± 7.4 years. The Society of Thoracic Surgeons predicted risk of mortality score was 11.7 ± 2.9. The total number of HITS during TAVR was not significantly different between the TF and the TA groups, respectively (375 ± 301, 440 ± 283, p = 0.58). The highest number of HITS occurred during wire manipulation in the arch and valve insertion (TF, 80 ± 110, 107 ± 81; TA, 120 ± 80, 92 ± 80). In the TF group only, severe arch calcification was associated with significantly higher number of HITS both in total number of HITS (Grade I/II, 278 ± 71; Grade III/IV, 568 ± 479, p = 0.05) and during wire manipulation in the arch and valve insertion (Grade I/II, 140 ± 46, Grade III/IV 294 ± 239, p = 0.04). CONCLUSIONS: Highest cerebral embolic exposure occurred during wire manipulation in the arch and valve insertion in both the TF and TA groups. Arch calcification appears to be associated with increased embolic risk, specifically in the TF approach. Understanding of the mechanism of cerebral embolism is needed for future strategies of cerebral protection during TAVR.

"Double wire" angio-seal closure technique after balloon aortic valvuloplasty.

OBJECTIVES: To report the feasibility of a collagen-mediated closure device using a modified Angio-Seal closure technique for access site management following percutaneous balloon aortic valvuloplasty (BAV). BACKGROUND: With the advent of percutaneous aortic valve replacement therapies, there has been a resurgence of interest in BAV procedures. Vascular complications, including bleeding, are a common source of morbidity post procedure as a result of the requirement for large bore femoral artery access. The use of vascular closure devices may reduce bleeding complications. METHODS: We describe a new technique for vascular closure in this setting. At the conclusion of the valvuloplasty procedure, two 0.035'' wires are inserted through the femoral artery sheath. A conventional collagen-mediated closure device (8F Angio-Seal) is deployed over the first wire and along side the second wire. If immediate hemostasis is not achieved, a second device is loaded onto the second wire and deployed to achieve hemostasis. RESULTS: Percutaneous BAV was performed in 21 patients. Hemostasis was successfully achieved in all patients with either a single 8F Angio-Seal closure device (18 patients) or after placement of a second device (three patients). CONCLUSIONS: The modified "Double Wire" Angio-Seal technique is a feasible method for hemostasis following percutaneous BAV.

Characteristics of adult patients with atrial septal defects presenting with paradoxical embolism.

BACKGROUND: The association between patent foramen ovale (PFO), atrial septal aneurysm, and cryptogenic stroke due to paradoxical embolism has been established. The correlation between atrial septal defect (ASD) in adults and paradoxical embolism is less well defined. METHODS: We examined our single center experience with 329 adult patients undergoing percutaneous device closure of interatrial communication defects to identify clinical and morphologic differences among adult patients with ASDs who presented with or without paradoxical embolism. Comparison was made with patients with PFO. RESULTS: Although a significant left-to-right shunt was the predominant indication for ASD closure, 20 patients (14%) presented with a paradoxical embolism. These patients tended to be younger and had smaller defects (both by size and shunt ratio) than ASD patients without paradoxical embolism, and were more likely to be female than PFO patients. CONCLUSIONS: The incidence of adult patients with ASD who presented with paradoxical embolism is higher than expected and suggests that this diagnosis should be considered in patients with cryptogenic stroke.