Contemporary suprasternal transcatheter aortic valve replacement: A multicenter experience using a simple, reliable alternative access approach.

OBJECTIVES: To describe outcomes after suprasternal (SS) transcatheter aortic valve replacement (TAVR) as a new alternative access approach. BACKGROUND: There still remains a cohort of the TAVR population who are not suitable for a transfemoral (TF) approach. SS-TAVR is a safe and effective alternative to TF-TAVR and has now become our preferred alternative access route. METHODS: We retrospectively reviewed all patients from New York Presbyterian Hospital, Columbia University Medical Center and Princeton Baptist Medical Center who underwent SS-TAVR from 2015 to July 2018. A total of 84 patients were included in the study. RESULTS: Technical success was achieved in all cases. Thirty-day survival was 98.8% (n = 83). There were minimal complications. Most notably, there were no transient ischemic attacks or strokes (0%, n = 0). Reexploration for bleeding was 3.6% (n = 3), and major bleeding was 1.7% (n = 1). We also achieved satisfactory results with a mean aortic valve gradient of 6.07 ± 3.79 mmHg and an aortic valve area of 2.21 ± 0.51 cm2 . No patients had anything more than mild paravalvular leak. The mean length of stay (LOS) in the intensive care unit was 1.42 ± 1.23 days, and hospital LOS was 4.20 ± 3.29 days. CONCLUSIONS: SS access for TAVR is an extremely important technique to have in any valve team's alternative access armamentarium. This technique can be safely and reliably reproduced with any standard hybrid operating room setup and no additional equipment, and it can be used with any commercially available valve system. In the current experience, minimal complications and excellent early term results were obtained.

Impact of Tricuspid Regurgitation on Outcomes of Mitral Valve Surgery after Transcatheter Edge-to-Edge Repair.

Tricuspid regurgitation (TR) severity after mitral transcatheter edge-to-edge repair (TEER) has been shown to impact outcomes but unknown in patients requiring mitral valve (MV) surgery after TEER. We sought to determine the impact of preoperative TR severity and right ventricular (RV) dysfunction on MV surgery after TEER. From 7/2009 to 7/2020, 260/332 patients in the CUTTING-EDGE registry who underwent MV surgery after TEER had paired echocardiographic evaluation on TR severity, and ≥moderate (2+) vs <2+ TR at the time of index TEER were compared. Median follow-up post-MV surgery was 9.1 months, 96.5% complete at 30 days and 81.9% complete at 1 year. Mean age was 73.8 ± 10.3; with primary/mixed and secondary MR present in 65.6% and 32.0%, respectively. Proportion of ≥2+ TR increased from TEER to MV surgery (40% vs 57%, P < 0.001). Compared to <2+ TR group, ≥2+ pre-TEER TR patients were older, had higher STS risk score at TEER, higher RVSP, more RV dysfunction, more MR post-TEER, and a shorter median interval from TEER to MV surgery (1.9 vs 4.9 months, P = 0.023). Mortality was higher in the ≥2+ pre-TEER TR group at 30 days(24.2% vs 13.8%, P = 0.043) and 1 year (45.3% vs 22.3%, P = 0.003). On Kaplan-Meier analysis, cumulative mortality was 23.8% at 1 year and 31.6% at 3 years after MV surgery overall, and was associated with preoperative RV dysfunction (P = 0.023), ≥2+ TR at pre-TEER (P = 0.001) and presurgery (P = 0.004), but not concomitant tricuspid surgery. Moderate or greater pre-TEER TR was associated with worse outcomes, and pre-TEER TR worsened significantly at MV surgery. Concomitant tricuspid surgery did not increase overall mortality.

Very low intravenous contrast volume protocol for computed tomography angiography providing comprehensive cardiac and vascular assessment prior to transcatheter aortic valve replacement in patients with chronic kidney disease.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is a lifesaving procedure for many patients high risk for surgical aortic valve replacement. The prevalence of chronic kidney disease (CKD) is high in this population, and thus a very low contrast volume (VLCV) computed tomography angiography (CTA) protocol providing comprehensive cardiac and vascular imaging would be valuable. METHODS: 52 patients with severe, symptomatic aortic valve disease, undergoing pre-TAVR CTA assessment from 2013-4 at Columbia University Medical Center were studied, including all 26 patients with CKD (eGFR<30 mL/min) who underwent a novel VLCV protocol (20 mL of iohexol at 2.5 mL/s), and 26 standard-contrast-volume (SCV) protocol patients. Using a 320-slice volumetric scanner, the protocol included ECG-gated volume scanning of the aortic root followed by medium-pitch helical vascular scanning through the femoral arteries. Two experienced cardiologists performed aortic annulus and root measurements. Vascular image quality was assessed by two radiologists using a 4-point scale. RESULTS: VLCV patients had mean (±SD) age 86 ± 6.5, BMI 23.9 ± 3.4 kg/m(2) with 54% men; SCV patients age 83 ± 8.8, BMI 28.7 ± 5.3 kg/m(2), 65% men. There was excellent intra- and inter-observer agreement for annular and root measurements, and excellent agreement with 3D-transesophageal echocardiographic measurements. Both radiologists found diagnostic-quality vascular imaging in 96% of VLCV and 100% of SCV cases, with excellent inter-observer agreement. CONCLUSIONS: This study is the first of its kind to report the feasibility and reproducibility of measurements for a VLCV protocol for comprehensive pre-TAVR CTA. There was excellent agreement of cardiac measurements and almost all studies were diagnostic quality for vascular access assessment.