Comparison of TransFemoral Transcatheter Aortic Valve Replacement Performed With a Minimally Invasive Simplified Technique: "FAST" Versus a Standard Approach.

OBJECTIVES: To assess the safety and efficacy of a new simplified procedure for transfemoral (TF) transcatheter aortic valve replacement (TAVR): the FAST protocol. BACKGROUND: A minimalist approach for TF-TAVR has been reported. The goal of this simplified strategy is to reduce the rate of specific complications associated with general anesthesia, second vascular access, and use of temporary pacemaker, and to reduce the length of stay. METHODS: We retrospectively reviewed all TF-TAVR cases performed at our center between January 2015 and December 2017. The FAST strategy consisted of local anesthesia with conscious sedation, echocardiographically guided TF puncture for main vascular access, radial approach for secondary arterial access, and left ventricular guidewire rapid pacing. Patients were sorted according to the initial strategy (FAST vs standard). The primary outcome was an early safety composite outcome including all-cause mortality, all stroke, life-threatening bleeding, acute kidney injury, coronary artery obstruction, major vascular complication, and valve-related dysfunction. RESULTS: A total of 285 consecutive patients were included in the present analysis (76 FAST patients and 209 standard patients). There were no baseline differences between groups. Complete FAST procedure was feasible in 83.0% of cases and all FAST procedures were successful. The primary outcome was significantly lower in the FAST group (1.3% vs 14.3%; P<.001). The use of FAST protocol resulted in a reduction of major bleeding (1.3% vs 10.1%; P=.01), blood transfusion (2.6% vs 14.3%; P<.01), and vascular complications related to the secondary access (0.0% vs 5.3%; P=.04). The length of stay was also significantly lower in the FAST group (4.9 days vs 6.4 days; P<.01). CONCLUSIONS: FAST can be safely performed and is associated with lower rates of iatrogenic complications and a shorter length of stay.

Results of elective cardiac surgery in patients with severe obesity (body mass index≥35 kg/m2).

BACKGROUND: The increasing number of obese patients eligible for cardiac surgery requires risks and benefits to be balanced in this population. AIMS: To study the results of cardiac surgery in severely obese patients (body mass index [BMI]≥35 kg/m2). METHODS: In this retrospective study of 3564 patients undergoing elective cardiac surgery between 2004 and 2012, the population was divided into two groups: BMI 20-34.9 kg/m2 (n=3282) and BMI≥35 kg/m2 (n=282). Patients with BMI<20 kg/m2 were excluded due to the well-known increased mortality risk. The primary endpoint was 90-day mortality. A multivariable analysis was performed to identify prognostic factors. RESULTS: Among our patients, 58.2% and 27.7% underwent isolated coronary or valvular surgery, respectively; 9.7% had combined valvular and coronary surgery and 4.4% had other procedures. Severely obese patients were younger: 62.5±9.3 years vs 67.8±10.7 years (P=0.0001). Overall 90-day mortality was 4.0%. Severe obesity did not influence postoperative mortality. In the multivariable analysis, the interaction between preoperative renal failure and severe obesity was an important mortality prognostic factor (hazard ratio: 11.17; P=0.03). Mediastinitis rates were similar between groups in non-diabetic patients; in diabetic patients, severe obesity was associated with higher mediastinitis rates (P=0.002). Superficial wound infections were higher in severely obese patients (P=0.003). CONCLUSION: Elective cardiac surgery in severely obese patients was not associated with increased perioperative morbimortality, but had a higher superficial wound infection risk. Nevertheless, severe obesity itself should not be a contraindication to elective surgery.

Extracorporeal membrane oxygenation with direct axillary artery perfusion.

Extracorporeal membrane oxygenation can be done through several cannulation sites. Axillary artery cannulation is commonly performed through a Dacron graft sutured in an end-to-side fashion to the axillary artery. Direct cannulation of the axillary artery appears a reliable technique with low rate of complications. We report our experience in 16 patients using the direct cannulation technique.