Catheter versus surgical approach for the management of concomitant aortic stenosis and coronary artery disease: An inverse probability treatment weighting analysis.

BACKGROUND: Two therapeutic strategies are available when aortic stenosis and coronary artery disease coexist: a transcatheter approach, with percutaneous coronary intervention followed by transcatheter aortic valve replacement; and a surgical approach, consisting of surgical aortic valve replacement combined with coronary artery bypass graft. AIM: We sought to compare the outcomes of these two strategies. METHODS: The study population consisted of 241 patients who benefited from aortic valve replacement and coronary revascularization (transcatheter, n=150; surgery, n=91). RESULTS: Patients in the transcatheter population were older (83.5 vs. 71.8years; P<0.001) and had a higher Logistic EuroSCORE (11.1% vs. 5.7%; P<0.001). At 30days postprocedure, patients who had surgery exhibited more life-threatening bleedings (12.1% vs 4.5%; P=0.034), acute kidney injury (12.1% vs. 1.3%; P<0.001) and atrial fibrillation (55.6% vs. 8.7%; P<0.001). After a median follow-up of 27months, the risk of major adverse cardiovascular or cerebrovascular events did not differ significantly between the two strategies (hazard ratio [HR] 1.41, 95% confidence interval [CI] 0.97-2.04; P=0.07), whereas estimated glomerular filtration rate<60mL/min (HR 2.22, 95% CI 1.58-3.12; P<0.001), peripheral artery disease (HR 2.00, 95% CI 1.37-2.91; P<0.001) and left ventricular ejection fraction<50% (HR 1.69, 95% CI 1.12-2.55; P=0.012) were associated with a negative prognosis. CONCLUSIONS: In our study, patients with aortic stenosis and coronary artery disease treated by catheter were older and had a higher co-morbidity burden than those treated by surgery. The surgical strategy was associated with a higher rate of 30-day complications, but long-term outcomes were similar between the two strategies.

Radiation Exposure During Transcatheter Aortic Valve Replacement: Impact of Arterial Approach and Prosthesis Type.

BACKGROUND: The impact of novel alternative access and valve type on radiation exposure during transcatheter aortic valve replacement (TAVR) has not yet been evaluated. This study sought to determine the impact of a transarterial approach and prosthesis type on physician and patient exposure to radiation during TAVR. METHODS: This was a prospective study including 140 consecutive patients undergoing TAVR by transfemoral (n = 102) or transcarotid (TC) (n = 38) access at 2 centers. Implanted valves were the self-expanding Evolut R/PRO system (Medtronic, Minneapolis, MN; n = 38) and the balloon-expandable SAPIEN 3 valve (Edwards Lifesciences, Irvine, CA; n = 102). The primary endpoint was first operator radiation exposure. The secondary endpoint was patient radiation exposure. RESULTS: First operator radiation exposure was 4-fold greater during TC TAVR (P < .001). The use of a self-expanding valve was associated with a longer x-ray time (P = .015) and a 2-fold greater first operator radiation dose (P = .018). Patient radiation dose was not significantly affected by arterial approach (P = .055) or valve type (P = .095). After adjustment for potential confounders, the TC approach remained associated with a 174.8% (95% confidence interval, 80.6-318.3, P < .001) increase in first operator radiation dose, whereas the use of a self-expanding valve no longer influenced the first operator dose (P = .630). CONCLUSIONS: TC access and the use of a self-expanding valve were associated with a 4- and 2-fold greater first operator radiation exposure during TAVR procedures, respectively. Unlike the arterial approach, the effect of bioprosthesis type on radiation exposure was mainly related to x-ray time and was no longer significant after adjustment.

Comparison of clinical outcomes after transcarotid and transsubclavian versus transfemoral transcatheter aortic valve implantation: A propensity-matched analysis.

BACKGROUND: Transcarotid and trans-subclavian access routes are increasingly used as alternative approaches for transcatheter aortic valve implantation (TAVI) when transfemoral access is not suitable. However, concerns remain about the risk of periprocedural stroke and long-term outcomes following transcarotid/trans-subclavian TAVI. AIMS: The present study sought to compare early and long-term outcomes of transcarotid/trans-subclavian TAVI versus transfemoral TAVI after propensity-score matching. METHODS: The 260 patients who underwent TAVI through a transfemoral (n=220), transcarotid (n=32) or trans-subclavian (n=8) approach at our institution over a 4-year period were identified. A 1:1 matching based on propensity score was performed, and led to a study population of 80 patients (40 transfemoral and 40 transcarotid/trans-subclavian). Primary endpoints were early complications; secondary endpoints were long-term outcomes. RESULTS: There were no differences in the baseline characteristics of the two groups. At 30 days after TAVI there were no significant differences between transfemoral and transcarotid/trans-subclavian TAVI in terms of death rates (5% vs 5%, respectively; P=1.00) and stroke rates (5% vs 2.5%, respectively; P=1.00). After a median follow-up of 21 months, the risk of death (P=0.95), stroke (P=0.82) and myocardial infarction (P=0.16) did not differ between the two groups. CONCLUSIONS: After propensity-score matching, no significant differences in early and long-term outcomes were observed between transfemoral and transcarotid/trans-subclavian TAVI. These findings should encourage heart teams to consider a transcarotid or trans-subclavian approach when transfemoral access is unavailable.

Abdominal aorta tortuosity on computed tomography identifies patients at risk of complications during transfemoral transcatheter aortic valve replacement.

BACKGROUND: Transcatheter aortic valve replacement is now indicated in patients at intermediate surgical risk and will probably soon be indicated in patients at low surgical risk, for whom the occurrence of serious procedural complications is not acceptable. AIMS: We aimed to investigate whether simple arterial variables from computed tomography scanning can predict the occurrence of severe early complications in patients undergoing transfemoral TAVR. METHODS: All patients with symptomatic severe aortic stenosis treated by transfemoral transcatheter aortic valve replacement in our centre, and for whom computed tomography images were available, were included. An exhaustive analysis of preprocedural computed tomography scans was performed retrospectively, in search of arterial tortuosity and vascular calcifications. The primary endpoint was a composite 30-day safety endpoint. RESULTS: Overall, 175 patients were included. The primary endpoint was observed in 60 patients (35%). Abdominal aorta tortuosity was identified in 28 patients (16%) and was strongly associated with the occurrence of a complication (adjusted odds ratio 2.7, 95% confidence interval 1.1-6.6; P=0.03). There was no significant association between iliofemoral tortuosity or vascular calcification and the occurrence of complications. CONCLUSIONS: A tortuous abdominal aorta was found to be a predictor of the occurrence of a complication in patients undergoing transfemoral transcatheter aortic valve replacement. This computed tomography variable should therefore be taken into account when choosing the approach, especially for patients at intermediate and low surgical risk.

Exposure to Ionizing Radiation in Patients Undergoing Transfemoral Transcatheter Aortic Valve Implantation.

Transcatheter aortic valve implantation (TAVI) is currently becoming an alternative to surgical valve replacement for patients at low risk, a population that is likely to experience an increase in the radiation-induced cancer risk following TAVI. We aimed to evaluate the overall exposure to ionizing radiation in patients who underwent transfemoral TAVI, including the procedure itself as well as the procedures performed in the preintervention work-up and the post-TAVI interventions. All patients who underwent transfemoral TAVI for symptomatic aortic stenosis in our center over a 26 months period were included. Dosimetric indicators from preprocedural coronary angiography and computed tomography (CT), the TAVI procedure, and any postprocedural interventions (electrophysiology study and/or pacemaker implantation) were collected and converted into an effective dose. A total of 119 transfemoral TAVI procedures were included. The mean cumulative effective dose (ED) was 37.3 mSv. Three irradiating procedures were necessary for 84 patients (71% of the population, i.e., coronary angiography, CT scan and the TAVI procedure itself), whereas 30 patients (25%) required a fourth procedure, and 5 required a fifth (4%). The majority of the dose was from the CT, while only 11% of the dose derived from the TAVI procedure itself. In conclusion, overall exposure to ionizing radiation for patients who underwent transfemoral TAVI seems acceptable, and the majority of the overall ED comes from the CT scan.

IMPACT OF THE TABLE HEIGHT AND THE OPERATOR'S HEIGHT ON THE LEVEL OF RADIATION DELIVERED TO INTERVENTIONAL CARDIOLOGISTS.

Interventional cardiologists count among the health professionals that are most exposed to ionising radiation. To minimise exposure, it is recommended that the patient be placed at the maximum distance possible from the X-ray source, but this recommendation has not been clinically validated. We aimed to investigate the impact of the average table height on the level of radiation delivered to cardiologists performing coronary interventions. The population for analysis included all invasive coronary procedures performed in our centre from March to June 2017. The primary endpoint was operator radiation exposure, as assessed using personal electronic dosimeters located on the operator's left arm. In total, 225 invasive coronary procedures were analysed. When the average table height was 1126 mm or more, the operators received a radiation dose that was, on average, 53% lower than when the table was lower than 1126 mm. This reduction remained significant by multivariate analysis adjusted for the operator.

Reduction in exposure of interventional cardiologists to ionising radiation over a 10-year period.

Exposure of operators to ionising radiation in interventional cardiology has likely diminished, but data confirming the magnitude of the reduction are lacking. The aim of this study was to compare the dose of radiation received by interventional cardiology operators at 11 years interval (2006 vs 2017). The study population comprised all interventional coronary procedures performed by a single operator in one catheterization laboratory (cathlab) of a large university hospital in north-eastern France. Exposure was compared between two periods, namely period 1 (from October 2005 to March 2006) and period 2 (from March 2017 to June 2017). The primary endpoint was the dose of radiation received by the operator, measured using an electronic dosimeter placed on the operator's left arm. In 2017, the dose of radiation received by the operators was, on average, 95% lower than the dose received in 2006 (p < 0.0001), even though the average fluoroscopy time increased by 73% over the same period (p < 0.0001). By multivariable analysis including body mass index, fluoroscopy time and performance of at least one (1) coronary angioplasty, the reduction in the operator's exposure to radiation remained significant. The dose of radiation received by interventional cardiology operators has decreased by 95% over the last ten years.