Amy Simone

Comparison of transfemoral transcatheter aortic valve replacement performed in the catheterization laboratory (minimalist approach) versus hybrid operating room (standard approach): outcomes and cost analysis.

OBJECTIVES The aim of this study was to compare transfemoral transcatheter aortic valve replacement (TF TAVR) performed in a catheterization laboratory (minimalist approach [MA]) with TF TAVR performed in a hybrid operating room (standard approach [SA]). BACKGROUND A MA-TF TAVR can be performed without general anesthesia, transesophageal echocardiography, or a surgical hybrid room. The outcomes and cost of MA-TF TAVR compared with those of the SA have not been described. METHODS Patients who underwent elective, percutaneous TF TAVR using the Edwards Sapien valve (Edwards Lifesciences, Irvine, California) were studied. Baseline characteristics, outcomes, and hospital costs of MA-TF TAVR and SA-TF TAVR were compared. RESULTS A total of 142 patients were studied (MA-TF TAVR, n = 70 and SA-TF TAVR, n = 72). There were no differences in baseline comorbidities (Society of Thoracic Surgeons score, 10.6 ± 4.3 vs. 11.4 ± 5.8; p = 0.35). All procedures in the MA-TF TAVR group were successful; 1 patient was intubated. Three patients in the SA-TF TAVR group had procedure-related death. Procedure room time (150 ± 48 min vs. 218 ± 56 min, p < 0.001), total intensive care unit time (22 h vs. 28 h, p < 0.001), length of stay from procedure to discharge (3 days vs. 5 days, p < 0.001), and cost (

Outcomes for Transcatheter Aortic Valve Replacement in Nonagenarians.

45,485 ± 14,397 vs.

Transcatheter Aortic Valve Replacement Results in Improvement of Pulmonary Function in Patients With Severe Aortic Stenosis.

55,377 ± 22,587, p < 0.001) were significantly less in the MA-TF TAVR group. Mortality at 30 days was not significantly different in the MA-TF TAVR group (0 vs. 6%, p = 0.12) and 30-day stroke/transient ischemic attack was similar (4.3% vs. 1.4%, p = 0.35). Moderate or severe paravalvular leak and device success were similar in the MA-TF TAVR and SA-TF TAVR groups (3% vs. 5.8%, p = 0.4 and 90% vs. 88%, p = 0.79, respectively) at 30 days. At a median follow-up of 435 days, there was no significant difference in survival (MA-TF TAVR, 83% vs. SA-TF TAVR, 82%; p = 0.639). CONCLUSIONS MA-TF TAVR can be performed with minimal morbidity and mortality and equivalent effectiveness compared with SA-TF TAVR. The shorter length of stay and lower resource use with MA-TF TAVR significantly lowers hospital costs.

Readmission rates after transcatheter aortic valve replacement in high- and extreme-risk patients with severe aortic stenosis

BACKGROUND Transcatheter aortic valve replacement (TAVR) may offer extreme-aged patients a treatment alternative to surgical aortic valve replacement (SAVR). The objective of this study was to describe outcomes of TAVR in nonagenarians using transfemoral and alternative access techniques. METHODS In a retrospective review, we found 95 nonagenarians who underwent TAVR from September 2007 through February 2014 at Emory University using a balloon expandable valve: transfemoral (n = 66), transapical (n = 14), transaortic (n = 14), and transcarotid (n = 1). Morbidity and 30-day and midterm mortality were assessed. Kaplan-Meier plots were used to determine midterm survival rates. RESULTS The mean age of the patients was 91.8 ± 1.8 years, and 49 (52%) were female. Postoperative morbidity included 1 patient (1%) each with stroke, myocardial infarction, pneumonia, and renal failure. The mean postoperative length of stay was 6.8 ± 5.1 days for all patients. Overall 30-day mortality was 3.2%, much less than The Society of Thoracic Surgeons predicted risk of mortality of 14.5% ± 7.3%. There were no deaths in the transfemoral patients, but there were 2 transapical deaths (14.3%) and 1 transaortic death (7.1%). The Kaplan-Meier estimate of median survival was 2.6 years. CONCLUSIONS Extreme-aged nonagenarian patients may have excellent outcomes from TAVR at 30-day and midterm follow-up. Alternative access TAVR is associated with higher morbidity and mortality than transfemoral TAVR. Referral for TAVR of nonagenarians should not be precluded based on age alone.

End‐stage renal disease and severe aortic stenosis: Does valve replacement improve one‐year outcomes?

BACKGROUND Chronic obstructive pulmonary disease (COPD) has been identified as a risk factor for morbidity and mortality after transcatheter aortic valve replacement (TAVR). We hypothesized that a portion of pulmonary dysfunction in patients with severe aortic stenosis may be of cardiac origin, and has potential to improve after TAVR. METHODS A retrospective analysis was made of consecutive TAVR patients from April 2008 to October 2014. Of patients who had pulmonary function testing and serum B-type natriuretic peptide data available before and after TAVR, 58 were found to have COPD (26 mild, 14 moderate, and 18 severe). Baseline variables and operative outcomes were explored along with changes in pulmonary function. Multiple regression analyses were performed to adjust for preoperative left ventricular ejection fraction and glomerular filtration rate. RESULTS Comparison of pulmonary function testing before and after the procedure among all COPD categories showed a 10% improvement in forced vital capacity (95% confidence interval: 4% to 17%) and a 12% improvement in forced expiratory volume in 1 second (95% confidence interval: 6% to 19%). There was a 29% decrease in B-type natriuretic peptide after TAVR (95% confidence interval: -40% to -16%). An improvement of at least one COPD severity category was observed in 27% of patients with mild COPD, 64% of patients with moderate COPD, and 50% of patients with severe COPD. There was no 30-day mortality in any patient group. CONCLUSIONS In patients with severe aortic stenosis, TAVR is associated with a significant improvement of pulmonary function and B-type natriuretic peptide. After TAVR, the reduction in COPD severity was most evident in patients with moderate and severe pulmonary dysfunction.

Does minimalist transfemoral transcatheter aortic valve replacement produce better survival in patients with severe chronic obstructive pulmonary disease

Objective In high‐ or extreme‐risk patients undergoing transcatheter aortic valve replacement, readmissions have not been adequately studied and are the subject of increased scrutiny by healthcare systems. The objectives of this study were to determine the incidence of 30‐day and 1‐year cardiac and noncardiac readmissions, identify predictors of readmission, and assess the association between readmission and 1‐year mortality. Methods A retrospective review was performed on 714 patients who underwent transcatheter aortic valve replacement from September 2007 to January 2015 at Emory University. Results Patients’ median age was 83 years, and 46.6% were female. Early all‐cause readmission for the cohort was 10.5%, and late readmission was 18.8%. Anemia was related to both early all‐cause (hazard ratio [HR], 0.74) and cardiovascular‐related readmission (HR, 0.60). A 23‐mm valve implanted was associated with early all‐cause readmission (HR, 1.73). Length of hospital stay was related to late all‐cause (HR, 1.14) and cardiovascular‐related readmission (HR, 1.21). Postoperative permanent stroke had an impact on late cardiovascular‐related readmission (HR, 3.60; 95% confidence interval, 1.13‐11.49). Multivariable analysis identified anemia as being associated with 30‐day all‐cause readmission, and anemia and postoperative stroke were associated with 30‐day cardiovascular‐related readmission. Readmissions seemed to be related to 1‐year mortality (HR, 2.04; 95% confidence interval, 1.33‐3.12). Conclusions We show some baseline comorbidities and procedural complications that are directly associated with early and late readmissions, and anemia and postoperative stroke were associated with an increase in mortality. Moreover, we found that readmission was associated with double the hazard of death within 1 year. Whether treatment of identified risk factors could decrease readmission rates and mortality warrants further investigation.

COMPARISON OF A MINIMALIST APPROACH TRANSFEMORAL TAVR WITH STANDARD APPROACH TRANSFEMORAL TAVR IN A US CENTER

Treatment for patients with end‐stage renal disease (ESRD) and severe aortic stenosis (AS) includes balloon aortic valvuloplasty (BAV), surgical (SAVR), or transcatheter (TAVR) aortic valve replacement. We compared outcomes among these strategies.

Transcaval Valve-in-Valve-in-Valve Aortic Valve Replacement for Bioprosthetic Valve Degeneration

To compare outcomes after minimalist and standard transfemoral transcatheter aortic valve replacement (TF‐TAVR) in patients with severe chronic obstructive pulmonary disease (COPD).

MINIMALIST VERSUS STANDARD TRANSFEMORAL TRANSCATHETER AORTIC VALVE REPLACEMENT IN PATIENTS WITH SEVERE CHRONIC OBSTRUCTIVE LUNG DISEASE

As transfemoral (TF) TAVR experience increases, specialized centers may consider performing TF TAVR without general anesthesia, TEE, or a surgical hybrid room. The purpose of this study was to evaluate our outcomes with a minimalist approach TF TAVR (MA-TF) compared with current standard approach (

TREATMENT OF SEVERE AORTIC STENOSIS IN PATIENTS WITH END-STAGE RENAL DISEASE ON DIALYSIS

A 74-year-old man presented with progressive dyspnea on exertion. History included peripheral arterial disease and coronary artery bypass grafting with aortic valve replacement 12 years ago. Subsequently, the surgical valve developed severe stenosis and moderate insufficiency. He underwent a transapical valve-in-valve transcatheter aortic valve replacement 5 years before presentation. This second valve developed a mean gradient of 66 mm Hg with mild insufficiency. The patient was treated with a third aortic valve using an alternative transcaval approach, significantly alleviating his symptoms.