Christopher Young

Long-term outcomes after transcatheter aortic valve implantation in high-risk patients with severe aortic stenosis: the U.K. TAVI (United Kingdom Transcatheter Aortic Valve Implantation) Registry.

OBJECTIVESnThe objective was to define the characteristics of a real-world patient population treated with transcatheter aortic valve implantation (TAVI), regardless of technology or access route, and to evaluate their clinical outcome over the mid to long term.nnnBACKGROUNDnAlthough a substantial body of data exists in relation to early clinical outcomes after TAVI, there are few data on outcomes beyond 1 year in any notable number of patients.nnnMETHODSnThe U.K. TAVI (United Kingdom Transcatheter Aortic Valve Implantation) Registry was established to report outcomes of all TAVI procedures performed within the United Kingdom. Data were collected prospectively on 870 patients undergoing 877 TAVI procedures up until December 31, 2009. Mortality tracking was achieved in 100% of patients with mortality status reported as of December 2010.nnnRESULTSnSurvival at 30 days was 92.9%, and it was 78.6% and 73.7% at 1 year and 2 years, respectively. There was a marked attrition in survival between 30 days and 1 year. In a univariate model, survival was significantly adversely affected by renal dysfunction, the presence of coronary artery disease, and a nontransfemoral approach; whereas left ventricular function (ejection fraction <30%), the presence of moderate/severe aortic regurgitation, and chronic obstructive pulmonary disease remained the only independent predictors of mortality in the multivariate model.nnnCONCLUSIONSnMidterm to long-term survival after TAVI was encouraging in this high-risk patient population, although a substantial proportion of patients died within the first year.

Transcatheter aortic valve implantation for severe aortic stenosis—a new paradigm for multidisciplinary intervention: A prospective cohort study

BACKGROUNDnTranscatheter aortic valve implantation (TAVI) is an alternative treatment option for patients with aortic stenosis deemed high risk or unsuitable for aortic valve replacement. The aim of this study was to assess the feasibility of TAVI in elderly patients, the delivery of this technology with a multidisciplinary approach, and the use of traditional surgical scoring systems.nnnMETHODSnOne hundred fifty-one consecutive patients (mean age 82.6 +/- 7.3 years) with severe aortic stenosis underwent TAVI with the Edwards Lifesciences (Irvine, CA) Sapien bioprosthesis using the transapical (n = 84; 56%) or transfemoral (n = 67; 44%) approach from August 2007 to September 2009 at Kings Health Partners, London, United Kingdom. We analyzed procedural outcome, complications, functional status, and midterm outcome of patients.nnnRESULTSnThe multidisciplinary team comprised interventional cardiologists, cardiothoracic surgeons, imaging specialists, cardiac anesthetists, and specialist nurses. Seventy percent of patients were in New York Heart Association class III/IV, and logistic EuroSCORE was 21.6 +/- 11.9. Procedural success was achieved in 98%. Postoperative complications included stroke (6%), complete atrioventricular block (5.3%), renal failure requiring hemofiltration (9.3%), and vascular injury (8.6%). Overall 30-day mortality was 9.9% (n = 15). The logistic EuroSCORE was a predictor of short-term mortality (logistic regression model, P < .05). Thirty-day mortality post-TAVI for patients with logistic EuroSCORE <20, 20 to 40, and >40 was 5.4%, 13.2%, and 22.2%, respectively.nnnCONCLUSIONSnTranscatheter aortic valve implantation is a feasible treatment option in this patient group with promising short/medium-term results. Renal failure is the commonest short-term complication, and the incidence of vascular complications remains high. Risk prediction/case selection remains challenging, and a multidisciplinary team approach appears to be helpful in appropriate patient selection.

Prospective Multicenter Evaluation of the Direct Flow Medical Transcatheter Aortic Valve System: 12-Month Outcomes of the Evaluation of the Direct Flow Medical Percutaneous Aortic Valve 18F System for the Treatment of Patients With Severe Aortic Stenosis (DISCOVER) Study.

OBJECTIVESnThe aim of this study was to assess the 1-year outcome after transcatheter aortic valve replacement (TAVR) of the Direct Flow Medical (DFM) valve in patients with severe symptomatic aortic stenosis who were contraindicated or high risk for surgery.nnnBACKGROUNDnThe DFM transcatheter heart valve is a new-generation, nonmetallic aortic valve with a pressurized support structure and conformable double-ring annular sealing delivered through an 18-F sheath. The device allows repositioning, retrieval, and assessment of valve performance before permanent implantation.nnnMETHODSnA prospective multicenter European registry was set up to determine the safety and performance of the valve in 100 consecutive patients (10 centers). Echocardiographic and angiographic data were evaluated by an independent core laboratory, and adverse events were adjudicated by a clinical events committee using Valve Academic Research Consortium criteria.nnnRESULTSnPatients were 83.1 ± 5.9 years of age and had a logistic EuroSCORE of 22.5 ± 11.3% and a Society of Thoracic Surgeons score of 9.7 ± 8.7%. Correct valve positioning was obtained in 99% of cases with a combined 30-day safety endpoint at 10%, including major stroke in 5.0%, major vascular complications in 2.0%, and death in 1%. At 12 months, 95% of patients were in New York Heart Association functional class I or II. Freedom from any death was 90%, and freedom from any death or major stroke was 85%. Echocardiography demonstrated none/trace to mild aortic regurgitation in 100% of patients and an unchanged mean aortic gradient of 12.2 ± 6.6 mm Hg and effective orifice area of 1.6 ± 0.4 cm(2).nnnCONCLUSIONSnAt 1 year, the DFM transcatheter heart valve had durable hemodynamics. This study demonstrates that the low rate of early complications and the low risk of significant aortic regurgitation translated into midterm clinical benefit.

Complications of transcatheter aortic valve implantation: avoidance and management.

Transcatheter aortic valve implantation (TAVI) has taken the world of cardiovascular therapies by storm. The possibility of implanting aortic valves without recourse to sternotomy or cardiopulmonary bypass has been embraced by cardiologists, surgeons and patients alike as a revolution in management. First performed in 2002 by Alain Cribier, the technique has exploded into common use during the last three years, such that over 20,000 implants have now been undertaken worldwide. This article discusses complications of TAVI, their avoidance and management.

Does intermittent cross-clamp fibrillation provide equivalent myocardial protection compared to cardioplegia in patients undergoing bypass graft revascularisation?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: does intermittent cross-clamp fibrillation provide equivalent myocardial protection compared to cardioplegia in patients undergoing bypass graft revascularisation? Altogether, 58 papers were found using the reported search, of which 13 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We identified 13 studies, of which eight were randomised prospective trials. None of these studies found increased mortality, seven analyzed serum cardiac enzymes and showed that intermittent ischemic arrest provides equal or better protection compared to cardioplegic techniques. Two studies found an increased usage of inotropes and intra aortic balloon pump (IABP) in the intermittent ischemic arrest group. We conclude that intermittent cross-clamp fibrillation is a versatile and cost-effective method of myocardial protection, with the immediate postoperative outcome comparable to cardioplegic arrest in first-time coronary artery bypass graft (CABG). The ischaemic duration associated with intermittent cross-clamp fibrillation is invariably shorter than that associated with cardioplegic arrest, and this may be one explanation for the comparable outcomes. There may also be an element of preconditioning protection during the intermittent cross-clamp fibrillation method, as has been shown experimentally. During elective CABG in patients with no clinical evidence of aortic or cerebro-vascular disease, the incidence of peri-operative microemboli (ME) and postoperative neuropsychological disturbances are shown to be comparable with both techniques of myocardial preservation.

Myocardial revascularisation in high-risk subjects

### Learning objectivesnnThe synergistic effect of comorbidity, coronary artery lesion complexity and left ventricular (LV)xa0systolic function can significantly increase the risk of adverse events at the time of myocardial revascularisation (figure 1). In patients with LV dysfunction and a large territory of ischaemia who have little reserve, further reductions in blood pressure can result in a spiral of haemodynamic compromise, culminating in cardiogenic shock or even death. In this article, we address factors that confer increased risk, current tools to quantify and guide revascularisation strategy in such patients; concluding with interventions to minimise risk including haemodynamic support devices, involvement of the heart team and technical considerations during procedural planning.nnnnFigure 1 nFactors increasing the risk of myocardial revascularisation.xa0LMS, left main stem; LV, left ventricle.nnnn### ComorbiditynnAn increasing number of revascularisation procedures are performed in patients over 70, despite poor representation in randomised controlled trialsxa0(RCT).1–3 Elderly patients are more likely to present with extensive coronary artery disease (CAD), higher lesion complexity and multiple comorbidities. Increasing age is associated with up to fourfold increased risk of death, myocardial infarction (MI), stroke, renal failure and bleeding, following percutaneous coronary interventionxa0(PCI), in both the acute and elective setting.4 5 Older age is also a predictor of in-hospital mortality and stroke following coronary artery bypass grafting (CABG) surgery, with the worst outcomes in those following urgent and emergency surgery.3 6 7 nnThere is often disparity between chronological and biological age, which is more difficult to quantify. ‘Frailty’,xa0a syndrome of physical functional decline, malnourishment, cognitive impairment and reduced physical capacity to stressors, is itself associated with adverse outcomes.8 9 The Charlson comorbidity index attempts to address some of these additional factors and has been shown to predict 1-year mortality in cardiac …