D.R. Wong

Regional systems of care to optimize outcomes in patients undergoing transcatheter aortic valve replacement

OBJECTIVES This study sought to describe the development of a multicenter, transcatheter aortic valve replacement program and regional systems of care intended to optimize coordinated, efficient, and appropriate delivery of this new therapy. BACKGROUND Transcatheter aortic valve replacement (TAVR) has become an accepted treatment option for patients with severe aortic stenosis who are at high surgical risk. Regional systems of care have led to improvements in outcomes for patients undergoing intervention for myocardial infarction, cardiac arrest, and stroke. We implemented a regional system of care for patients undergoing TAVR in British Columbia, Canada. METHODS We describe a prospective observational cohort of 583 patients who underwent TAVR in British Columbia between 2012 and 2014. Regionalization of TAVR care in British Columbia refers to a centrally coordinated, funded, and evaluated program led by a medical director and a multidisciplinary advisory group that oversees planning, access to care, and quality of outcomes at the 4 provincial sites. Risk-stratified case selection for transfemoral TAVR is performed by heart teams at each site on the basis of consensus provincial indications. Referrals for lower volume and more complicated TAVR, including nontransfemoral access and valve-in-valve procedures, are concentrated at a single site. In-hospital and 30-day outcomes are reported. RESULTS The median age was 83 years (interquartile range [IQR]: 78 to 87 years) and median STS score was 6% (IQR: 4% to 8%). Transfemoral access was performed in 499 (85.6%) cases and nontransfemoral in 84 (14.4%). Transcatheter valve-in-valve procedures in for failed bioprosthetic valves were performed in 43 patients (7.4%). A balloon-expandable valve was inserted in 386 (66.2%) and a self-expanding valve in 189 (32.4%). All-cause 30-day mortality was 3.5%. All-cause in-hospital mortality and disabling stroke occurred in 3.1% and 1.9%, respectively. Median length of stay was 3 days (IQR: 3 to 6 days), with 92.8% of patients discharged directly home. CONCLUSIONS This experience demonstrates the potential benefits of a regional system of care for TAVR. Excellent outcomes were demonstrated: most patients had short in-hospital stays and were discharged directly home.

Transcatheter Aortic Valve Replacement in Bicuspid Aortic Stenosis Using Lotus Valve System.

Bicuspid aortic stenosis (BAS) has been excluded in clinical trials on transcatheter aortic valve replacement (TAVR) due to the presumed uneven expansion of the aortic prosthesis, leading to significant paravalvular regurgitation (PVR). There is no transcatheter heart valve (THV) commercially approved for treating BAS. The Lotus Valve System mitigates PVR by possessing an adaptive seal and being fully re‐positionable. The latter is also important in preventing embolization, as the location of prosthesis fixation in BAS could be variable due to the presence of less expandable raphe. We report our early experience with the Lotus Valve System in three consecutive TAVR for BAS. They all provide good clinical and hemodynamic results without significant PVR. We conclude that the use of Lotus Valve System for treating BAS is feasible and safe, and may have advantages over the previous generation TAVR systems.

Huge aortic pseudoaneurysm arising from the coronary anastomosis after aortic root replacement.

An 87-year-old man was admitted with chest pain. His troponin was elevated and his electrocardiogram showed anterior ST depression. The patient had undergone aortic root replacement 13 years earlier using a mechanical valved conduit with re-implantation of the coronary arteries. Although lost to follow-up, he continued on warfarin. He initially received treatment for a suspected acute coronary syndrome. However, a subsequent echocardiogram suggested a circumferential haematoma around the aorta. Contrast computed tomography (CT) demonstrated a large aortic pseudoaneurysm arising from the …