Robert Li

Factors Associated With Vascular Complications in Patients Undergoing Balloon-Expandable Transfemoral Transcatheter Aortic Valve Replacement via Open Versus Percutaneous Approaches

Background—Vascular complications after transfemoral transcatheter aortic valve replacement are common and associated with significant morbidity and mortality. Little is known about the effect of access approach on vascular complications. Methods and Results—Between 2007 and 2013, 331 patients underwent transfemoral transcatheter aortic valve replacement via open surgical (OS) or fully percutaneous (PC) approaches. Patient data and clinical outcomes were collected. Valve Academic Research Consortium–defined vascular complications were noted. Multivariable analysis with propensity matching was performed, and vascular complications, mortality, and length of stay were assessed. One hundred twenty patients were treated with the OS approach and 211 patients via the PC approach. There were fewer major vascular complications (11% versus 20%; P=0.03) and shorter length of stay (7.5 versus 9.9 days; P=0.003) in the PC group when compared with those in the OS group. In multivariable analysis, vascular complications were more likely in women (odds ratio, 2.2; P=0.02) and with increasing differences between sheath outer diameter and minimal artery diameter (overall vascular complications: odds ratio, 1.4; P=0.02 and major vascular complications: odds ratio, 2.0; P<0.001). Propensity-matched analysis demonstrated no difference in vascular complications between the OS and the PC groups (22% versus 19%; P=0.73) but significantly reduced length of stay in the PC group (7.9 versus 10.0 days; P=0.04). Conclusions—Transfemoral transcatheter aortic valve replacement performed via the PC route is associated with similar risk of vascular complications and significantly lower postprocedural length of stay than the OS route. The degree of sheath oversizing with respect to iliofemoral minimal artery diameter and female sex are associated with vascular complications regardless of access approach.

Rationale, development, implementation, and initial results of a fast track protocol for transfemoral transcatheter aortic valve replacement (TAVR)

The care pathway for patients undergoing transcatheter aortic valve replacement (TAVR), particularly in the US, was initially based on open surgical techniques and often includes general anesthesia, transesophageal echocardiographic monitoring, and cardiothoracic intensive care unit (ICU) stays. Whether a subgroup of patients could benefit from early extubation, fewer days in the ICU, and early ambulation in terms of both cost and effectiveness is unknown.

Conscious Sedation Versus General Anesthesia for Transcatheter Aortic Valve Replacement: Insights from the National Cardiovascular Data Registry Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry

Background: Conscious sedation is used during transcatheter aortic valve replacement (TAVR) with limited evidence as to the safety and efficacy of this practice. Methods: The National Cardiovascular Data Registry Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry was used to characterize the anesthesia choice and clinical outcomes of all US patients undergoing elective percutaneous transfemoral TAVR between April 1, 2014, and June 30, 2015. Raw and inverse probability of treatment-weighted analyses were performed to compare patients undergoing TAVR with general anesthesia with patients undergoing TAVR with conscious sedation on an intention-to-treat basis for the primary outcome of in-hospital mortality, and secondary outcomes including 30-day mortality, in-hospital and 30-day death/stroke, procedural success, intensive care unit and hospital length-of-stay, and rates of discharge to home. Post hoc falsification end point analyses were performed to evaluate for residual confounding. Results: Conscious sedation was used in 1737/10 997 (15.8%) cases with a significant trend of increasing usage over the time period studied (P for trend<0.001). In raw analyses, intraprocedural success with conscious sedation and general anesthesia was similar (98.2% versus 98.5%, P=0.31). The conscious sedation group was less likely to experience in-hospital (1.6% versus 2.5%, P=0.03) and 30-day death (2.9% versus 4.1%, P=0.03). Conversion from conscious sedation to general anesthesia was noted in 102 of 1737 (5.9%) of conscious sedation cases. After inverse probability of treatment-weighted adjustment for 51 covariates, conscious sedation was associated with lower procedural success (97.9% versus 98.6%, P<0.001) and a reduced rate of mortality at the in-hospital (1.5% versus 2.4%, P<0.001) and 30-day (2.3% versus 4.0%, P<0.001) time points. Conscious sedation was associated with reductions in procedural inotrope requirement, intensive care unit and hospital length of stay (6.0 versus 6.5 days, P<0.001), and combined 30-day death/stroke rates (4.8% versus 6.4%, P<0.001). Falsification end point analyses of vascular complications, bleeding, and new pacemaker/defibrillator implantation demonstrated no significant differences between groups after adjustment. Conclusions: In US practice, conscious sedation is associated with briefer length of stay and lower in-hospital and 30-day mortality in comparison with TAVR with general anesthesia in both unadjusted and adjusted analyses. These results suggest the safety of conscious sedation in this population, although comparative effectiveness analyses using observational data cannot definitively establish the superiority of one technique over another.Background —Conscious sedation is used during transcatheter aortic valve replacement (TAVR) with limited evidence as to the safety and efficacy of this practice. Methods —The NCDR STS/ACC TVT Registry was used to characterize the anesthesia choice and clinical outcomes of all U.S. patients undergoing elective percutaneous transfemoral TAVR between April 1, 2014 and June 30, 2015. Raw and inverse probability of treatment weighted (IPTW) analyses were performed to compare general anesthesia patients with conscious sedation patients on an intention-to-treat basis for the primary outcome of in-hospital mortality, and secondary outcomes including 30-day mortality, in-hospital and 30-day death/stroke, procedural success, ICU and hospital length-of-stay, and rates of discharge to home. Post-hoc falsification endpoint analyses were performed to evaluate for residual confounding. Results —Conscious sedation was used in 1,737/10,997 (15.8%) cases with a significant trend of increasing usage over the time period studied (p for trend Conclusions —In U.S. practice, conscious sedation is associated with briefer length of stay and lower in-hospital and 30-day mortality compared to TAVR with general anesthesia in both unadjusted and adjusted analyses. These results suggest the safety of conscious sedation in this population, though comparative effectiveness analyses using observational data cannot definitively establish the superiority of one technique over another.

Outcomes of transcatheter aortic valve replacement in patients with chronic liver disease

Transcatheter aortic valve replacement (TAVR) has emerged as an alternative to high‐risk surgery in patients with comorbid conditions. The role of TAVR in patients with liver disease has not been examined.

The utility of atrioventricular pacing via pulmonary artery catheter during transcatheter aortic valve replacement.

HE DEVELOPMENT OF TRANSCATHETER aortic valve replacement (TAVR) has led to the treatment of calcific aortic stenosis in patients whose condition might otherwise be considered inoperable if relegated to traditional aortic valve surgery. Although the ability to replace a patient’s aortic valve in this manner represents an important advancement in the treatment of aortic valve disease, there remain many challenges associated with successfully performing the procedure. One of these challenges is the ability to maintain hemodynamic stability during valve positioning and then recover stability after its deployment. Several factors can complicate this mission. The most obvious relate to the patient’s underlying aortic valve pathology as well as other concomitant cardiac disease. During valve positioning, the interposition of the deployment system across an already compromised aortic valve will further limit the native valve’s effective orifice area and also can promote regurgitation. Mechanical or functional mitral regurgitation also may occur during this process, producing additional strain on the myocardium. The cardiovascular system is further burdened by the need for cardiac “stand-still” during valve deployment. This is achieved by inducing rapid ventricular pacing (V-pacing). Hemodynamic recovery after this may be difficult, particularly if the pacing runs are protracted or successive. Delayed recovery can promote further myocardial ischemia, initiating a downward spiral that may prove intractable without significant intervention, including the need for mechanical circulatory support. Management can be complicated further by the development of conduction abnormalities (CA) after TAVR. This association has been well documented, but most of the literature has discussed them in regard to postoperative management, particularly the potential need for permanent pacemaker (PPM) placement. 1–4 However, CAs typically present during or immediately after valve deployment 5 and their acute hemodynamic effects have, in contrast, largely been ignored in published reports. This may be an important omission because the acute loss of atrioventricular (AV) synchrony may be tolerated poorly given the common association of ventricular hypertrophy and diastolic dysfunction in patients with aortic stenosis. In addition, because of the percutaneous nature of the procedure there are limited intraoperative rhythm management options available should the CA be associated with hemodynamic instability. Because of these concerns, all patients undergoing TAVR at this institution have percutaneous right atrial (RA) and right ventricular (RV) endocardial pacing wires placed via a specialized pulmonary artery catheter (PAC), unless they already have a PPM or have pre-existing atrial fibrillation (Fig 1). What follows is the discussion of a case that exemplifies the important benefits of this technique. CASE A 91-year-old woman with progressive dyspnea on exertion secondary to critical aortic stenosis presented for TAVR. The patient’s medical history also was significant for coronary artery disease with drug-eluting stents placed 2 years earlier, non–insulin-dependent diabetes mellitus, and temporal arteritis. Preoperative echocardiography revealed normal left ventricular function but with severe concentric hypertrophy, moderate mitral valve stenosis and regurgitation, and moderate-to-severe tricuspid regurgitation. The baseline electrocardiogram (ECG) was notable for sinus rhythm at 76 beats/min with an incomplete right bundle-branch block (RBBB) and a PR interval of 156 ms. A transaortic surgical approach was chosen because of the presence of a small and tortuous aorta with significant atheroma as well as the patient’s small body size, the combination of which limited both transapical and transfemoral deployment. After the induction of general anesthesia, a thermodilution PAC with two additional ports allowing the introduction of endocardial pacing wires into both the RA and RV (A-V Paceport Catheter, Edwards Lifesciences Corp., Irvine, CA) was inserted through a 9- French introducer sheath that had been placed into the right internal jugular vein (IJV). In order to properly position the pacing wires, the PAC was advanced while the pressure waveforms of both the catheter tip and the RV Paceport orifice were simultaneously monitored. Once the catheter tip entered the pulmonary artery (PA), it was further advanced until an RV pressure waveform was seen from the RV Paceport orifice, which indicated that this port had crossed the tricuspid

TAVR IS SAFE AND IMPROVES CARDIAC FUNCTION IN PATIENTS WITH EXTREMELY LOW EJECTION FRACTIONS

Background: Patients with a very low ejection fraction (EF) have been excluded from major TAVR trials. As a consequence, the safety and efficacy of TAVR in this cohort remains uncertain. In this study, patients with pre-TAVR EF≤20% were analyzed to determine survival and effects on cardiac