Sergey Gurevich

Outcomes of transcatheter aortic valve replacement using a minimalist approach

BACKGROUNDnTranscatheter Aortic Valve Replacement (TAVR) is increasingly performed using a minimalist approach under monitored anesthesia care (MAC). The safety of this approach remains controversial and adoption has been low in the US.nnnMETHODSnThe study cohort was comprised of 130 patients (98% male) who underwent TAVR between 4/2015 and 4/2017 at the Minneapolis VA. We compared the outcomes of 81 patients who underwent TAVR using a standard approach (standard TAVR) and 49 who underwent TAVR using a minimalist approach (minimalist TAVR). Outcome measures included device and procedural success, procedural efficiency, length of intensive care unit (ICU) and hospital stay, procedural complications and hospital readmissions.nnnRESULTSnMean age was 80 (±9) years and median (IQR) STS score was 5 (4-6). Access included transfemoral (nxa0=xa0111, 85%) and alternative (nxa0=xa019, 15%). Minimalist TAVR was associated with reduced procedural time: median 101xa0min (IQR: 78-135) versus 127xa0min (IQR: 97-182, pxa0=xa00.03), fluoroscopy time: median 18xa0min (IQR: 12-26) versus 24xa0min (IQR: 16-38), pxa0=xa00.001), contrast volume 90xa0ml (IQR: 70-120xa0ml) versus 140xa0ml (IQR: 86-213xa0ml, pxa0<xa00.001).nnnCONCLUSIONSnA minimalistic approach to TAVR is associated with improved procedural efficiency and reduced length of stay without compromising procedural success or clinical outcomes.

Avoiding the Learning Curve for Transcatheter Aortic Valve Replacement

Objectives. To evaluate whether collaboration between existing and new transcatheter aortic valve replacement (TAVR) programs could help reduce the number of cases needed to achieve optimal efficiency. Background. There is a well-documented learning curve for achieving procedural efficiency and safety in TAVR procedures. Methods. A multidisciplinary collaboration was established between the Minneapolis VA Medical Center (new program) and the University of Minnesota (established program since 2012, n = 219) 1 year prior to launching the new program. Results. 269 patients treated with TAVR (50 treated in the first year at the new program). Mean age was 76 (±18) years and STS score was 6.8 (±6). Access included transfemoral (n = 35, 70%), transapical (n = 8, 16%), transaortic (n = 2, 4%), and subclavian (n = 5, 10%) types. Procedural efficiency (procedural time 158 ± 59 versus 148 ± 62, p = 0.27), device success (96% versus 87%, p = 0.08), length of stay (5 ± 3 versus 6 ± 7 days, p = 0.10), and safety (in hospital mortality 4% versus 6%, p = 0.75) were similar between programs. We found no difference in outcome measures between the first and last 25 patients treated during the first year of the new program. Conclusions. Establishing a partnership with an established program can help mitigate the learning curve associated with these complex procedures.

Computed tomography (CT) assessment of the membranous septal anatomy prior to transcatheter aortic valve replacement (TAVR) with the balloon-expandable SAPIEN 3 valve

OBJECTIVESnThe lower limit of the membranous septum (MS) is considered an anatomic landmark for the emergence of the Bundle of His into the left ventricle. Computed tomography (CT) assessment of MS anatomy may provide useful information about the risk of conduction abnormalities following transcatheter aortic valve replacement (TAVR).nnnMETHODS AND RESULTSnThe study included 102 consecutive patients undergoing TAVR with the Edwards Sapien 3 (S3) valve. Using pre-TAVR CT and post-procedure angiography we evaluated for the presence of calcium in the left ventricular outflow tract (LVOT), calcium depth (CD), implantation depth (ID) and MS length. The MS length minus the prosthesis ID was calculated (Delta MSID). Outcomes included new left bundle branch block (LBBB) or permanent pacemaker (PPM) within 30days. Seventeen patients (17%) received a PPM and 28 (27%) developed new LBBB following TAVR. Mean (±SD) MS length and delta MSID were 7.5mm (2) and 0.9mm (4.5), respectively. Twenty-one patients (20%) had calcium in the device landing zone and the mean (SD) CD was 6.8mm (±4). Calcium in the device landing zone (37% versus 16%, p=0.02) and implantation depth (6mm (4-8) versus 4mm (4-5), p=0.02) predicted new conduction abnormalities after TAVR.nnnCONCLUSIONSnThe presence of calcium in the device landing zone is associated with increased risk of conduction abnormalities after TAVR with S3. In such cases, a more aortic deployment of the prosthesis may be warranted.

Outcomes of intermediate-risk patients treated with transcatheter and surgical aortic valve replacement in the Veterans Affairs Healthcare System: A single center 20-year experience

Transfemoral transcatheter aortic valve replacement (TAVR) was superior to surgical aortic valve replacement (SAVR) in the placement of aortic transcatheter valves (PARTNER) 2A trial (P2). The generalizability of the trial results to the broader population of patients with intermediate surgical risk remains unknown.

Exposure to glucocorticoids prior to transcatheter aortic valve replacement is associated with reduced incidence of high-degree AV block and pacemaker

BACKGROUNDnTissue edema and inflammation, which occur at the device landing zone during valve deployment, may contribute to the pathophysiology of conduction abnormalities after transcatheter aortic valve replacement (TAVR). We hypothesized that exposure to glucocorticoids prior to TAVR will reduce the incidence of conduction abnormalities requiring PPM implantation after TAVR.nnnMETHODSnWe included 167 consecutive patients treated with TAVR at the Minneapolis VA Medical Center and University of Minnesota. Exposure to glucocorticoids was assessed by linking electronic medical and pharmacy records. The primary outcome was a new PPM within 30u202fdays of the index TAVR procedure.nnnRESULTSnOf the 167 patients included, 16 (9.5%) were exposed to glucocorticoids prior to TAVR. No differences in age, STS score, pre-existing right bundle branch block, implantation depth or valve type were seen among patients exposed to glucocorticoids versus those who were unexposed. Patients exposed to glucocorticoids were more likely to have moderate/severe COPD (43% versus 18%, pu202f<u202f0.01). The cumulative incidence of PPM implantation at 30-days after TAVR was 18%. None of the patients exposed to glucocorticoids required a PPM while 30 (19%) of the unexposed patients did (pu202f=u202f0.04).nnnCONCLUSIONSnExposure to glucocorticoids prior to TAVR may be associated with reduced incidence of PPM requirement though larger studies are needed to support these findings. Tissue edema and inflammation may be significant contributors to the pathophysiology of conduction abnormalities after TAVR and could represent a therapeutic target.

CALCIFICATION IN THE BASAL SEPTUM, BUT NOT MEMBRANOUS SEPTAL LENGTH, PREDICTS AV CONDUCTION DISTURBANCE AND PACEMAKER IMPLANTATION FOLLOWING TRANSCATHETER AORTIC VALVE REPLACEMENT WITH A BALLOON-EXPANDABLE VALVE (S3)

Background: The lower end of the membranous septum (MS) represents an anatomic landmark for the emergence of the His Bundle into the left ventricle. Computed tomography (CT) assessment of the membranous septal anatomy prior to transcatheter aortic valve replacement (TAVR) may provide information

Routine use of anticoagulation after transcatheter aortic valve replacement: Initial safety outcomes from a single-center experience

BACKGROUNDnSubclinical leaflet thrombosis (SCLT) can be seen in up to 12% of patients after transcatheter aortic valve replacement (TAVR). Anticoagulation appears to prevent and reverse SCLT but concerns exist about bleeding risk.nnnMETHODSnOur program adopted a strategy of routine anticoagulation after TAVR, starting warfarin on post-procedure day 0 and continuing for 3months in 10/2015. We report the initial safety and efficacy outcomes of this approach. Bleeding events were assessed using Valve Academic Research Consortium (VARC) and Bleeding Academic Research Consortium (BARC) definitions.nnnRESULTSnThe median (IQR) age of the population (n=191) was 82years (72-87) and the median (IQR) STS score was 5.6% (3-8). A total of 101 (53%) patients were discharged on anticoagulation (warfarin 97%) while 90 (47%) received antiplatelet therapy alone. The mean duration of anticoagulation therapy was 81±17 days. During follow-up 7 patients (4%) had a stroke or TIA, 3 (3%) in the anticoagulation group and 4 (4%) in the antiplatelet group (p=0.71). A total of 8 patients (4.2%) had BARC bleeding events during follow-up, 3 patients in the anticoagulation group (2.9%) and 5 in the antiplatelet group (5.5%, p=0.48). All bleeding events (VARC and BARC) were numerically lower in the anticoagulation group (8% versus 13%, p=0.20).nnnCONCLUSIONSnA strategy of routine anticoagulation for 3-months after TAVR is well tolerated and associated with similar or lower bleeding risk compared to antiplatelet therapy.