Uday Trivedi

Transcatheter aortic valve implantation for stenosed and regurgitant aortic valve bioprostheses CoreValve for failed bioprosthetic aortic valve replacements.

Transcatheter aortic valve implantation is increasingly being used to treat severe aortic stenosis in patients with high operative risk. In an aging population the incidence of aortic stenosis is rising, and increasing numbers of elderly patients are undergoing aortic valve replacement with bioprosthetic valves. Therefore, there is a corresponding increase in prosthetic degeneration. This presents cardiologists with a cohort of patients for whom the risk of re-do aortic valve surgery is prohibitive. We present the first series of such patients with degenerative bioprosthetic stenosis or regurgitation successfully treated with CoreValve (Medtronic, Luxembourg) implantation.

Large calibre arterial access device closure for percutaneous aortic valve interventions: Use of the prostar system in 118 cases

: Percutaneous aortic valve treatments, balloon aortic valvuloplasty (BAV) and transcatheter aortic valve implantation (TAVI), are effective ways to treat patients with symptomatic aortic stenosis when open surgical repair is not feasible or considered too high risk. Large bore vascular access is required, and successful management of this arterial access is key to overall procedural success. We report outcomes and complications using the Prostar vascular closure device following BAV and TAVI.

Transaortic transcatheter aortic valve implantation within a previous bioprosthetic aortic valve replacement.

This report documents the first reported case of transaortic transcatheter aortic valve implantation (TAVI) using the CoreValve ReValving system (Medtronic CoreValve System, Luxembourg), within a previous bioprosthetic aortic valve replacement. TAVI has become a recognized percutaneous treatment for patients with severe native or bioprosthetic aortic valve stenosis. However, as the number of patients screened for TAVI increases, a number of patients are found with absolutely no option for peripheral arterial access, either from the femoral or subclavian routes. Transaortic CoreValve placement offers an alternate minimally invasive hybrid surgical/interventional technique when peripheral access is not possible. A CoreValve prosthesis was implanted via the transaortic route in an 81‐year‐old woman with severe bioprosthetic aortic valve stenosis (21 mm Mitroflow pericardial valve, peak instantaneous gradient of 99 mmHg, effective valve orifice area (EOA) of 0.3 cm2, as ilio‐femoral and left subclavian angiography revealed small calibre vessels (<6 mm). Access was achieved via a mini thoracotomy via the left anterior second intercostal space. The procedure went without complication. Post procedure the patient was transferred directly to the Cardiac Care Unit for recuperation. Post procedure echocardiography showed that the TAVI was well positioned with no para‐valvular leak and a reduction in peak instantaneous gradient to 30 mmHg and an increase in EOA to 1.5 cm2. She was discharged on the third post‐procedural day in sinus rhythm with a narrow QRS complex. CoreValve implantation within previous surgical bioprosthesis is now an established treatment. The transaortic approach to transcatheter implantation is a promising recent development, when due to anatomical reasons, transfemoral or subclavian TAVI is not feasible.

Poor mobility predicts adverse outcome better than other frailty indices in patients undergoing transcatheter aortic valve implantation

Surgical risk scoring systems are poor at predicting outcome in patients undergoing transcatheter aortic valve implantation (TAVI). Frailty indices might more accurately predict outcome. Aims: To examine multiple frailty indices as markers of performance to see whether they predict outcomes both in the shorter (30 days) and longer terms (5 years) in patients who have undergone TAVI.

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.

Coronary revascularisation in the elderly

### Leaning objectivesnnTo date, there remains no universal definition for ‘elderly’, and indeed for some, biological age does not correspond with chronological age. However, most now consider elderly as those aged ≥80u2005years.nnWithin the Western world, the general population is ageing; therefore, the proportion of octogenarians (defined as age >80u2005years) in the general population is expected to triple by the year 2050.1nnAdvanced age is associated with an increased incidence of coronary heart disease, with patients presenting with both stable and unstable (acute coronary syndromes (ACS)) symptoms.2 ,3 Hence, cardiovascular disease is a leading cause of morbidity and mortality in older people, and increasingly, elderly patients are referred for revascularisation. As such, they represent an important high-risk subgroup of patients. Myocardial revascularisation is appropriate when the expected benefits, in terms of survival or health outcomes (symptoms, functional status and/or quality of life (QoL)), exceed the expected negative consequences of the procedure.4nnHowever, revascularisation in this high-risk population is not without risk. It can often be a very difficult clinical decision whether or not an elderly patient should undergo attempted revascularisation, irrespective of the modality, whether that be by coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). Many have significant comorbid pathology, and previous studies have shown that octogenarians experience increased in-hospital complications and mortality relative to younger patients.3 ,5nnTo date, many revascularisation trials have focused on a younger patient demographic, with octogenarians often under-represented, and with varying definitions. Therefore, the existing evidence and guidelines that exist are often extrapolated from trial based on a younger patient population into this rapidly growing …

Acute Ischemic Complications of PCI and CABG: Who Should Cover Whom for Coronary Revascularization?

INTRODUCTIONnPercutaneous coronary intervention (PCI) has historically required cardiothoracic backup in the event of ischemic complications. However, many complications occurring during PCI can now be effectively treated at the time of the indexed procedure. Equally, ischemic complications, which occur following coronary artery bypass grafting (CABG), which were previously treated medically or with reoperation, may now also be effectively treated by acute PCI.nnnAIMS AND METHODSnTo identify the rate, cause, treatment, and outcomes of ischemic complications from PCI or isolated CABG procedures undertaken from January 2004 to January 2011 where there was immediate crossover from PCI to CABG or vice versa, and to determine from the indexed revascularization procedure, whether or not the ischemic complications were rectified by either CABG with respect to PCI or PCI with respect to CABG.nnnRESULTSnThree hundred fifty-six PCI major ischemic complications were identified. Three hundred forty-seven (97.5%) were rectified percutaneously and 9 (2.5%) required emergency CABG. The commonest reason for emergency CABG was occlusive dissection (n=7). Of the 9 patients that underwent emergency CABG, 3 patients (33.3%) died. Forty CABG major ischemic complications were identified. Twenty-seven (67.5%) were treated medically. Thirteen (32.5%) underwent diagnostic angiography. The etiology of the ischemia was found in all cases. Consequently, 2 underwent reoperation, one was treated medically, and 10 underwent acute PCI.nnnCONCLUSIONnAcute coronary ischemia remains a small but significant complication of both PCI and CABG. Resolution of ischemia requires prompt diagnosis and early discussion between cardiothoracic surgeon and cardiac interventionalist to determine the safest and therefore most appropriate way to resolve the problem.

One-Year Outcomes of Transcatheter Aortic Valve Implantation Using the Direct Aortic Approach

BACKGROUNDnThe direct aortic (DA) approach allows for transcatheter aortic valve implantation (TAVI) in patients with difficult peripheral vascular anatomy. The CoreValve ADVANCE Direct Aortic (ADVANCE DA) study was performed to assess the outcomes of DA TAVI with the CoreValve System (Medtronic, Minneapolis, MN) in routine practice.nnnMETHODSnPatients were selected for the DA approach by local cardiac surgical teams, and TAVI was performed with patients under general anesthesia. Safety events were adjudicated according to the Valve Academic Research Consortium-2 definitions by an independent clinical events committee. All imaging data, including that from multislice computed tomography and follow-up echocardiography, were analyzed by an independent core laboratory.nnnRESULTSnFrom September 2012 to February 2014, 100 patients were enrolled (52.0% male, age 81.9 ± 5.9 years, The Society of Thoracic Surgeons Score 5.9 ± 3.2%) at 9xa0centers in Europe. Peripheral vascular disease was present in 51.0% of patients, and 38.0% had diabetes. Of the 100 patients enrolled, 92 underwent TAVI. At 30 days after TAVI, 98.1% were free of moderate or severe paravalvular leak. At 1 year, 16 patients had died (Kaplan-Meier rate 17.9%), 1 (1.1%) patient had had a stroke, classified as nondisabling, and 15 (17.0%) patients had received a permanent pacemaker. Most patients experienced improved quality of life as measured by the Kansas City Cardiomyopathy Questionnaire overall summary score (mean change from baseline to 1 year, 39.6 ± 26.3; pxa0< 0.01).nnnCONCLUSIONSnThe DA approach provides a feasible alternative for patients with challenging anatomic features that may otherwise preclude use of the TAVI procedure.

Vascular Closure After Transcatheter Aortic Valve Interventions—The Current State of Play

Transcatheter aortic valve implantation (TAVI) is an effective way to treat patients with symptomatic aortic stenosis when open surgical repair is not feasible or considered too high risk. Large bore vascular access is required (18F-24F), and successful management of this arterial access is the key to overall procedural success. We review the current state of play with regard to vascular closure following retrograde transfemoral TAVI.

Maintaining a minimally invasive approach—vascular closure after trans-catheter aortic valve intervention

Trans-catheter aortic valve implantation (TAVI) is now recognised as an effective way to treat patients with symptomatic aortic stenosis when open surgical repair is not feasible or considered too high risk. Retrograde trans-femoral TAVI (TF-TAVI) requires large bore vascular access (18–24F), and successful management of the access site is key to maintaining the minimally invasive nature of the procedure. This editorial reviews the current techniques available to facilitate percutaneous vascular closure and the common complications associated with vascular access.