Vascular Complications After Transcatheter Aortic Valve Replacement: Insights From the PARTNER (Placement of AoRTic TraNscathetER Valve) Trial.
ABSTRACT This study sought to identify incidence, predictors, and impact of vascular complications (VC) after transfemoral (TF) transcatheter aortic valve replacement (TAVR).
VC after TF-TAVR are frequent and may be associated with unfavorable prognosis.
From the randomized controlled PARTNER (Placement of AoRTic TraNscathetER Valve) trial, a total of 419 patients (177 from cohort B [inoperable] and 242 from cohort A [operable high-risk]) were randomly assigned to TF-TAVR and actually received the designated treatment. First-generation Edwards-Sapien valves and delivery systems were used, via a 22- or 24-F sheath. The 30-day rates of major and minor VC (modified Valve Academic Research Consortium definitions), predictors, and effect on 1-year mortality were assessed.
Sixty-four patients (15.3%) had major VC and 50 patients (11.9%) had minor VC within 30 days of the procedure. Among patients with major VC, vascular dissection (62.8%), perforation (31.3%), and access-site hematoma (22.9%) were the most frequent modes of presentation. Major VC, but not minor VC, were associated with significantly higher 30-day rates of major bleeding, transfusions, and renal failure requiring dialysis, and with a significantly higher rate of 30-day and 1-year mortality. The only identifiable independent predictor of major VC was female gender (hazard ratio [HR]: 2.31 [95% confidence interval (CI): 1.08 to 4.98], p = 0.03). Major VC (HR: 2.31 [95% CI: 1.20 to 4.43], p = 0.012), and renal disease at baseline (HR: 2.26 [95% CI: 1.34 to 3.81], p = 0.002) were identified as independent predictors of 1-year mortality.
Major VC were frequent after TF-TAVR in the PARTNER trial using first-generation devices and were associated with high mortality. However, the incidence and impact of major VC on 1-year mortality decreased with lower-risk populations.
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ABSTRACT: Transcatheter aortic valve replacement (TAVR) is entering its second decade. Three major clinical challenges have emerged from the first decade of experience: vascular complications, stroke, and paravalvular leak (PVL). Major vascular complications remain common and independently predict major bleeding, transfusion, renal failure, and mortality. Although women are more prone to vascular complications, overall they have better survival than men. Further predictors of major vascular complications include heavily diseased femoral arteries and operator experience. Strategies to minimize vascular complications include a multimodal approach and sleeker delivery systems. Although cerebral embolism is very common during TAVR, it mostly is asymptomatic. Major stroke independently predicts prolonged recovery and increased mortality. Identified stroke predictors include functional disability, previous stroke, a transapical approach, and atrial fibrillation. Embolic protection devices are in development to mitigate the risk of embolic stroke after TAVR. PVL is common and significantly decreases survival. Undersizing of the valve prosthesis can be minimized with 3-dimensional imaging by computed tomography or echocardiography to describe the elliptic aortic annulus accurately. The formal grading of PVL severity in TAVR is based on its percentage of the circumferential extent of the aortic valve annulus. Further emerging management strategies for PVL include a repositionable valve prosthesis and transcatheter plugging. The first decade of TAVR has ushered in a new paradigm for the multidisciplinary management of valvular heart disease. The second decade likely will build on this wave of initial success with further significant innovations.Journal of cardiothoracic and vascular anesthesia 11/2012; 27(1). DOI:10.1053/j.jvca.2012.09.002 · 1.48 Impact Factor
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ABSTRACT: Although transcatheter aortic valve implantation has been available for 10 years, reports of cardiovascular morphologic studies after the procedure are virtually nonexistent. The investigators describe such findings in 2 patients, both 86 years of age, who died early (hours or several days) after transcatheter aortic valve implantation. Although the prosthesis in each was seated well, and each of the 3 calcified cusps of the native aortic valves was well compressed to the wall of the aorta, thus providing a good bioprosthetic orifice, the ostium of the dominant right coronary artery in each was obliterated by the native right aortic valve cusp. Atherosclerotic plaques in the common iliac artery led to a major complication in 1 patient, who later died of hemorrhagic stroke. The other patient developed fatal cardiac tamponade secondary to perforation of the right ventricular wall by a pacemaker catheter.The American journal of cardiology 11/2012; 111(3). DOI:10.1016/j.amjcard.2012.09.038 · 3.43 Impact Factor
- 12/2012; 2(4):E7-E11. DOI:10.3978/j.issn.2223-3652.2012.11.05