Transcatheter aortic valve implantation for high-risk patients with severe aortic stenosis: a systematic review. J Thorac Cardiovasc Surg

Department of Cardiothoracic Surgery, The University of Sydney, Royal Prince Alfred Hospital, Sydney 2050, Australia.
The Journal of thoracic and cardiovascular surgery (Impact Factor: 4.17). 10/2009; 139(6):1519-28. DOI: 10.1016/j.jtcvs.2009.08.037
Source: PubMed


The present systematic review objectively assessed the safety and clinical effectiveness of transcatheter aortic valve implantation for patients at high surgical risk with severe aortic stenosis.
Electronic searches were performed in 6 databases from January 2000 to March 2009. The end points included feasibility, safety, efficacy, and durability. Clinical effectiveness was synthesized through a narrative review with full tabulation of results of all included studies.
The current evidence on transcatheter aortic valve implantation for aortic stenosis is limited to short-term observational studies. The overall procedural success rates ranged from 74% to 100%. The incidence of major adverse events included 30-day mortality (0%-25%), major ventricular tachyarrhythmia (0%-4%), myocardial infarction (0%-15%), cardiac tamponade (2%-10%), stroke (0%-10%), conversion to surgery (0%-8%), moderate to major paravalvular leak (4%-35%), vascular complication (8%-17%), valve-in-valve procedure (2%-12%), and aortic dissection/perforation (0%-4%). The overall 30-day major adverse cardiovascular and cerebral events ranged from 3% to 35%. The mean aortic valve area ranged from 0.5 to 0.8 cm(2) before and 1.3 to 2.0 cm(2) after transcatheter aortic valve implantation. The mean pressure gradient ranged from 34 to 58 mm Hg before and 3 to 12 mm Hg after transcatheter aortic valve implantation. There was no significant deterioration in echocardiography measurements during the assessment period. Death rate at 6 months postprocedure ranged from 18% to 48%. No studies had adequate follow-up to reliably evaluate long-term outcomes.
The procedure has a potential for serious complications. Although short-term efficacy based on echocardiography measurements is good, there is little evidence on long-term outcomes. The use of transcatheter aortic valve implantation should be considered only within the boundaries of clinical trials.


Available from: Michael P Vallely
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    • "Determining exactly valve location and minimizing the use of contrast injections are urgently needed during the surgical intervention, because complications can arise from a misplaced valve. These complications have been reported [1] such as high-degree atrioventricular block (10-30%), paravalvular leak (4-35%), coronary ostia occlusion (0.5-1%), aortic dissection (0-4%) and cardiac tamponade (1-9%). The 30-day mortality of the TAVI in Europe is 5-10% [2]. "
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    ABSTRACT: The main objective of this work is to track the aortic valve plane in intra-operative fluoroscopic images in order to optimize and secure Transcatheter Aortic Valve Implantation (TAVI) procedure. This paper is focused on the issue of aortic valve calcifications tracking in fluoroscopic images. We propose a new method based on the Tracking-Learning-Detection approach, applied to the aortic valve calcifications in order to determine the position of the aortic valve plane in intra-operative TAVI images. This main contribution concerns the improvement of object detection by updating the recursive tracker in which all features are tracked jointly. The approach has been evaluated on four patient databases, providing an absolute mean displacement error less than 10 pixels (≈2mm). Its suitability for the TAVI procedure has been analyzed.
    Conference proceedings: ... Annual International Conference of the IEEE Engineering in Medicine and Biology Society. IEEE Engineering in Medicine and Biology Society. Conference 07/2013; 2013:4378-4381. DOI:10.1109/EMBC.2013.6610516
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    • "As shown in previous studies, the very elderly are more likely to experience postoperative complications, and consequently, a prolonged hospitalization and intensive therapy [21,22]. However, the length of hospital and ICU stay reported in our study (18.5 ± 5.4 and 3.36 ± 1.9 days respectively) is comparable to data for younger patients (7 to 17 days and 2.8 days respectively [23]. "
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    ABSTRACT: Background Nonagenarians are mostly denied from different therapeutic strategies due to high comorbidity index and risk-benefit calculation. We present the results of nonagenarians with high comorbidity index not eligible for conventional aortic valve surgery undergoing transcatheter aortic valve implantation (TAVI) with the CoreValve system. Methods Our retrospective analysis include baseline parameters, procedural characteristics, morbidity, mortality as well as twelve-lead surface ECG and echocardiographic parameters which were revealed preinterventionally, at hospital discharge and at 30-day follow-up. Clinical follow-up was performed 6 months after TAVI. Results Out of 158 patients 11 nonagenarians with a mean age of 92.6 ± 1.3 years suffering from severe aortic valve stenosis and elevated comorbidity index (logistic EuroSCORE of 32.0 ± 9.5%, STS score 25.3 ± 9.7%) underwent TAVI between January 2008 and January 2011 using the third-generation percutaneous self-expanding CoreValve prosthesis. Baseline transthoracic echocardiography reported a mean aortic valve area (AVA) of 0.6 ± 0.2 cm2 with a mean and peak pressure gradient of 60.2 ± 13.1mmHg and 91.0 ± 27.4mmHg, respectively. The 30-day follow up all cause and cardiovascular mortality was 27.3% and 9.1%, respectively. One major stroke (9.1%), 2 pulmonary embolisms (18.2%), 1 periprocedural (9.1%) and 1 (9.1%) spontaneous myocardial infarction occured. Life-threatening or disabling bleeding occurred in 2 cases (18.2%), and minor bleeding in 7 cases (63.6%). Mean severity of heart failure according to NYHA functional class improved from 3.2 ± 0.8 to 1.36 ± 0.5 while mean AVA increased from 0.6 ± 0.2cm2 to 1.8 ± 0.2cm2. At 6-months follow-up 8 patients (72.7%) were alive without any additional myocardial infarction, pulmonary embolism, bleeding, or stroke as compared to 30-day follow-up. Conclusion Our case series demonstrate that even with elevated comorbidity index, clinical endpoints and valve-associated results are relatively favorable in nonagenarians treated with CoreValve.
    BMC Cardiovascular Disorders 09/2012; 12(1). DOI:10.1186/1471-2261-12-80 · 1.88 Impact Factor
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    • "However, conventional AVR as a redo procedure after CABG with patent grafts can be performed with excellent results and a lower mortality than estimated [3], even in case of both IMA grafts, thanks to the use of an adapted surgical strategy [1]. TAVI procedure with its less invasive nature has been believed to offer a safer treatment solution for high risk patients [2] and we could expect to observe a benefit impact of TAVI in the specific situation of patients with previous CABG. According to our short series, the advantage of TAVI in comparison with AVR is not obvious. "
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    ABSTRACT: We report a prospective comparison between transcatheter valve implantation (TAVI, n = 13) and surgical aortic valve replacement (AVR, n = 10) in patients with severe aortic valve stenosis and previous coronary bypass surgery (CABG). All patients had at least bilateral patent internal thoracic arteries bypass without indication of repeat revascularization. After a similar post-procedure outcome, despite one early death in TAVI group, the 1-year survival was 100% in surgical group and in transfemoral TAVI group, and 73% in transapical TAVI group. When previous CABG is the lone surgical risk factor, indications for a TAVI procedure have to be cautious, specially if transfemoral approach is not possible.
    Journal of Cardiothoracic Surgery 05/2012; 7(1):47. DOI:10.1186/1749-8090-7-47 · 1.03 Impact Factor
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