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Feasibility and outcomes of combined transcatheter aortic valve replacement with other structural heart interventions in a single session: a matched cohort study.

Khattab AA, Gloekler S, Sprecher B, Shakir S, Guerios E, Stortecky S, O'Sullivan CJ, Nietlispach F, Moschovitis A, Pilgrim T, Buellesfeld L, Wenaweser P, Windecker S, Meier B - Open Heart (2014)

Bottom Line: The outcome was validated according to the Valve Academic Research Consortium (VARC) criteria.Procedural time (126±42 vs 83±40 min, p=0.0016), radiation time (34±8 vs 22±12 min, p=0.0001) and contrast dye (397±89 vs 250±105 mL, p<0.0001) were higher in the combined intervention group than in the TAVI-only group.Despite these drawbacks, no difference in the VARC endpoints was evident during the in-hospital period and after 30 days (VARC combined safety endpoint 32% for TAVI only and 20% for combined intervention, p=1.0).

View Article: PubMed Central - PubMed

Affiliation: Cardiology, Cardiovascular Department , Bern University Hospital , Bern , Switzerland.

ABSTRACT

Background: Concurrent cardiac diseases are frequent among elderly patients and invite simultaneous treatment to ensure an overall favourable patient outcome.

Aim: To investigate the feasibility of combined single-session percutaneous cardiac interventions in the era of transcatheter aortic valve implantation (TAVI).

Methods: This prospective, case-control study included 10 consecutive patients treated with TAVI, left atrial appendage occlusion and percutaneous coronary interventions. Some in addition had patent foramen ovale or atrial septal defect closure in the same session. The patients were matched in a 1:10 manner with TAVI-only cases treated within the same time period at the same institution regarding their baseline factors. The outcome was validated according to the Valve Academic Research Consortium (VARC) criteria.

Results: Procedural time (126±42 vs 83±40 min, p=0.0016), radiation time (34±8 vs 22±12 min, p=0.0001) and contrast dye (397±89 vs 250±105 mL, p<0.0001) were higher in the combined intervention group than in the TAVI-only group. Despite these drawbacks, no difference in the VARC endpoints was evident during the in-hospital period and after 30 days (VARC combined safety endpoint 32% for TAVI only and 20% for combined intervention, p=1.0).

Conclusions: Transcatheter treatment of combined cardiac diseases is feasible even in a single session in a high-volume centre with experienced operators.

No MeSH data available.


Related in: MedlinePlus

Representative course of action in case 2.
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OPENHRT2013000014F1: Representative course of action in case 2.

Mentions: Beforehand, coronary angiography with invasive haemodynamic assessment, CT angiography (CTA) and TEE for aortic root assessment and exclusion of LAA thrombi were performed. Three of the 10 cases were transmitted live to international interventional courses. If indicated by angiographic stenosis degree, PCI was performed first by transfemoral access with 5 or 6 Fr guiding catheters and exclusively using drug-eluting stents (DES), which was the case in 6 of the 10 combined patients. Two did not suffer from CAD and in two, the CAD was treated earlier in a separate procedure. Next, TAVI was performed under mild sedoanalgaesia and inguinal local anaesthesia only via transfemoral access. A single or both femoral arteries were accessed and a suture-based vascular closure device preinstalled on the respective side of access for TAVI. Aortic stenosis was crossed using an Amplatzer left diagnostic catheter and a straight tipped wire. Via a stiff wire, balloon aortic valvuloplasty under rapid pacing (180/min) was performed. After advancement of a 16–20 F femoral sheath, the Edwards Sapien bioprosthesis (balloon-expandable titanium frame containing bovine pericardial leaflets) or Medtronic Corevalve bioprosthesis (self-expandable nitinol frame containing porcine pericardial leaflets in supra-annular position) was deployed. Selection of the device size was based on previous aortic root assessment by TEE, CTA or angiography. After TAVI, LAA exclusion and septal closure procedures followed on. In all cases the first generation Amplatzer Cardiac Plug (ACP) was used. Similar to TAVI, LAA occlusion was performed in a frugal manner without general anaesthesia or TEE guidance, that is, under fluoroscopy only: after accessing the left atrium through a trans-septal puncture or passage through a pre-existing PFO or ASD, the device size was selected based on biplane angiography of the LAA through the 9–13 F delivery sheath. After deployment, sustained tugging with the delivery cable tested ACP seating within the LAA and another biplane left atrial angiography was performed prior to the release. In case of unsatisfactory positioning or anchoring, the plug was recaptured and redeployed in a different angle or changed for a more suitable sized device. On the way back, a pre-existing PFO or ASD was closed by the same cable and delivery sheath using Amplatzer PFO or ASD occluders. After closure of the percutaneous arterial access and slight compression of the femoral vein, patients were posthydrated with normal saline according to the standard protocol and transferred to a cardiac intermediate care ward (see figures 1 and 2 for a representative course of action in case 2). Restart of oral anticoagulation was omitted. A dose of 75 mg of clopidogrel daily for 3–6 months and 100 mg of acetylsalicylic acid were prescribed indefinitely. For documentation of aortic bioprosthesis performance and exclusion of device displacement or pericardial effusion, transthoracic echocardiography was performed on day one after intervention and after 30 days. The patients were discharged on postprocedure days 3–7.


Feasibility and outcomes of combined transcatheter aortic valve replacement with other structural heart interventions in a single session: a matched cohort study.

Khattab AA, Gloekler S, Sprecher B, Shakir S, Guerios E, Stortecky S, O'Sullivan CJ, Nietlispach F, Moschovitis A, Pilgrim T, Buellesfeld L, Wenaweser P, Windecker S, Meier B - Open Heart (2014)

Representative course of action in case 2.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4195934&req=5

OPENHRT2013000014F1: Representative course of action in case 2.
Mentions: Beforehand, coronary angiography with invasive haemodynamic assessment, CT angiography (CTA) and TEE for aortic root assessment and exclusion of LAA thrombi were performed. Three of the 10 cases were transmitted live to international interventional courses. If indicated by angiographic stenosis degree, PCI was performed first by transfemoral access with 5 or 6 Fr guiding catheters and exclusively using drug-eluting stents (DES), which was the case in 6 of the 10 combined patients. Two did not suffer from CAD and in two, the CAD was treated earlier in a separate procedure. Next, TAVI was performed under mild sedoanalgaesia and inguinal local anaesthesia only via transfemoral access. A single or both femoral arteries were accessed and a suture-based vascular closure device preinstalled on the respective side of access for TAVI. Aortic stenosis was crossed using an Amplatzer left diagnostic catheter and a straight tipped wire. Via a stiff wire, balloon aortic valvuloplasty under rapid pacing (180/min) was performed. After advancement of a 16–20 F femoral sheath, the Edwards Sapien bioprosthesis (balloon-expandable titanium frame containing bovine pericardial leaflets) or Medtronic Corevalve bioprosthesis (self-expandable nitinol frame containing porcine pericardial leaflets in supra-annular position) was deployed. Selection of the device size was based on previous aortic root assessment by TEE, CTA or angiography. After TAVI, LAA exclusion and septal closure procedures followed on. In all cases the first generation Amplatzer Cardiac Plug (ACP) was used. Similar to TAVI, LAA occlusion was performed in a frugal manner without general anaesthesia or TEE guidance, that is, under fluoroscopy only: after accessing the left atrium through a trans-septal puncture or passage through a pre-existing PFO or ASD, the device size was selected based on biplane angiography of the LAA through the 9–13 F delivery sheath. After deployment, sustained tugging with the delivery cable tested ACP seating within the LAA and another biplane left atrial angiography was performed prior to the release. In case of unsatisfactory positioning or anchoring, the plug was recaptured and redeployed in a different angle or changed for a more suitable sized device. On the way back, a pre-existing PFO or ASD was closed by the same cable and delivery sheath using Amplatzer PFO or ASD occluders. After closure of the percutaneous arterial access and slight compression of the femoral vein, patients were posthydrated with normal saline according to the standard protocol and transferred to a cardiac intermediate care ward (see figures 1 and 2 for a representative course of action in case 2). Restart of oral anticoagulation was omitted. A dose of 75 mg of clopidogrel daily for 3–6 months and 100 mg of acetylsalicylic acid were prescribed indefinitely. For documentation of aortic bioprosthesis performance and exclusion of device displacement or pericardial effusion, transthoracic echocardiography was performed on day one after intervention and after 30 days. The patients were discharged on postprocedure days 3–7.

Bottom Line: The outcome was validated according to the Valve Academic Research Consortium (VARC) criteria.Procedural time (126±42 vs 83±40 min, p=0.0016), radiation time (34±8 vs 22±12 min, p=0.0001) and contrast dye (397±89 vs 250±105 mL, p<0.0001) were higher in the combined intervention group than in the TAVI-only group.Despite these drawbacks, no difference in the VARC endpoints was evident during the in-hospital period and after 30 days (VARC combined safety endpoint 32% for TAVI only and 20% for combined intervention, p=1.0).

View Article: PubMed Central - PubMed

Affiliation: Cardiology, Cardiovascular Department , Bern University Hospital , Bern , Switzerland.

ABSTRACT

Background: Concurrent cardiac diseases are frequent among elderly patients and invite simultaneous treatment to ensure an overall favourable patient outcome.

Aim: To investigate the feasibility of combined single-session percutaneous cardiac interventions in the era of transcatheter aortic valve implantation (TAVI).

Methods: This prospective, case-control study included 10 consecutive patients treated with TAVI, left atrial appendage occlusion and percutaneous coronary interventions. Some in addition had patent foramen ovale or atrial septal defect closure in the same session. The patients were matched in a 1:10 manner with TAVI-only cases treated within the same time period at the same institution regarding their baseline factors. The outcome was validated according to the Valve Academic Research Consortium (VARC) criteria.

Results: Procedural time (126±42 vs 83±40 min, p=0.0016), radiation time (34±8 vs 22±12 min, p=0.0001) and contrast dye (397±89 vs 250±105 mL, p<0.0001) were higher in the combined intervention group than in the TAVI-only group. Despite these drawbacks, no difference in the VARC endpoints was evident during the in-hospital period and after 30 days (VARC combined safety endpoint 32% for TAVI only and 20% for combined intervention, p=1.0).

Conclusions: Transcatheter treatment of combined cardiac diseases is feasible even in a single session in a high-volume centre with experienced operators.

No MeSH data available.


Related in: MedlinePlus