ABSTRACT
Considering the surgical risk stratification for patients with severe calcific aortic stenosis (AS), transcatheter aortic valve replacement (TAVR) is a reliable alternative to surgical aortic valve replacement (SAVR) (Fan et al., 2020, 2021; Lee et al., 2021). Despite the favorable clinical benefits of TAVR, stroke remains a dreaded perioperative complication (Auffret et al., 2016; Kapadia et al., 2016; Kleiman et al., 2016; Huded et al., 2019). Ischemic overt stroke, identified in 1.4% to 4.3% of patients in TAVR clinical practice, has been associated with prolonged disability and increased mortality (Auffret et al., 2016; Kapadia et al., 2016; Levi et al., 2022). The prevalence of hyperintensity cerebral ischemic lesions detected by diffusion-weighted magnetic resonance imaging (DW-MRI) was reported to be about 80%, which is associated with impaired neurocognitive function and vascular dementia (Vermeer et al., 2003; Barber et al., 2008; Kahlert et al., 2010).
Subject(s)
Humans , Transcatheter Aortic Valve Replacement , Aortic Valve Insufficiency , Diffusion Magnetic Resonance Imaging , Aortic Valve Stenosis , StrokeABSTRACT
Objective:To evaluate the effectiveness and prognosis of emergent transcatheter aortic valve replacement (TAVR) and to provide standardized procedural suggestion for the development of emergent TAVR in China.Methods:From January 2020 to April 2021, 12 patients who underwent emergent or salvage TAVR in the Second Affiliated Hospital Zhejiang University School of Medicine were retrospectively enrolled from the TORCH registry (Transcatheter Aortic Valve Replacement Single Center Registry in Chinese Population, a prospective cohort study; NCT02803294). Baseline, periprocedural and 30-day follow up data were collected. Post-operative data were compared with pre-operative data using Paired-Samples test.Results:Patients’ median Society of Thoracic Surgeons score (STS score) was 15.432%. There was a significant decrease of mean gradient after emergent TAVR procedure (1.69 m/s vs. 4.90 m/s, P<0.01). During the 30-day follow up, there were 1 patient (8.3%) died and 2 patients received permanent pacemaker implantation. No disabling stroke, acute kidney injury, major vascular complication occurred during the first month after emergent TAVR. Among the survival patients, there was a significant releasing of heart failure symptoms to New York Heart Association function stage Ⅰ/Ⅱ in 81.8% patients at 30-day follow up. Left ventricular ejection fraction also improved significantly from (47.4±9.5)% to 58.8±8.0% ( P= 0.026). The mean gradient were (1.57±0.30) cm 2 and no patients had a moderate or severe paravalvular leakage. Besides, a significant decrease of pro-B-type natriuretic peptide (1 089.9 pg/mL vs. 12 215.5 pg/mL , P=0.001) and troponin T (0.020 ng/mL vs. 0.337 ng/mL, P=0.003) were found at 30 days after emergent TAVR. Conclusions:For patients with severe aortic stenosis and acute cardiac decompensated, emergent TAVR is a safe and effective rescue treatment.
ABSTRACT
Transcatheter aortic valve replacement (TAVR) has emerged as a viable treatment option for patients with severe aortic stenosis regardless of its surgical risk stratification (Otto et al., 2021). Aortic angulation is usually measured as the angle between the horizontal and the aortic annulus planes based on preprocedural multidetector computed tomography (MDCT) (Al-Lamee et al., 2011). Extremely horizontal aorta, defined as an aortic angulation greater than 70°, is an unfavorable anatomic structure that poses particular technical challenges for TAVR. Abramowitz et al. (2016) have proved that an extremely horizontal aorta increased the risk of procedural complications, such as lower device success rates, more moderate or even severe perivalvular leakage (PVL), and the need for second valve implantation. Because of the long stent frame, inflexibility, and non-steerability, it is challenging to pass the delivery system of self-expanding valves (SEVs) through an extremely horizontal aorta. As a result, patients with an extremely horizontal aorta have always been excluded from the clinical trials of TAVR, and transfemoral (TF)-TAVR with SEV is considered as an "off-label" use of TAVR (Adams et al., 2014; Kaneko et al., 2020). Herein, we present a technically difficult case, in which a patient with an extremely horizontal aorta underwent TF-TAVR with SEV by applying a unique apical-to-femoral rail strategy.
Subject(s)
Humans , Aorta , Lower Extremity , Multidetector Computed Tomography , Transcatheter Aortic Valve ReplacementABSTRACT
Objective:To explore the value of transesophageal echocardiography(TEE) guidance for transcatheter DragonFly? system edge-to-edge tricuspid regurgitation (TR) repair.Methods:Five cases who were chosen in the Second Affiliated Hospital, Zhejiang University School of Medicine from December 2020 to January 2021 with surgical high-risk and severe functional TR underwent transcatheter DragonFly edge-to-edge repair with the guidance of TEE. Preoperative TEE was used to evaluate the tricuspid valve anatomy and the origin and etiology of regurgitation in detail; intra-procedure guidance of TEE was performed during the DragonFly system for tricuspid valve edge-to-edge repair intervention and after release of the DragonFly clip, the effect of surgery was assessed immediately and compared with pre-procedure TEE.Results:A total of 10 DragonFly clips were implanted in 5 patients (3 in each of patients, 2 in 1 patient, and 1 in each of patients). One of the 3 clips in 1 patient fell off unilaterally from the septal valve after release, and the other 9 clips were well positioned and fixed. Immediately post-operation assessment by TEE depicted the TR in 3 patients declined to mild and 2 to moderate. The vena contracta area by using three-dimensional color blood flow quantitative assessment was reduced[(0.93±0.26)cm 2 vs (0.20±0.11)cm 2]. No complications such as serious tricuspid valve injury, pericardial tamponade, thromboembolism occurred in the 5 patients. Conclusions:TEE plays an important role in guiding and monitoring transcatheter DragonFly system edge-to-edge TR repair during the entire procedure.