Enfoque minimalista en el implante de válvula aórtica percutánea / A minimalist approach for transcatheter aortic valve replacement

RESUMEN INTRODUCCIÓN: En pacientes con estenosis Aórtica (EA) severa sintomática, el implante de válvula aórtica percutánea transcatéter (TAVI) por vía transfemoral constituye el estándar de tratamiento en aquellos de riesgo quirúrgico intermedio o alto. El uso de un abordaje minimalista ha demostrado ser seguro y efectivo, si bien no existen reportes sobre la realidad nacional Métodos: Estudio descriptivo sobre la experiencia con pacientes sometidos al implante de TAVI bajo un protocolo minimalista en Unidad de Cardiología Intervencional y Hemodinamia del Hospital Sótero del Río desde Enero de 2018. Se analizaron las variables clínicas de los pacientes y del procedimiento así como desenlaces clínicos intrahospitalarios y seguimiento alejado. Resultados: Entre Enero 2018 hasta Abril 2019, un total de 10 pacientes fueron sometidos al implante de TAVI por vía transfemoral. El score STS-PROM promedio fue de 7,1. Se logró un implante exitoso en el 100% de los casos con un gradiente medio residual de 8 mmHg y sin leak moderado a severo en ningún paciente. No hubo eventos cerebrovasculares isquémicos perioperatorios ni muerte en este grupo. Se requirió implante de marcapasos definitivo en 3 pacientes y un paciente presentó hematoma femoral perioperatorio que requirió transfusión de glóbulos rojos. La mediana de la estadía hospitalaria fue de 2 días. Conclusiones: El uso de una estrategia minimalista para el implante de TAVI en nuestra realidad nacional es seguro y aplicable. Los resultados perioperatorios y a 30 días fueron comparables a los descritos en experiencias internacionales.

ABSTRACT BACKGROUND: In patients with symptomatic severe aortic stenosis, transcatheter percutaneous aortic valve implant (TAVI) is the standard treatment in those with intermediate or high surgical risk. The use of a minimalist approach has proven to be safe and effective, although there are no reports on the national reality Methods: Descriptive study on the experience with patients undergoing TAVI implantation under a minimalist protocol at the Interventional Cardiology and Hemodynamics Unit of the Hospital Sótero del Río since January 2018. Clinical characteristics of the patients and the procedure were analyzed as well as intrahospital outcomes and at 30-days follow up. Results: Between January 2018 and April 2019, a total of 10 patients underwent TAVI implantation by transfemoral approach in our institution. The average STS-PROM score was 7.1. A successful implant was achieved in 100% of cases with an average residual gradient of 8 mmHg and no moderate to severe leak in any patient. There were no perioperative ischemic cerebrovascular events nor death in this group. A definitive pacemaker implant was required in 3 patients and one patient developed femoral hematoma that required red blood cell transfusion. The median hospital stay was 2 days. Conclusions: The use of a minimalist strategy for TAVI implantation in our national reality is safe and applicable. Immediate results and at 30-days follow up were comparable to those described in international experiences.

Inhalational anesthesia maintenance with the Janus facial mask for transcatheter aortic-valve replacement: a case series / Manutenção da anestesia inalatória com a máscara facial Janus para substituição de válvula aórtica transcateter: uma série de casos

Abstract Background and objectives Aortic stenosis is the most common type of heart valve disease. Percutaneous aortic valve replacement has become the alternative for patients considered at high risk for surgery. Controlled mechanical ventilation with tracheal intubation has been the choice for this type of procedure, however the use of noninvasive ventilation in cardiac patients has shown to be beneficial. Janus is a novel full-face mask that allows application of noninvasive ventilation support during anesthesia. Our main objective was to evaluate the feasibility of transcatheter aortic valve replacement with prolonged transesophageal echocardiographic monitoring under deep inhalational sedation delivered through a new mask for noninvasive ventilation. Methods A case series observational study that included five patients with critical aortic stenosis that underwent inhalational anesthesia with sevoflurane for transcatheter aortic valve replacement in a hybrid room of a teaching hospital. Standard monitors and bispectral index were used, followed by inhalational induction and placement of the Janus mask. Anesthesia was maintained with sevoflurane. Patients were transferred to intensive care unit after the procedure. Complications related to the mask use, transesofageal echocardiography accessibility and respiratory implications to the patients were recorded. Results All procedures were uneventful and no major complications were observed intraoperatively. One patient presented CO2 retention (50 mmHg) and sevoflurane leak around the central opening of the mask, both without clinical significance. Conclusions The use of inhalational anesthesia with the facial mask Janus is a safe and efficient alternative to general anesthesia with tracheal intubation for transcatheter aortic valve replacement and can easily accommodate the use of transesophageal echocardiography intraoperatively.

Resumo Justificativa e objetivos A estenose aórtica é o tipo mais comum de doença valvular cardíaca. A substituição percutânea de válvula aórtica tornou-se a alternativa para pacientes cirúrgicos considerados de alto risco. A ventilação mecânica controlada com intubação traqueal tem sido a escolha para esse tipo de procedimento; porém, o uso de ventilação não invasiva em pacientes cardíacos mostrou ser benéfico. Janus é uma nova máscara facial que permite a aplicação de suporte à VNI durante a anestesia. Nosso objetivo primário foi avaliar a viabilidade da substituição transcateter de valva aórtica com monitoração ecocardiográfica transesofágica prolongada sob sedação inalatória profunda através de uma nova máscara para ventilação não invasiva. Métodos Estudo observacional de série de casos que incluiu cinco pacientes com estenose aórtica em fase crítica, submetidos à anestesia inalatória com sevoflurano para substituição transcateter de valva aórtica em uma sala híbrida de um hospital universitário. Monitores padrão e índice bispectral foram usados, seguidos de indução inalatória e colocação da máscara Janus. A anestesia foi mantida com sevoflurano. Os pacientes foram transferidos para a unidade de terapia intensiva após o procedimento. As complicações relacionadas ao uso da máscara, a acessibilidade da ecocardiografia transesofágica e as implicações respiratórias para os pacientes foram registradas. Resultados Todos os procedimentos transcorreram sem incidentes e não foram observadas complicações maiores no intraoperatório. Um paciente apresentou retenção de CO2 (50 mmHg) e vazamento de sevoflurano em torno da abertura central da máscara, ambos sem significância clínica. Conclusões O uso de anestesia inalatória com a máscara facial Janus é uma opção segura e eficiente à anestesia geral com intubação traqueal para substituição transcateter de valva aórtica e pode facilmente acomodar o uso de ecocardiografia transesofágica no intraoperatório.

TAVI in Intermediate-risk patients: a review in purpose of a case / TAVI en pacientes de riesgo intermedio: una revisión a propósito de un caso

Abstract: Background: Aortic stenosis is the most common valvular heart disease worldwide. The prognosis is adverse without a valve replacement. Transcatheter aortic valve implantation (TAVI) has proven to be an effective treatment in high-surgical risk patients. Recent trials have highlighted the non-inferiority of TAVI compared with open surgery in patients with intermediate surgical risk. Case report: A 76-year-old man with severe aortic stenosis and intermediate surgical risk (STS-PROM 4.8%) who underwent TAVI with no complications. Results: Hospital discharge was decided five days after the procedure and continued outpatient follow-up. After two years remains in NYHA functional class I with a normofunctional percutaneous prosthesis. Conclusion: As this clinical case shows, TAVI has proven to be an effective treatment in patients with aortic stenosis and intermediate surgical risk. This is the first experience in this type of patients reported in our country.(AU)

Resumen: Antecedentes: La estenosis aórtica es la valvulopatía más común en todo el mundo. El pronóstico es sombrío sin reemplazo valvular. La implantación valvular aórtica transcatéter (TAVI) ha demostrado ser un tratamiento eficaz en pacientes de alto riesgo quirúrgico. Ensayos muy recientes destacaron la no-inferioridad de TAVI en comparación con la cirugía abierta en pacientes con riesgo quirúrgico intermedio. Caso clínico: Se presenta un hombre de 76 años de edad con estenosis aórtica severa y riesgo quirúrgico intermedio (STS-PROM 4.8%), al que se realiza TAVI sin complicaciones. Resultados: El alta hospitalaria se decide cinco días después del procedimiento para continuar el seguimiento ambulatorio. Después de dos años, el seguimiento permanece en la clase funcional I de la NYHA con una prótesis percutánea normofuncional. Conclusión: Como muestra este caso clínico, TAVI ha demostrado ser un tratamiento eficaz en pacientes de riesgo quirúrgico intermedio. Ésta es la primera experiencia en el uso de esta tecnología en este tipo de pacientes reportada en nuestro país.(AU)

A new experimental device for transapical access of the aortic and mitral valves as well as the aorta in its various segments

Abstract Objective: To present the results of a new experimental device developed to facilitate the transapical access in endovascular treatment of structural heart diseases. It aims to reduce the risk of bleeding and complications in this type of access and demonstrate the device as a safe, fast and effective alternative. Methods: CorPoint is composed of three parts: introducer, base with coiled spring, and closing capsule. By rotating movements, the spring is introduced into the myocardium and progressively approaches the base to the surface of the heart. Guidewires and catheters are inserted through the hollow central part and, at the end of the procedure, the capsule is screwed over the base, therefore stopping any bleeding. Results: The device was implanted in 15 pigs, weighing 60 kg each, through an anterolateral thoracotomy, while catheters were introduced and guided by fluoroscopy. All animals had minimal bleeding; introducers with diameter up to 22 Fr were used and various catheters and guidewires were easily handled. After finishing the procedure, the closing capsule was attached and no bleeding was observed at the site. Conclusion: This new device has proved effective, fast and secure for the transapical access. This shows great potential for use, especially by ensuring an easier and direct access to the mitral and aortic valves; the shortest distance to be traveled by catheters; access to the ascending and descending aorta; decreased bleeding complications; decreased surgical time; and the possibility of allowing the technique to evolve and become totally percutaneous.

Transcatheter aortic valve implantation with balloonexpandable valve: early experience from China / Implantação da válvula aórtica transcateter com válvula balão-expansível: experiência inicial da China

AbstractObjective:The aim of the current study was to evaluate the early experience of the application of transcatheter aortic valve implantation with the balloon-expandable system in China. The transcatheter aortic valve implantation technology has been widely used for patients with inoperable severe aortic stenosis in the developed world. The application of transcatheter aortic valve implantation is still in the early stages of testing in China, particularly for the balloon-expandable valve procedure.Methods:This was a retrospective study. All patients undergoing transcatheter aortic valve implantation with balloon-expandable system in our hospital between 2011 and 2014 were included. Edwards SAPIEN XT Transcatheter Heart Valve was used. The improvement of valve and heart function was evaluated as well as 30-day mortality and major complications according to the VARC-2 definition.Results:A total of 10 transcatheter aortic valve implantation procedures with the balloon-expandable system were performed in our hospital, of which 9 were transfemoral and 1 was transapical. The median age was 76 years, and the median STS score and Logistic EuroSCORE (%) were 8.9 and 16.2. The implantation was successfully conducted in all patients, only 2 patients had mild paravalvular leak. There was no second valve implantation. Moreover, no 30-day mortality or complications was reported. Following the transcatheter aortic valve implantation procedure, the heart and valve functions had improved significantly. During the follow-up period of 3-34 months, one patient died of lung cancer 13 months after the operation.Conclusion:This early experience has provided preliminary evidence for the safety and efficacy of transcatheter aortic valve implantation procedure with the balloon-expandable system in the developing world with an increasing aging population.

ResumoObjetivo:O objetivo do presente estudo foi avaliar a experiência inicial da aplicação do implante percutâneo da válvula aórtica com o sistema balão-expansível na China. A tecnologia TAVI tem sido amplamente utilizada para pacientes com estenose aórtica grave inoperável no mundo desenvolvido. A aplicação de implante percutâneo da válvula aórtica está ainda nas etapas iniciais de teste na China, em particular o procedimento de válvula balão-expansível.Métodos:O estudo foi retrospectivo e todos os pacientes submetidos a implante percutâneo da válvula aórtica com sistema balão-expansível em nosso hospital entre 2011 e 2014 foram incluídos. Edwards SAPIEN XT Válvula Cardíaca Transcatheter foi usado. A melhoria do funcionamento da válvula e do coração foi avaliada, bem como mortalidade em 30 dias e as principais complicações de acordo com a definição VARC-2.Resultados:Um total de 10 procedimentos Tavi com o sistema balão-expansível foram realizados em nosso hospital, dos quais 9 foram transfemorais e 1 foi transapical. A idade média foi de 76 anos, e os STS mediana marcar e Logistic EuroSCORE (%) foram de 8,9 e 16,2. A implantação foi realizada com sucesso em todos os pacientes, apenas 2 pacientes tiveram vazamento paravalvar leve. Não houve um futuro implante valvar. Além disso, mortalidade em 30 dias ou complicações não foram relatadas. Seguindo o procedimento de implante percutâneo da válvula aórtica, as válvulas cardíacas e funções melhoraram significativamente. Durante o período de acompanhamento de 3-34 meses, um paciente morreu de câncer de pulmão 13 meses após a operação.Conclusão:Esta experiência inicial apresentou elementos de prova preliminar para a segurança e eficácia do procedimento implante percutâneo da válvula aórtica com o sistema balão-expansível no mundo em desenvolvimento com crescente envelhecimento da população.

Mid‑term survival after transcatheter aortic valve implantation: Results with respect to the anesthetic management and to the access route (transfemoral versus transapical).

Context: Several studies have analyzed the long‑term survival after transcatheter aortic valve implantation (TAVI). However, no previous studies have looked at survival beyond 1‑year with respect to the type of anesthesia. Aims: The aim was to evaluate the mid‑term survival after TAVI with respect to the type of anesthesia (general anesthesia [GA] vs. local anesthesia ± sedation [LASedation]) or the type of procedure (transfemoral [transfem] vs. transapical TAVI) performed. Settings and Design: Retrospective cohort study. Subjects and Methods: This retrospective study included TAVI’s between January 2009 and June 2013. Patients were divided into three groups: transfem TAVI under GA, transfem TAVI under LASedation and transapical TAVI. A total of 176 patients were eligible. The following clinical outcomes were evaluated: (1) Mortality, (2) Major cardiovascular complications, (3) Conduction abnormalities and arrhythmias, (4) Acute kidney injury, (5) Aortic regurgitation, (6) Neurologic events, (7) Vascular complications, (8) Pulmonary complications, (9) Bleeding, (10) Infectious complications, (11) Delirium. Statistical Analysis Used: A Kruskal–Wallis test was performed to test significance between the three groups for quantitative variables. Categorical variables were compared using a Chi‑square test. Survival was estimated using Kaplan–Meier method. Results: There was no statistically significant difference between the survival of both transfem TAVI’s (P = 0.46). The short‑term outcome of the transfem TAVI groups was better than the transapical arm, but their mid‑term survival did not show any significant difference (P = 0.69 transapical vs. transfem GA; P = 0.07 transapical vs. transfem LASedation). Conclusions: Our results demonstrate that the type of anesthesia and the access route do not influence mid‑term survival after TAVI.