One-year results of transcatheter aortic valve implantation as an alternative treatment for severe aortic stenosis in high-risk patients.

BACKGROUND: Aortic valve replacement (AVR) remains the gold standard treatment for symptomatic severe aortic stenosis (AS). For the past 10 years, transcatheter aortic valve implantation (TAVI) has been applied in patients with high surgical mortality and morbidity risks. The preliminary results of our TAVI patients are presented in this study. METHODS: Ten high-risk patients with severe AS, for AVR, were referred and accepted for TAVI in the 6 month period from May 2010 to October 2010. The patient age, logistic EuroSCORE, femoral arterial diameter, aorta annulus size, aorta valve area (AVA), mean aortic pressure gradient (MPG), as well as coronary angiography results were all collected. Six patients were treated via the transapical approach in March 2010, whereas the other four were treated with the transfemoral approach, according to their femoral artery diameter and arterial quality. This study focuses on the immediate, 1 month, 3 month, and 1 year results of TAVI. RESULTS: The average age of the 10 patients receiving TAVI was 81.5 years. The mean calculated EuroSCORE was 28.3 ± 7.9%. The mean AVA was 0.61 ± 0.19 cm(2). The MPG was 48 ± 16 mmHg. The surgical technical success achieved 100%. There was no reported moderate to severe postoperative paravalvular aortic regurgitation, permanent complete atrioventricular block, major access site complication, or embolic stroke. Chronic renal failure, which necessitated permanent hemodialysis, developed in 10% of the patients. One acute myocardial infarction and one case of pneumonia developed postoperatively. The AVA was increased by 251%, whereas the MPG was decreased by 80% at the 3 month follow-up. The 30-day mortality rate was 10%. The all-cause 1-year mortality rate was 20%. CONCLUSION: This new technique and device requires greater caution and needs more practice to accumulate sufficient experience. The studied patients were very fragile, due to old age and multiple comorbidities. Our results are similar to findings of multicenter trials. With careful patient screening and selection, TAVI can be a promising treatment for high-risk severe AS patients.

Concomitant Bentall operation plus aortic arch replacement surgery.

BACKGROUND: The Bentall operation is recommended for thoracic aortic dissection or aneurysm involving the aortic root. However, if the lesion extends to the aortic arch, concomitant Bentall operation plus aortic arch replacement (CoBAAR) surgery is required. CoBAAR is challenging because of its complex cardiopulmonary procedure, prolonged cardiopulmonary bypass time, and demanding operative techniques. Therefore, surgical mortality and morbidity rates for CoBAAR are very high. However, the Bentall operation performed as a single procedure may lead to reoperation if the residual aneurysm progresses. Therefore, CoBAAR as a one-stage surgery can lower the need for reoperation and possible further complications. METHODS: Nine patients received CoBAAR during January 2005 to May 2010. Six patients were diagnosed with Sanford type A aortic dissection and three with nondissecting ascending aortic and arch aneurysm. Four patients received a Bentall operation plus hemiarch replacement. The others received a Bentall operation plus total arch replacement along with elephant trunk because of extensive lesions. RESULTS: The in-hospital mortality was 11.1% (1 patient with total arch replacement). Morbidity included stroke (2 patients), spinal cord injury (1 patient), mechanical ventilation for more than 72 hours (5 patients), and temporary renal dialysis (3 patients). Eight patients survived. CONCLUSION: CoBAAR is a demanding operative technique requiring complex cardiopulmonary bypass. However, surgeons can perform this procedure on extensive ascending aortic dissection or aneurysm patients, achieving satisfactory results.

Thrombelastography change after bridging to left ventricular assist device from extracorporeal membrane oxygenation patients.

BACKGROUND: Circulatory assist devices are applied to support patients with end-stage heart failure or circulatory collapse. Extracorporeal membrane oxygenation (ECMO) and ventricular assist device (VAD) are the two devices that are commonly used in these situations. However, in patients undergoing ECMO, complications occur more frequently and are more severe than in those with VAD, especially in patients with coagulopathy. The cause of coagulopathy is seldom reported; therefore, the current prospective study was designed to compare the coagulation status between patients who received ECMO and bridged VAD thereafter. METHODS: The cases for our study were collected between December 2005 and January 2010. A total of 21 patients with VAD were enrolled. Seven patients received initial ECMO support and were subsequently shifted to VAD. Use of blood transfusion products by patients was recorded during application of ECMO and VAD. Thrombelastography (TEG) was performed pre-ECMO and pre-VAD, and thereafter to 1 week post-VAD implantation. The relevant parameters that were examined included coagulation time (R: resting, K: kinetics, seconds), angle (α, degrees), maximal amplitude (MA, mm), clot strength (G, dynes/cm(2)), and estimated percent lysis in 30 minutes (LY30, %). Coagulation status and average unit per day of blood transfusion at pre-VAD and post-VAD status were recorded. TEGs of pre-VAD and post-VAD implantation were compared in order to determine the frequency of bleeding. RESULTS: Average results from seven cases were incorporated into the current analysis. The patient transfusion requirement was reduced after implantation of the VAD. The TEG of post-VAD implantation was improved from the earlier pre-VAD results (ECMO status). Ultimately, TEG resulted in significant differences in R, K, angle, MA, and G, postoperatively. CONCLUSION: Coagulopathy of patients with VAD improved after bridging from ECMO, which can be attributed to improved coagulation factor and platelet function. Thus, bleeding complications are reduced.