Catheterization and Cardiovascular Interventions最新文献

Background

A minimalist approach to transcatheter aortic valve replacement (TAVR) has accompanied the increase in TAVR procedures worldwide. Comprehensive evidence regarding the safety of non-anesthetist-led conscious sedation for TAVR is lacking.

Aims

We aimed to evaluate the outcomes of patients undergoing TAVR with non-anesthetist-led conscious sedation.

Methods

This retrospective analysis included consecutive patients who underwent percutaneous transfemoral TAVR with non-anesthetist-led conscious sedation, from March 2018 to 2025, in a single high-volume center. Thirty-day outcomes were assessed.

Results

Of 2854 patients who underwent TAVR, 2000 (70.1%) had non-anesthetist-led conscious sedation (age: 80.7 ± 6.5 years, 42.1% female). The annual proportion of non-anesthetist-led conscious sedation procedures increased from 37% (2018–2019) to 81% (2024–2025). Fentanyl was administered to 1986 (99.3%) patients (median: 75 mcg [IQR: 50–100]) and Midazolam to 945 (47.3%) patients (median: 1.5 mg [IQR: 1.0–2.0]). Mean procedural duration was 81.3 ± 67.7 min. Emergency anesthetic support was required for 53 (2.7%) patients, due to: vascular access complications (n = 15), cardiac arrest (n = 14), annular rupture/aortic dissection (n = 9), profound hypotension (n = 8), agitation (n = 4), ventricular perforation (n = 2) and reduced consciousness (stroke) (n = 1). Conversion to general anesthesia was required for 24 (1.2%) patients. Emergency bail-out surgery (cardiac/vascular) was undertaken in 15 patients (0.75%). Among the 2000 patients, 30-day mortality was 1.3%, and VARC-3 technical success, device success, and early safety were achieved in 97.2%, 92.7%, and 78.9% of patients, respectively.

Conclusions

Non-anesthetist-led conscious sedation can be delivered safely in most patients undergoing percutaneous transfemoral TAVR. The need for emergency anesthetic support is low.

Background

Valve-in-valve aortic valve implantation (ViV-TAVI) offers a less invasive treatment option for patients with a failing surgical bioprosthesis, avoiding the need for redo surgery. ViV-TAVI within a stentless bioprosthetic valve poses unique technical challenges. We report an international, multicentre experience evaluating procedural and clinical outcomes for patients undergoing ViV-TAVI for failed stentless bioprosthetic aortic valves.

Aims

To evaluate the procedural feasibility, safety, and clinical outcomes of ViV-TAVI performed for failed stentless bioprosthetic aortic valves in an international, multicentre cohort.

Methods

We retrospectively analysed 65 patients who underwent ViV-TAVI for stentless valve failure between 2010 and 2024. Outcome endpoints were based on the Valve Academic Research Consortium 3 (VARC-3) criteria.

Results

Sixty-five patients (mean age 78.8 ± 10.2 years; 66.1% male; mean STS-PROM 6.9 ± 4.7) were included. The mean interval between surgical valve implantation and failure was 12.9 ± 4.1 years, with regurgitation the predominant mechanism of valve dysfunction (52.3%). Procedural success was achieved in 92.3%. 17 patients (26.2%) had upfront coronary protection. Despite this, six patients required unplanned percutaneous coronary intervention (PCI) for coronary obstruction. The 30-day and 1-year mortality rate was 0% and 8% respectively.

Conclusions

ViV-TAVI was an effective intervention for patients with failing stentless bioprosthetic valves, with high procedural success rates despite unique technical challenges. Careful preprocedural imaging, planning, and implementation of coronary protection strategies are critical for optimal patient outcomes.

Background

One-year clinical and hemodynamic outcomes after transcatheter aortic valve replacement (TAVR) using the latest generation balloon-expandable valve (BEV) and self-expandable valve (SEV) is not well understood. This study is aimed to compare 1-year morality and hemodynamics between the latest generation BEV and SEV after TAVR.

Methods

We retrospectively analyzed 1393 patients undergoing TAVR using BEV (63.7%) (SAPIEN3 Ultra RESILIA) and SEV (36.3%) (Evolut FX). The incidence of all-cause mortality and bioprosthetic valve dysfunction (BVD) over 1-year were compared between BEV and SEV in both overall and propensity score (PS) matched cohort.

Results

During 1-year follow-up, the incidence of all-cause mortality was comparable between BEV and SEV in the overall (10.8% vs. 8.0%, log-rank p = 0.30) and PS matched cohort (11.0% vs. 8.9%, log-rank p = 0.40). The incidence of BVD through 1-year was also comparable between BEV and SEV in the overall (6.2% vs. 6.9%, p = 0.59) and PS matched cohort (6.7% vs. 8.2%, p = 0.55). Of BVD component, post-procedural mean pressure gradient more than 20mmH was higher in BEV, while para-valvular leakage more than moderate was higher in SEV. There was non-linear relationship between annulus size and BVD, in which TAVR with BEV had higher BVD in a small annulus, while SEV had higher BVD in a large annulus.

Conclusions

In TAVR using the latest generation valves, incidences of mortality and valve performance during 1-year were comparable between BEV and SEV. Whereas, the impact of annulus size on the difference of valve hemodynamics between BEV and SEV is still observed.

Background

Transcatheter edge-to-edge repair (TEER) is widely used for high-risk degenerative mitral regurgitation (DMR), but the range of leaflet lesions that can be managed with one single clip remains unclear. This study aimed to evaluate the range of leaflet lesions treatable with one clip during TEER in DMR patients.

Methods

We retrospectively analyzed intraoperative echocardiograms from 106 DMR patients undergoing TEER. Logistic regression was used to identify anatomical factors affecting satisfactory results after the first clip. Optimal cut-off values were determined using Receiver-operator characteristics (ROC) curve analysis and subsequently validated with follow-up data.

Results

Forty-three patients achieved satisfactory result after the first clip. Multivariate analysis identified prolapse width (p < 0.001) and prolapse gap (p = 0.039) as independent predictors for satisfactory result after the first clip. ROC analysis showed superior predictive value for prolapse width (AUC = 0.877 vs. 0.734). The optimal prolapse width cut-off value was 14 mm when the Youden index reached maximum value of 0.699 (sensitivity 0.746, specificity 0.953). Patients with width > 14 mm had significantly higher adverse event rates (Log-rank, Breslow, Tarone-Ware p = 0.007, 0.007, 0.006). Consistent results were also obtained in the subgroup of patients finished TEER with 1 clip (Log-rank, Breslow, Tarone-Ware p = 0.065, 0.030, 0.038).

Conclusions

Prolapse width is a key independent predictor of outcomes after the first clip implantation in TEER procedure. The incidence of postoperative severe adverse events is higher in patients with a prolapse width exceeding 14 mm, regardless of the number of clips implanted.

Background

Transcaval transcatheter aortic valve implantation (TAVI) is well described for patients with severe peripheral arterial disease. Conventionally, secondary arterial access via the femoral artery is used to allow bail-out stenting of the aortotomy site in case of complications. Transradial access may reduce the risk of complications related to the secondary access itself but prevents effective bail-out. We use the transradial approach for secondary access, accepting this risk.

Aim

We aim to report the feasibility and acute outcomes following transcaval TAVI with transradial secondary access.

Methods

All patients with transcaval TAVI performed from November 2016 to March 2024 at our center were identified. Patients with secondary access via the radial artery were included. The primary outcome was postprocedural mortality to hospital discharge. Secondary outcomes were the incidence of major vascular complications, bleeding, and stroke up to 72 h after the procedure.

Results

A total of 20 patients were included. Procedural success was achieved in all the patients. Ten (50%) patients received cerebral protection via the right radial artery in addition to left radial secondary access. All 20 patients had successful closure of the aortotomy with a 10/8 or 8/6 mm Amplatzer ductal occluder (Abbott, USA). No patient had major complications of the aortocaval shunt either during or after the procedure. No patient needed a bailout aortic intervention. There was one death (5%) secondary to peri-procedural stroke. Patients were usually discharged on the first postprocedural day.

Conclusions

Transcaval TAVI with transradial secondary access appeared to be safe. Bailout stenting is not possible but is rarely needed. Overall, procedural vascular risks are reduced.

Mitral regurgitation (MR) is common in patients undergoing transcatheter aortic valve replacement (TAVR). However, it is unclear how MR severity affects prognosis. This meta-analysis evaluated the associations among baseline MR severity, cardiovascular outcomes, and mortality after TAVR. Eligible studies included adult patients undergoing TAVR with stratified MR severity (MR ≥ 2 or MR ≥ 3) and reported the post-TAVR clinical outcomes. Sensitivity analyses stratified by follow-up duration, leave-one-out sensitivity, and meta-regression were also conducted. Forty-two studies (n = 67,257 patients) were included. MR ≥ 2 was associated with increased all-cause mortality during follow-up (> 30 days) (hazard ratio [HR]: 1.40; 95% confidence interval [CI]: 1.26, 1.55) and cardiovascular mortality (risk ratio [RR]: 1.80; 95% CI: 1.05, 3.08), but not with stroke, transient ischemic attack, myocardial infarction (MI), or heart failure hospitalization. MR ≥ 3 conferred an even higher risk of all-cause mortality during follow-up (RR: 1.55; 95% CI: 1.24, 1.94) and rehospitalization (RR: 1.40; 95% CI: 1.17, 1.67), but not for stroke and MI. MR improvement occurred in 41% of patients within < 1-year post-TAVR, declined to 15% at > 1-year post-TAVR. Baseline moderate-to-severe MR (MR ≥ 2) predicts all-cause mortality during follow-up and cardiovascular mortality after TAVR, particularly severe MR (MR ≥ 3). While no consistent associations were found with nonfatal outcomes such as stroke, TIA, MI, or heart failure hospitalization, the prognostic impact of MR appears to be predominantly mortality-centered.