Access Options for Transcatheter Aortic Valve Replacement in Patients with Unfavorable Aortoiliofemoral Anatomy

In the current era, 10–15 % of transcatheter aortic valve replacement (TAVR)-eligible high and prohibitive risk patients with severe symptomatic aortic stenosis are not candidates for transfemoral arterial access. Knowledge of the various alternative access options can enable TAVR teams to provide improved quality of life and potentially life-saving treatment for a group of patients who otherwise have no viable options. In this article, we review approach to patients with unfavorable femoral arterial anatomy and provide an in-depth discussion on the various alternative routes for TAVR.     

Feasibility of Coronary Access and Aortic Valve Reintervention in Low-Risk TAVR Patients

ObjectivesThe aim of this study was to evaluate the feasibility of coronary access and aortic valve reintervention in low-risk patients undergoing transcatheter aortic valve replacement (TAVR) with a balloon-expandable transcatheter heart valve (THV).BackgroundYounger, low-risk TAVR patients are more likely than older, higher risk patients to require coronary angiography, percutaneous coronary intervention, or aortic valve reintervention, but their THVs may impede coronary access and cause coronary obstruction during TAVR-in-TAVR.MethodsThe LRT (Low Risk TAVR) trial (NCT02628899) enrolled 200 subjects with symptomatic severe aortic stenosis to undergo TAVR using commercially available THVs. Subjects who received balloon-expandable THVs and who had 30-day cardiac computed tomographic scans were included in this study. In a subgroup, the feasibility of intentional THV crimping on the delivery catheter to pre-determine commissural alignment was tested.ResultsIn the LRT trial, 168 subjects received balloon-expandable THVs and had 30-day cardiac computed tomographic scans, of which 137 were of adequate image quality for analysis. The most challenging anatomy for coronary access (THV frame above and commissural suture post in front of a coronary ostium) was observed in 9% to 13% of subjects. Intentional THV crimping did not appear to meaningfully affect commissural alignment. The THV frame extended above the sinotubular junction in 21% of subjects, and in 13%, the distance between the THV and the sinotubular junction was <2 mm, signifying that TAVR-in-TAVR may not be feasible without causing coronary obstruction.ConclusionsTAVR may present challenges to future coronary access and aortic valve reintervention in a substantial number of low-risk patients.     

CoreValve bioprosthesis dysfunction treated with a Sapien 3 valve-in-valve transcatheter aortic valve replacement and BASILICA technique

Structural deterioration of transcatheter heart valve (THV) has been previously described. With the expansion of transcatheter aortic valve replacement (TAVR) indications toward treating lower risk patients with longer life expectancy, there will be increased necessity of managing the patients with THV dysfunction including those at risk for coronary obstruction or sinus sequestration. Coronary access also remains a challenge in such cases with THV dysfunction undergoing valve-in-transcatheter heart valve (ViTHV) TAVR. A unique and first reported case of THV deterioration treated with Sapien 3 ViTHV-TAVR inside a 31 mm CoreValve bioprosthesis along with left coronary leaflet laceration using the BASILICA technique has been presented.     

Successful implantation of the edwards sapien THV via direct aortic access in a patient with previous pneumonectomy and no other access

The Edwards Sapien transcatheter heart valve (THV) is available for treatment of severe symptomatic aortic stenosis via transfemoral access or trans‐apical access when ilio‐femoral vessels are considered unsuitable. Some patients, however, may be unsuitable for access via either of these routes. We describe successful implantation of an Edwards Sapien THV via direct access of the ascending aorta in a patient with previous right pneumonectomy and pulmonary disease who was considered unsuitable for implantation via femoral vessels or via trans‐apical approach. The potential advantages of this novel access route over trans‐apical approach are discussed. © 2011 Wiley Periodicals, Inc.     

Excellent Outcomes for Transcatheter Aortic Valve Replacement Within 1 Year of Opening a Low-Volume Centre and Consideration of Requirements

BackgroundAfter the approval of transcatheter aortic valve replacement (TAVR) for high-risk or inoperable patients with severe aortic stenosis (AS), many low- and moderate-volume TAVR programs were initiated. Contemporary outcomes from these newly initiated centres remain unknown.MethodsIn March 2013, our institution was authorized by the Québec Ministry of Health to perform 30 TAVR procedures. After thorough clinical screening and imaging evaluation, suitable patients underwent transfemoral TAVR with the balloon-expandable SAPIEN XT (Edwards Lifesciences, Irvine, CA) transcatheter heart valve (THV). In-hospital and 30-day outcomes were prospectively collected and reported according to Valve Academic Research Consortium 2 guidelines.ResultsFrom April 2013 to January 2014, 30 consecutive high-risk (n = 16 [53.3%]) or inoperable (n = 14 [46.7%]) patients (mean age, 84.6 years; mean Society of Thoracic Surgery score, 7) with symptomatic severe AS underwent transfemoral TAVR. No catastrophic intraprocedural complications such as annulus rupture, valve embolization, aortic dissection, or coronary occlusion occurred, and there were no deaths at 30 days. Disabling stroke occurred in 1 (3.3%) patient 48 hours after THV implantation. Major vascular complications and major bleeding occurred in 1 (3.3%) patient. No moderate or severe paravalvular leak was observed. The median length of stay was 2 (1-3) days, with 8 (26.7%) patients discharged within 24 hours after the procedure.ConclusionsExcellent outcomes can be achieved in newly initiated relatively low-volume centres, which compares favorably to previously published large series. Important considerations include appropriate team training, rigorous patient screening, use of multimodality imaging techniques, a heart team approach, constant integration of lessons learned from larger published experiences, and maintaining a recommended minimum volume of 25 cases per year.     

Unilateral Access Is Safe and Facilitates Peripheral Bailout During Transfemoral-Approach Transcatheter Aortic Valve Replacement

ObjectivesThe aim of this study was to compare the rate and trend of vascular complications when placing a second arterial sheath in the contralateral femoral artery during transcatheter aortic valve replacement (TAVR) unilaterally versus bilaterally.BackgroundVascular complications occur in approximately 5% to 8% of TAVR procedures. Many operators place a second arterial sheath in the contralateral femoral artery to perform aortic root angiography. The authors surmised that placing the second sheath ipsilateral and distal to the delivery sheath would be an easier option with similar safety.MethodsThe Cleveland Clinic Aortic Valve Center TAVR database was accessed, and data for patients undergoing transfemoral TAVR (TF-TAVR) from January 2014 to December 2017 were analyzed retrospectively. The primary outcome was the rate of peripheral vascular complications.ResultsA total of 1,208 patients who underwent TF-TAVR were included in this study. One thousand seven patients (83.36%) underwent bilateral femoral access, and 201 patients (16.64%) underwent TF-TAVR using a unilateral femoral approach. Over the study duration, use of the unilateral access approach trended upward significantly, reaching 43.7% of total cases in 2017. A gradual decline in access site–related vascular complications was observed, from 13.7% in 2014 to 7.4% in 2017. After propensity-score matching, peripheral vascular complications were similar between bilateral access and unilateral access (10.8% vs. 8.6%) (p = 0.543).ConclusionsThere was a significant decline in vascular complications from 2014 to 2017. Unilateral-access TF-TAVR provided similar safety compared with bilateral-access TF-TAVR and is a more accessible approach for managing access site–related complications and possibly achieving better patient satisfaction.     

Right subclavian approach in transcatheter aortic valve implantation using the CoreValve prosthesis

Typically, transfemoral access using the self-expanding CoreValve Revalving System is the initial default strategy in patients undergoing transcatheter aortic valve implantation (TAVI). Subclavian access is a potential alternative to the femoral route in patients with peripheral vascular disease. The left subclavian is preferred due to the favourable orientation of the delivery system through the aortic arch and annulus. However, right subclavian access may also be feasible in cases with specific anatomical conditions of the aortic root and valve annulus. We present a case where TAVI using the CoreValve prosthesis was performed via right subclavian artery with good 1 year outcome.     

Simultaneous thoracic aortic endovascular graft and transfemoral transcatheter aortic valve replacement in a patient with a descending aortic thrombus

Severe descending thoracic and abdominal aortic pathology can deter consideration of transfemoral (TF) access for transcatheter aortic valve replacement (TAVR) in adults with severe symptomatic aortic stenosis (AS) and may lead to utilization of alternative access sites. We report a case of an 88-year-old frail woman with severe symptomatic AS referred for TAVR with demonstration of a large thrombus in the descending thoracic aorta immediately distal to the left subclavian artery. Given concerns of thrombus embolization with femoral advancement of the transcatheter valve, coverage with a thoracic aortic endograft was planned immediately prior to the TAVR.     

The alternative approach to transcatheter aortic valve replacement

• An alternative route for transcatheter aortic valve replacement (TAVR) is needed whenever transfemoral vascular access is not feasible.
• The choice of alternative access differs between centers and depends mainly on the operators' preferences and site‐specific expertise of the “heart team.”
• In a multi‐center Italian Registry, the alternative access site (transapical vs. trans‐subclavian) was not an independent predictor of short‐ or long‐term mortality.

     

Iliofemoral artery predilation prior to transfemoral transcatheter aortic valve implantation in patients with aortic valve stenosis and advanced peripheral artery disease

Objectives

To investigate the feasibility and safety of percutaneous transluminal angioplasty (PTA) of the iliofemoral arteries (IFA) before transfemoral transcatheter aortic valve implantation (Tf-TAVI) in patients with advanced peripheral artery disease (PAD).

Background

Although Tf-TAVI represents the access of choice, alternative vascular access routes are preferred for patients displaying advanced PAD. PTA of the IFA represents a less invasive option, broadening the spectrum of patients eligible for Tf-TAVI.

Methods

All patients requiring PTA of the IFA before Tf-TAVI, between 2012 and 2021, were included. Primary efficacy endpoint was the rate of successful transcatheter heart valve (THV) delivery and implantation. Primary safety endpoint was the rate of PTA and access-site-related vascular complications, procedural- and in-hospital complications.

Results

Among 2726 Tf-TAVI procedures, 59 patients required IFA predilation. Successful THV delivery and implantation was achieved in 57 (96.6%) patients, respectively. Sheath placement was achieved in 59 (100%) patients with only one minor dissection and no major vascular complications following iliofemoral PTA. Regarding access site complications, two (3.4%) vessel perforations and one (1.7%) vessel rupture were observed, with eight (13.5%) patients requiring unplanned endovascular interventions. There was one intraprocedural death due to THV-induced vessel laceration, while in-hospital all-cause mortality was 8.5% in the present high-risk patient cohort.

Conclusions

Predilation of IFA is safe and effective in patients with advanced PAD. Careful preprocedural planning is paramount in improving procedural safety and efficacy. This strategy has the potential to broaden the spectrum of patients eligible for Tf-TAVI.     

Carotid artery access for transcatheter aortic valve replacement

We report three patients who had successful transcatheter aortic valve replacement (TAVR) via carotid artery access. None were candidates for thoracotomy (including minimal access incisions) and had no other vascular access sites that would accommodate the transcatheter valve sheath. Antegrade carotid perfusion and retrograde insertion of the delivery sheath maintained cerebral blood flow without sequelae. Carotid access for TAVR is an option for unusual patients without other access. © 2012 Wiley Periodicals, Inc.     

Device closure of paravalvular defects following transcatheter aortic valve replacement with the Edwards Sapien valve

Paravalvular aortic insufficiency (AI) is observed in the majority of patients undergoing transcatheter aortic valve replacement (TAVR). While paravalvular AI is most commonly modest following TAVR, moderate or severe AI was seen in 10.5% and 6.8% of the PARTNER inoperable and high‐risk cohorts at 1 year and has been reportedly associated with dyspnea and diminished survival. We report two cases of transcatheter heart valve (THV) associated paravalvular defects closed using catheter delivered devices. Both patients derived hemodynamic and symptomatic improvement from device closure. Additional research is warranted to define the adverse consequences of THV associated AI, indications for treatment, and risks associated with device closure of these defects. © 2012 Wiley Periodicals, Inc.     

Subclinical leaflet thrombosis following transcatheter aortic valve replacement

Since the inception of transcatheter aortic valve replacement (TAVR), there have been significant reductions in complications due to improvements of transcatheter heart valve (THV) designs and technologies. Given expanding TAVR applications, reducing complications further and better understanding THV durability has become a focus within the structural heart space. Recently, dedicated cardiac computed tomographic angiography (CTA) performed at 1 month post‐TAVR has identified subclinical leaflet thrombosis (SLT), with rates as high as 40%. From the SLT imaging hallmarks of hypoattenuated leaflet thickening (HALT) to hypoattenuation affecting motion (HAM), a postulated timeline of THV thrombosis advancing to clinical symptoms can be recognized. This review article focuses on leaflet thrombosis particularly following TAVR explaining the spectrum of this disease process, its diagnosis, current treatment options, and future directions in the field.

     

Successful minimal approach transcatheter aortic valve replacement in an allograft heart recipient 19 years post transplantation for severe aortic stenosis: A case report

BACKGROUND Aortic stenosis is one of the rare valvular complications in a transplanted heart.Over the past 8 years, transcatheter approach for aortic valve replacement(TAVR) has been slowly evolving to be the preferred approach in these patient population when compared to the surgical approach. We report a second case in the United States with successful transfemoral minimal approach with minimal sedation for TAVR in a heart transplant recipient 19 years post transplantation for severe symptomatic calcified aortic stenosis.CASE SUMMARY We present a case of 73-year-old male who has undergone successful minimal approach transcatheter aortic valve replacement in an allograft heart. Patient had received orthotopic heart transplantation 19 years ago for non-ischemic cardiomyopathy. Follow up transthoracic echocardiograms as per routine protocol did not show any aortic valve disease until 15 years post transplantation.Aortic valve was noted to be mildly sclerotic at that time and gradually progressed to severe symptomatic aortic stenosis over the next 4 years. Patient had complaints of worsening shortness of breath that limited his functional capacity. Overall his post heart transplantation period has been mostly uneventful except for allograft non occlusive vasculopathy and aortic stenosis.His Society of Thoracic Surgery risk score was 12.205% and he was considered to be a high-risk surgical candidate by surgeon. Decision was made to undergo transcatheter aortic valve replacement.CONCLUSION With the improved survival of these patients, we think it is time to look intopathophysiology of valvular disease in transplant heart recipients. Some other unanswered questions include, underlying donor and recipient risk factors for valvular diseases in heart transplant recipients.     

Outcomes After Transcatheter Aortic Valve Replacement Using a Novel Balloon-Expandable Transcatheter Heart Valve: A Single-Center Experience

ObjectivesEvaluation of 30-day outcomes after transcatheter aortic valve replacement (TAVR) with the novel balloon-expandable SAPIEN 3 (S3) transcatheter heart valve (THV) (Edwards Lifesciences, Irvine, California) emphasizing the updated Valve Academic Research Consortium (VARC-2) criteria.BackgroundPreliminary data on clinical performance with the S3 THV are promising. However, information regarding 30-day outcome is limited.MethodsA total of 250 consecutive patients undergoing transfemoral TAVR with the S3 THV at our center were enrolled, and outcomes according to VARC-2 criteria were analyzed at 30 days.ResultsThe mean age was 81.0 ± 6.2 years, median logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) and Society of Thoracic Surgeons score were 12.1% and 4.4%, respectively. VARC-2–defined device success was achieved in 244 patients (97.6%); moderate paravalvular leakage developed in 5 patients (2.0%). One patient (0.4%) died of a noncardiac cause and 8 patients (3.2%) had a stroke. Life-threatening bleeding and major vascular complications occurred in 12 (4.8%) and 9 (3.6%) of the patients, respectively. From discharge to 30 days, 5 patients (2.0%) were hospitalized due to valve-related symptoms or worsening of heart failure. The VARC-2 composite early safety endpoint was observed in 25 patients (10.0%). Permanent pacemaker implantation rate at 30 days was 15.2%. Myocardial infarction, coronary obstruction requiring intervention, valve-related dysfunction, and endocarditis were not observed.ConclusionsWe found very good 30-day results using the novel S3 THV with a low rate of clinical events according to VARC-2 criteria. The S3 THV is associated with high procedural success and favorable early safety profile. The need for pacemaker implantations appears to be more frequent than with its predecessor.     

Prophylactic Retrograde Distal Common Femoral Access as a Bail-out Strategy in Patients with Increased Risk for Femoral Access Complication During Transfemoral Aortic Valve Replacement

ObjectiveSeveral patients undergoing transfemoral transcatheter aortic valve replacement (TAVR) have complex peripheral arterial disease (PAD) that increases risk of vascular complications and failure of vascular closure device (VCD). Endovascular bailout of failed VCD is performed through contralateral femoral access. Further due to multiple different anatomic reasons the contralateral femoral access and “up and over” approach is unavailable for endovascular bailout of the VCD failure. We evaluated a novel bailout technique of obtaining an additional access in ipsilateral common femoral artery (CFA) or superficial femoral artery (SFA) distal to the main CFA access used for TAVR device.MethodsWe prospectively identified patients who were at high risk for VCD failure and had unavailable contralateral CFA approach from the pre-TAVR evaluation with multislice CT angiography. The data was collected prospectively for the TVT registry and retrospectively reviewed. All patients had an additional distal access obtained in the CFA or proximal SFA under direct fluoroscopy guidance after achieving main CFA access for TAVR. Using an inner 0.021″ micro-dilator from the 4-Fr micropuncture mini stick max access kit (AngioDynamics, Marlborough, MA) and a 200 cm long 0.018″ wire, the distal access was secured in place through the TAVR procedure. After completing the TAVR if the VCD gained successful hemostasis, the 0.021″ dilator was removed with manual pressure. If the VCD failed to achieve hemostasis, the distal access was upsized to a 7 Fr sheath for carrying out endovascular repair of the TAVR access. If the distal access was upsized to 7 Fr, that access was treated with VCD. The patients were monitored for acute in-hospital complication and followed for 6 months.ResultsDuring 2017 & 2018, 97.4% of 186 TAVRs were performed via femoral approach at our center. Six patients met the criteria for high-risk access and non-availability of the contralateral “up and over” approach. Of the 6 patients enrolled in this prospective study, 3 required endovascular management of TAVR access because of failed VCDs and were treated with covered stents using the distal ipsilateral access. The remaining 3 patients had successful use of VCDs for the TAVR access and the prophylactic access with 0.021″ dilator was managed with manual pressure. None of the six patients suffered any further vascular complication or bleeding. At the 6-month follow up no vascular complications or clinically driven events were identified from the TAVR access or additional distal ipsilateral access.ConclusionThis novel technique of prophylactic ipsilateral distal femoral access can provide an alternative bailout strategy for patients at high risk of closure device failure and unavailable contralateral femoral approach during transfemoral TAVR.     

Current status of transcatheter aortic valve replacement

Surgical aortic valve replacement (SAVR) has long been the mainstay of therapy for severe aortic stenosis. However, transcatheter aortic valve replacement (TAVR) is now generally accepted as the new standard of care for patients with symptomatic aortic stenosis who are not candidates for open surgery. Arguably TAVR may also be a preferred alternative to SAVR in carefully selected high-risk, but still operable, patients in whom morbidity and mortality may be reduced. Although TAVR outcomes continue to improve, concerns remain with respect to vascular injury, stroke, paravalvular regurgitation, and valve durability. However, it seems likely that with ongoing refinement of transcatheter valve systems, techniques, and patient selection TAVR is becoming an increasingly appealing option for a much broader range of patients. Randomized trials and ongoing surveillance will play an important role as we enter a new era of rigorous clinical evaluation for minimally invasive therapies for structural heart disease.     

Ischemic colitis after transcatheter aortic valve implantation

Transcatheter aortic valve implantation is a novel therapeutic approach for high‐risk patients with severe symptomatic aortic stenosis. The success rate of this new procedure is high; however, it is associated with issues such as vascular access site complications and embolization related to the advancement of a large bore delivery catheter through the femoral and iliac arteries and aortic arch. Using the Edwards SAPIEN transcatheter heart valve, we describe a case of transfemoral catheter aortic valve implantation complicated by a mobile mass attached to the valve, probable due to atherosclerotic plaque from the aorta. Shortly thereafter, the patient presented with ischemic colitis and subsequently died. © 2012 Wiley Periodicals, Inc.     

Balloon Expandable Sheath for Transfemoral Aortic Valve Implantation: A Viable Option for Patients with Challenging Access

Background and Objectives

Transcatheter aortic valve replacement (TAVR) via femoral access is a new option for patients with severe aortic valve stenosis considered to be at high risk for conventional open‐heart surgery. This procedure requires peripheral arteries that are able to accommodate the large sheaths required for valve delivery. We present a series of patients with suboptimal vascular conditions, who received a self‐expandable vascular sheath.

Methods and Results

From January 2009 to September 2011, a total of 96 patients (43% male) were treated with the 18F Medtronic CoreValve (Medtronic, Minneapolis, MN, USA). The patients' average age was 82.5 ± 4.6 years, and the mean EuroSCORE was 29%. In eight cases, vascular conditions were inadequate either due to advanced atherosclerotic disease (n = 5, 62.5%), or an arterial diameter ≤7 mm (n = 3, 37.5%). Instead of the standard 18F sheath, a balloon‐expandable transfemoral introducer (SoloPath?‐Introducer, Onset Medical Corporation, Irvine, CA, USA) was delivered and removed without complications in all but one (87.5%) patient. In the last case, rupture of the right femoral artery occurred after removal of the sheath with the need of vascular surgery.

Conclusion

The SoloPath sheath is a feasible alternative to conventional sheaths for transfemoral TAVR patients with difficult femoral vascular access.

     

经股动脉经导管主动脉瓣置换术治疗单纯主动脉瓣关闭不全

【摘要】 目的 探讨Venus-A支架瓣膜行经股动脉经导管主动脉瓣置换术治疗单纯主动脉瓣关闭不全患者的可行性。方法 回顾性调阅2018年12月至2019年12月在阜外医院接受经股动脉经导管主动脉瓣置换术的15例单纯主动脉瓣关闭不全患者的床资料。其中男性12例, 女性3例,年龄68—83岁,平均年龄(74.65±5.52)岁。患者术前均有左心功能不全症状,且术前心脏超声诊断均为单纯主动脉瓣重度返流。结果 患者行经股动脉经导管主动脉瓣置换术。所有病例成功植入Venus-A支架瓣膜。全组病例无死亡。出院前对患者进行临床评估和超声心动图检查。术中行瓣中瓣治疗3例,少量瓣周返流2例。其余病人均无明显瓣周返流,并且顺利出院。结论 经股动脉经导管主动脉瓣置换术治疗单纯主动脉瓣关闭不全患者是可行的,术后早期结果满意。