Czech TAVI registry – Hospital outcome

The first TAVI in the Czech Republic was performed in 2008 and since then, more than 90% of TAVI procedures have been involved in the online all comers Czech TAVI Registry. 1532 TAVI procedures from 2008 till June 2016 in a high risk population with symptomatic severe aortic stenosis (logistic EuroSCORE 18.2, median age 80 years) were relatively safe (in-hospital mortality 3.9%, severe paravalvular aortic regurgitation after TAVI 1.0%) and highly effective (index of aortic valve area before versus after TAVI was 0.4 cm²/m² versus 1.0 cm²/m², respectively). Majority of patients (83.7%) underwent TAVI because of their high risk for surgery assessed by the Heart team discussion and 71.9% of them were discharged home.     

Czech TAVI Registry—rationale and design

Aortic stenosis is the most common type of valve disease in the adults. Until recently its treatment was an exclusive domain of cardiac surgery. At the same time the aortic valve replacement (SAVR) was not indicated in about 1/3 of the patients, though the prognosis of conservatively treated patients is very unfavourable with one-year mortality rate of 50%. These facts were the main reasons for starting a new interventional era of the aortic valve disease therapy in 2002 and from 2007 two types of valves fixed in stents have been commercially available.In the early phase the transcatheter aortic valve implantation (TAVI) was used just in patients with contraindication to SAVR or with high perioperative risk after surgery. Before applying this therapy to less risky patients some problems have to be solved: 1. clinical impact of the relatively high rate of paravalvular leaks and 2. long-term function of the implanted valve in follow-up exceeding 5 years.In the Czech Republic the first TAVI was performed in Prague, IKEM in December 2008. During a short period of time the TAVI programme was initiated also in other complex cardiovascular centres in Hradec Kralove, Brno, Prague—FN Kralovske Vinohrady and Trinec. Including the later starting centres (Usti n. Labem, Olomouc, Ceske Budejovice and other three centres in Prague—Nemocnice na Homolce, FN Motol and VFN) there is a total of 11 centres providing the TAVI at present. All centres except one (FN Motol) are part of the Czech TAVI Registry that was developed with the support of the Czech Society of Cardiology and started on 1 September, 2010. In general and more theoretically there are two parts of the Registry: 1. “Retrospective” including all the TAVI procedures from the beginning of the TAVI programme in the Czech Republic that was terminated on June 30, 2011 and 2. “Prospective” that has been following. Institute of Biostatistics and Analyses of Masaryk University takes care of the online and anonymized database.The results of the national Czech TAVI Registry should help to answer the clinical relevant questions mentioned above.     

TAVI的应用进展及长期效果

经导管主动脉瓣置换术（Transcatheter Aortic Valve Implantation, TAVI）,通过股动脉、心尖或其他动脉途径送入导管,将人工心脏瓣膜输送至主动脉瓣区打开,从而完成人工瓣膜置换,恢复瓣膜功能。由于其手术无需开胸、创伤小、术后恢复快,即刻及中远期治疗效果显著,受到了目前心血管领域高度关注的新技术,引领了微创心脏外科的新革命。但也因其手术适应症窄,手术技术经验要求高,手术并发症多等因素,使其广泛应用于临床面临着诸多考验。本文对TAVI的应用进展及长期效果,包括适应证的选择、器械及手术入路和手术并发症及中-远期生存率作一综述。     

Fermeture des fuites para-prothétiques des TAVI

Literature concerning transcutaneous symptomatic para valvular cardiac leaks closure (PVLC) after trans aortic valve implantation (TAVI) is relatively scarce. Hereby we present 2 clinical cases, one on an Edwards® Sapien 3 valve and the other one on a Medtronic® Evolut R valve. We present also the preliminary results of the 7 PVLC on TAVI included in our prospective FFPP registry during the 2 first years of enrolment (2017–2018), for a total of 158 inclusions for all valves. Seven procedures were performed on 8 leaks, using a majority of vascular plugs (3 Abbott® Amplatzer Vascular Plugs 2 (AVP2), 3 AVP3, 1 AVP4, and 1 muscular Ventricular Septal Defect (VSD) occluder). All procedures were successful without complication. At 1-month follow-up, all patients became asymptomatic. One-year follow-up was already available for 4 patients: 3 of them were symptoms free, and one–who had a second leak not suitable for PVLC-, underwent a « TAVI in TAVI » procedure 2 months after PVLC. This short experience demonstrates the feasibility, the efficacy and the safety of PVLC on TAVI. We expect to be able to offer more in depth information at the end of our prospective ongoing study.     

Who is the right patient for TAVI?

Transcatheter aortic valve implantation (TAVI) has rapidly emerged as a valid therapeutic option for patients with severe symptomatic aortic stenosis who are high risk or ineligible for conventional surgical aortic valve replacement. Despite its minimally invasive nature, TAVI is invariably associated with complications in these old patients that may affect outcomes. Although the success of TAVI is determined by multiple factors, good screening and appropriate patient selection is crucial. Selection of the right patient includes the determination of risk levels and feasibility of a safe procedure in each individual case. Here, we describe below our critical appraisal of patient selection for TAVI.     

À quel patient proposer un TAVI en 2019 ?

The therapeutic management of aortic stenosis has been drastically changed by the advent of percutaneous valve replacement (TAVI). Since the first implantation, the indications have progressively been extended from the inoperable patient to the patient at low surgical risk. The main objective of this review is to describe the currently recommended main indications of TAVI depending on an individualized assessment of each patient's risk, technical characteristics and anatomical valvular criteria.     

Cardiac Rehabilitation After TAVI –A Systematic Review and Meta-Analysis

Despite the increasing popularity of Transcatheter aortic valve implantation (TAVI) in patients with high surgical risk, there is no current guideline for the management of patients following the intervention. This systematic review and meta-analysis aims to summarize and analyse all clinical data and evidence regarding the effectiveness and outcomes of CR following TAVI. The first meta-analysis measured the walked distance in the Six-Minute Walk Test (6MWT) and the second meta-analysis included studies that showed the Barthel Index (BI) before and after CR. The mean distance walked prior to CR was 235.88 ± 69.36 m increased to 292.12 ± 54.92 m after rehabilitation, signifying a moderate clinically relevant effect size (0.593 (0.42, 0.76); P=0.00). The mean BI score before CR was 76.6 ± 11.5 which increased to 89.8 ± 5.5 after the programme and similarly demonstrated a significant standardized mean improvement (0.75 (0.57, 0.93); I= 0.00). Exercise-based CR in patients with aortic stenosis treated with TAVI demonstrated a significant improvement in exercise tolerance and functional independence shown by the 6MWT and BI.     

TAVI:经股动脉径路的指征和结果

The average age of patients in Germany reporting first ever symptoms due to valvular heart disease （VHD） was （49＋9）years in 1965, （63 ±11 ） years in 1985, and （76±13） years in 2005. The increasing age went parallel with the change in etiology of VHD, with rheumatic mitral stenosis prevailing in 1965 and degenerative aortic stenosis （AS） in 2005.     

Les différentes prothèses pour le TAVI

Since the first human implantation of a percutaneous aortic valve in 2002, tavi prosthesis didn’t stop to improve their results. These improvements allowed to decrease dramatically tavi's complications and to extend the technic to patients with mid indeed low surgery risk. So tavi became the first treatment of aortic stenosis in France since a few years.     

TAVI chez les femmes,des résultats très encourageants

The population of elderly patients comprises a high percentage of women. This population is more vulnerable due to the presence of numerous comorbidities and is, therefore, particularly exposed to the risk of aortic valve degeneration, resulting in aortic valve stenosis whose symptoms are predictors of poor short-term outcomes. In the presence of symptomatic aortic stenosis, the recommended therapeutic option in this vulnerable population is the implementation of transcatheter aortic valve implantation, preferably via the femoral route. The outcomes of this procedure are better in women than in men despite a more frequent occurrence of vascular, bleeding and cerebral complications. Several hypotheses have been reported in the literature regarding the reasons for such differences. Among other reasons, it is likely that in female patients, the myocardium adjusts better to the occurrence of aortic stenosis and that recovery after valve treatment is also more optimal. Another explanation is the higher frequency of coronary artery disease in this older population. This has a considerable impact on the outcome even when coronary lesions are treated prior to valve implantation. There is still room for improvement and progress can be achieved by further reducing the size of the equipment used in order to decrease the diameter of the vascular access, and by continuing to simplify TAVI procedures. Less invasive techniques should result in decreased complication rates. In addition, dedicated studies should allow us to further improve our practice in this growing population of vulnerable patients.     

CT TAVI Planning技术在经导管主动脉置换术前的预测性研究

目的:探讨使用飞利浦CT TAVI Planning软件对主动脉瓣膜狭窄的患者在经导管主动脉置换术(TAVI)围手术期的术前指导价值,对主动脉进行综合测量评估,根据测量结果对TAVI瓣膜支架的型号进行预测性研究,并与术中经食道超声测量结果对比分析。方法:回顾性研究,搜集我院2017年1月至2019年6月经临床诊断严重主动脉瓣病变,并具有外科治疗的高危因素和手术禁忌证,最终行TAVI手术的患者32例,男性18例,女性14例,年龄68～84岁,平均年龄(70.82±6.07)岁,使用TAVI Planning软件测量主动脉瓣环、主动脉窦、窦管交界、主动脉瓣环下5 mm左心室流出道、窦管交界上方4 cm升主动脉、冠状动脉开口、主动脉窦高度及最佳投影角度,根据测量结果对患者手术瓣膜支架型号进行预测分析,计算CT预测准确率;根据经食道超声测量结果,计算超声预测准确率。结果:CT TAVI Planning软件测量主动脉瓣环直径大于经食道超声瓣环直径,CT预测准确率为87.5%,经食道超声预测准确率56.3%,将两者准确率使用卡方检验进行比较分析,差异有统计学意义(P均0.05)。将CT和超声测量主动脉瓣环直径建立ROC曲线,CT敏感度及特异度均高于经食道超声。结论:使用CT TAVI Planning软件进行主动脉CTA检查要优于经食道超声检查,可以为TAVI手术提供重要的参考价值。     

Oversizing, undersizing or just the right sizing for TAVI patients?

Background Postprocedural aortic regurgitations following transcatheter aortic valve implantation (TAVI) procedures remain an issue. Benefit of oversizing strategies to prevent them isn’t well established. We compared different level of oversizing in our cohort of consecutive patients to address if severe oversizing compared to normal sizing had an impact on post-procedural outcomes. Methods From January 2010 to August 2013, consecutive patients were referred for TAVI with preoperative Multislice-CT (MSCT) and the procedures were achieved using Edwards Sapien^? or Corevalve devices^?. Retrospectively, according to pre-procedural MSCT and the valve size, patients were classified into three groups: normal, moderate and severe oversizing; depending on the ratio between the prosthesis area and the annulus area indexed and measured on MSCT. Main endpoint was mid-term mortality and secondary endpoints were the Valve Academic Research Consortium (VARC-2) endpoints. Results Two hundred and sixty eight patients had a MSCT and underwent TAVI procedure, with mainly Corevalve^?. While all-cause and cardiovascular mortality rates were similar in all groups, post-procedural new pacemaker (PM) implantation rate was significantly higher in the severe oversizing group (P = 0.03), while we observed more in-hospital congestive heart-failure (P = 0.02) in the normal sizing group. There was a trend toward more moderate to severe aortic regurgitation (AR) in the normal sizing group (P = 0.07). Conclusions Despite a higher rate of PM implantation, oversizing based on this ratio reduces aortic leak with lower rates of post-procedural complications and a similar mid-term survival.     

Strukturelle und organisatorische Voraussetzungen zur Durchführung des Transkatheter-Aortenklappenersatzes (TAVI)

This paper summarises personal, organisational and structural requirements which seem necessary for performing TAVI procedures in a high quality manner. The recommendations are widely in line with the joint statement of the German Societies for Cardiology (DGK) and Heart Surgery (DGTHG) published earlier in this journal. Based on the analysis and interpretation of current registry data and the partner studies the following treatment modalities also seem acceptable: Well functioning cooperations between cardiologists, heart surgeons, anaesthesiologists and imaging specialists also apart from the so-called institutionalised or in-house heart surgery should be accepted as long as the given prerequisites are fulfilled. Patients who do not have a realistic option for heart surgery beyond a treatment for myocardial perforation or who strictly refuse heart surgery (possibly by a written statement) could also be treated in an optimally equipped catheterisation laboratory by an experienced team of cardiologists following the aforementioned definitions and criteria.     

Difficultés de cathétérisme coronaire après TAVI

PurposeCoronary catheterization after transcatheter aortic valve implantation (TAVR) may be challenging. The main objective of the study is to assess the feasibility of coronary catheterization and angioplasty according to each type of valve.Patients and methodWe retrospectively studied coronary angiography or percutaneous angioplasty procedures after TAVR in two different centers. The catheterization success of coronary artery was evaluated according to the quality of engagement in ostium and opacification of the artery. Other indicators were collected including catheters used, fluoroscopy and angiography times, DAP and the volume of the contrast agent.ResultsAmong 1512 TAVR procedures, 33 patients were included. The Sapien 3® valve was implanted in 22 patients and the Evolut® in 11 patients (7 Evolut-R® and 4 Evolut Pro®). Coronary angiography with selective or partially selective catheterization has been successfully performed in all patients with a Sapien 3® valve. In the Evolut® group we identified 3 cases of non-selective catheterization for the right coronary and 1 case for the left coronary. Standard Judkins catheters seem to be the most suitable for both types of valve with very good efficiency.ConclusionThe results of our study is promising for the future of TAVR with a coronary catheterization success rate close to 100% with some difficulties for the Evolut® supra-annular valves. Special attention should be paid to the technique of implantation and orientation of cups in the aortic sinus.