Prevalence of noncardiac findings in computed tomography angiography before transcatheter aortic valve replacement

ObjectiveThis study sought to determine the prevalence of significant and nonsignificant noncardiac findings in patients undergoing preprocedural dual-source CT (DSCT) before transcatheter aortic valve implantation (TAVI).MethodsPatients (n = 204; aged, 80.5 ± 5.1 years; 106 men) underwent preprocedural DSCT of the thoracoabdominal aorta and the pelvic arterial vessels. Noncardiac findings were recorded and categorized as nonsignificant (group A), incidental findings requiring follow-up examinations (group B), and significant findings with a demand for clinical treatment (group C).ResultsIn 60 of 204 DSCT examinations (29.4%) no noncardiac findings were observed. Of the remaining 144 examinations (70.6%), 260 had noncardiac findings; 35 of 204 patients (17.1%) had a total of 37 clinically significant noncardiac findings. Eight malignancies were detected; 5 of them were incidentally diagnosed on DSCT and changed patient management. A total of 223 nonsignificant findings were observed in 116 of 204 patients (56.9%; group A), the most frequent findings were pleural effusions or colorectal diverticulosis. The prevalence of incidental and significant findings on DSCT before TAVI increased with patient age (r² = 0.69; P = .01).ConclusionSignificant noncardiac findings are common in patients referred to routine preprocedural DSCT for planning TAVI (17.1%).     

Surgical treatment of advanced heart failure: alternatives to heart transplantation and mechanical circulatory assist devices

Although orthotopic heart transplantation is the gold standard for definitive surgical treatment of end-stage heart failure, other operative therapies exist for dealing with severe systolic left ventricular dysfunction. The choice of surgical intervention depends on the etiology and functional characteristics of the patient's ventricular dysfunction. In patients with ischemic cardiomyopathy, surgical revascularization improves survival. Patients with mitral regurgitation experience significant functional improvement from mitral valve repair and replacement. In patients with aortic valve dysfunction, aortic valve replacement results in improved survival and functional status. Although surgical ventricular reconstruction is controversial, significant data exist suggesting that it is an effective therapy in a subset of patients with left ventricular dysfunction. Finally, passive restraint devices are effective at halting further ventricular dilation. Although cardiac surgery in patients with severe ventricular dysfunction can be complicated by significant morbidity and mortality, experienced centers have demonstrated acceptable outcomes in carefully selected patients.     

Implications médicolégales de l’implantation transcathéter de la valve aortique (TAVI)

Compassionally reserved for inoperable patients in 2002, Transcatheter Aortic Valve Implantation has now a place almost equivalent to surgical valve replacement. The pioneering teams first succeeded in demonstrating a benefit on the mortality of extremely serious patients, while managing a learning curve that seemed unreachable without a strong partnership with cardiac surgeons. This win/win challenge enabled cardiologists to surpass the limits they did not dare to brave (management of large arterial approach, annular rupture and tamponade) and surgeons to appropriate the endovascular's culture. The technological contribution, the maturity of the teams and the expansion to less severe populations have reduced the perioperative mortality of TAVI to less than 3%. At this stage, it seemed interesting to take stock of forensic developments around this technique. After a review of the studies and the healthcare requirements, we reported and analyzed the claims received from one of the leaders of the medical insurance in France. From this feedback, attempts will be made to identify ways of improving the prevention and subsequent treatment of complications, which will undoubtedly limit the risk of subsequent complaints.     

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.     

Same day discharge after transcatheter aortic valve replacement: Are we there yet?

Early discharge after transcatheter aortic valve replacement (TAVR) has been increasingly reported, and is now becoming routinely performed in experienced TAVR centers. However, to the best of our knowledge, no case has been described where a patient was safely discharged on the same the day of the procedure. This report will present the case of a patient who underwent a successful transfemoral TAVR and was safely discharged home the same day. Specific requirements and criteria are proposed to ensure the safety of this approach. © 2015 Wiley Periodicals, Inc.     

Single-source dual energy CT to assess myocardial extracellular volume fraction in aortic stenosis before transcatheter aortic valve implantation (TAVI)

PurposeTo assess myocardial extracellular volume fraction (ECV) measurement provided by a single-source dual-energy computed tomography (SSDE-CT) acquisition added at the end of a routine CT examination before transcatether aortic valve implantation (TAVI) compared to cardiac magnetic resonance imaging (MRI).Materials and methodsTwenty-one patients (10 men, 11 women; mean age, 86 ± 4.9 years [SD]; age range: 71–92 years) with severe aortic stenosis underwent standard pre-TAVI CT with additional cardiac SSDE-CT acquisition 7 minutes after intravenous administration of iodinated contrast material and myocardial MRI including pre- and post-contrast T1-maps. Myocardial ECV and standard deviation (σECV) were calculated in the 16-segments model. ECV provided by SSDE-CT was compared to ECV provided by MRI, which served as the reference. Analyses were performed on a per-segment basis and on a per-patient involving the mean value of the 16-segments.ResultsECV was slightly overestimated by SSDE-CT (29.9 ± 4.6 [SD] %; range: 20.9%–48.3%) compared to MRI (29.1 ± 3.9 [SD] %; range: 22.0%–50.7%) (P < 0.0001) with a bias and limits of agreement of +2.3% (95%CI: −16.1%– + 20.6%) and +2.5% (95%CI: −2.1%– + 7.1%) for per-segment and per-patient-analyses, respectively. Good (r = 0.81 for per-segment-analysis) to excellent (r = 0.97 for per-patient-analysis) linear relationships (both P < 0.0001) were obtained. The σECV was significantly higher at SSDE-CT (P < 0.0001). Additional radiation dose from CT was 1.89 ± 0.38 (SD) mSv (range: 1.48–2.47 mSv).ConclusionA single additional SSDE-CT acquisition added at the end of a standard pre-TAVI CT protocol can provide ECV measurement with good to excellent linear relationship with MRI.