Page 17 - Journal of Structural Heart Disease Volume 4, Issue 2

Original Scienti c Article
38
Table 4. Success rate and complications.
Device success
(%) no./total no. On table death (%) no./total no.
Emergency on table valve in valve implan- tation for severe AR (%) no./total no.
96.1(369/384) 0.8 (3/384) 3.1(12/384)
0.0 (0/383)
5.8 (23/384)
0.3 (1/383) 2.0 (8/383) 0.3 (1/383) 2.1 (8/384) 14.3 (55/384)
10.5 (40/381) 12.8 (48/381) 3.7 (14/383)
6.1 (23/377) 1.0 (4/380) 1.3 (5/384)
9.3 (36/384 15.2 (45/296)
PARTNER B (5.0%) [17] and PARTNER A (5.2%) [18] cohorts. Our 1-year mortality was 15.8%, which is comparable to rates in the overall UK TAVI registry, in which mortality was 21.4% at 1 year and 26.3% at 2 years [12].
While we do not advocate “routine use” of this technique, this minimalist method may represent an option for patients who present in an urgent or emer- gency setting. Our data suggest that reasonable re- sults can be obtained using this strategy. Indeed, one might hope for improved results now that reposition- able self-expanding prostheses are available.
Potential Roles for Primary TAVI
Bridging the acute aortic stenosis patient with balloon aortic valvuloplasty is often undertaken in the absence of full assessment, but this strategy is not ideal. While it may stabilize an acutely unwell patient, balloon aortic valvuloplasty is not a low-risk procedure. Contemporary data from the UK registry suggest a procedural complication rate of 6.3%, com- prising death (2.4%), blood transfusion ≥ 2 U (1.2%), cardiac tamponade (1.0%), stroke (1.0%), vascular surgical repair (1.0%), coronary embolism (0.5%), and permanent pacemaker (0.2%). In this registry, mortal- ity was 13.8% at 30 days and 36.3% at 12 months [6]. Furthermore, if primary TAVI is performed at the time of index admission, there would be no need for a sec- ond intervention, limiting patient risk and overall cost.
Two small-volume single-center studies support this idea. Landes et al. recently reported 27 cases of urgent TAVI in patients admitted with refractory and persistent heart failure despite optimal medical thera- py. Patients were more likely to be frail and have high- er Society of Thoracic Surgeons score or EuroSCORE. Pre-procedural assessment used fewer imaging mo- dalities, yet implantation success remained high and reached 96.3%, with no di erence in rate of peri-pro- cedural complications (VARC-2) compared with that among 342 elective patients. The patient groups had similar 30-day mortality rates and MACE [10].
Frecker et al. reported outcomes from 27 patients who underwent emergency TAVI presenting with car- diogenic shock due to acutely decompensated aor- tic stenosis. Three patients died within 72 hours of successful valve deployment, and a further six died within 1 month, giving a 30-day mortality of 33.3%,
TAVI N=384
Conversion to emergency open valve surgery
(%) no./total
In Hospital MACE
(In hospital death/MI/CVA)
(%) no./total
Post procedural VARC de ned complications (30-day)
Myocardial infarction (%) no./total CVA/TIA (%) no./total Device embolization (%) no./total Tamponade (%) no./total
no.
no.
no. no. no. no.
Conduction abnormality requiring pacing (%) no./total no. AR>2+ moderate/severe - TTE (%) no./total no. AR>2+ moderate/severe - angiographic (%) no./total no. Major and minor vascular access site injury (%) no./total no. Major and minor bleeding (%) no./total no.
Haemo ltration/dialysis (%) no./total no.
Subsequent valve in valve implantation (%) no./total no.
Death (%) no./total no.
30 day (%) no./total no. 1 year (%) no./total no.
CVA = cerebrovascular accident; TIA = transient ischaemic attack; AR = aortic regurgitation; TTE = transthoracic echocardiogram
Principle Findings
Within our patient cohort, 30-day mortality was 9.3%. This is comparable to rates in other historical registries: 7.1% in the UK TAVI registry [12], 10.4% in the Canadian registry [13], 8.5% in the SOURCE regis- try [14], 12.7% in the FRANCE registry [15], and 8.2% in the German registry [16]. Our all-comer results are also similar to those achieved in the randomized
Journal of Structural Heart Disease, April 2018
Volume 4, Issue 2:33-41