Elsevier

American Heart Journal

Volume 160, Issue 2, August 2010, Pages 237-243
American Heart Journal

Clinical Investigation
Valvular and Congenital Heart Disease
Transcatheter aortic valve implantation for severe aortic stenosis—a new paradigm for multidisciplinary intervention: A prospective cohort study

https://doi.org/10.1016/j.ahj.2010.05.014Get rights and content

Background

Transcatheter aortic valve implantation (TAVI) is an alternative treatment option for patients with aortic stenosis deemed high risk or unsuitable for aortic valve replacement. The aim of this study was to assess the feasibility of TAVI in elderly patients, the delivery of this technology with a multidisciplinary approach, and the use of traditional surgical scoring systems.

Methods

One hundred fifty-one consecutive patients (mean age 82.6 ± 7.3 years) with severe aortic stenosis underwent TAVI with the Edwards Lifesciences (Irvine, CA) Sapien bioprosthesis using the transapical (n = 84; 56%) or transfemoral (n = 67; 44%) approach from August 2007 to September 2009 at King's Health Partners, London, United Kingdom. We analyzed procedural outcome, complications, functional status, and midterm outcome of patients.

Results

The multidisciplinary team comprised interventional cardiologists, cardiothoracic surgeons, imaging specialists, cardiac anesthetists, and specialist nurses. Seventy percent of patients were in New York Heart Association class III/IV, and logistic EuroSCORE was 21.6 ± 11.9. Procedural success was achieved in 98%. Postoperative complications included stroke (6%), complete atrioventricular block (5.3%), renal failure requiring hemofiltration (9.3%), and vascular injury (8.6%). Overall 30-day mortality was 9.9% (n = 15). The logistic EuroSCORE was a predictor of short-term mortality (logistic regression model, P < .05). Thirty-day mortality post-TAVI for patients with logistic EuroSCORE <20, 20 to 40, and >40 was 5.4%, 13.2%, and 22.2%, respectively.

Conclusions

Transcatheter aortic valve implantation is a feasible treatment option in this patient group with promising short/medium-term results. Renal failure is the commonest short-term complication, and the incidence of vascular complications remains high. Risk prediction/case selection remains challenging, and a multidisciplinary team approach appears to be helpful in appropriate patient selection.

Section snippets

Patient population

The study is based on a registry prospectively including all patients undergoing TAVI at King's Health Partners from August 2007 to September 2009. Transcatheter aortic valve implantation has been approved for use in patients with symptomatic severe AS who are deemed unfit for conventional, surgical aortic valve replacement (logistic EuroSCORE >20 or Society of Thoracic Surgeons (STS) score >10% or turned down by 2 separate cardiothoracic surgeons). The United Kingdom National Institutes for

Results

The baseline clinical characteristics are shown in Table I. Most patients were >75 years old (87.4%, mean age 82.6 years). Echocardiographic features are consistent with severe AS in all cases: mean peak pressure gradient of 79.2 ± 25.5 mm Hg, mean gradient of 49.7% ± 11.5%, and mean aortic valve orifice area of 0.62 ± 0.16 cm2. The majority had isolated AS with concomitant mitral regurgitation (≥moderate) and aortic regurgitation (≥moderate) in only 16% and 10.6%, respectively. Most patients

Discussion

Percutaneous catheter-based approaches to the treatment of valve disease have been studied in animal models for several years, but it was Bonhoeffer et al9 who performed the first human percutaneous valve implantation (in the pulmonary position) in 2000. Aortic valve implantation was achieved shortly after this in 2002 by Alan Cribier.10 The Edwards-Sapien bioprosthesis has now been approved for clinical use in the European Union and preliminary guidance for its use has been published by the

Acknowledgements

We would like to thank our cardiac anesthetic colleagues Dr Emma Alcock, Dr Kailasam Rajagopal, Dr Amit Chawla, and Dr Andrej Wielogorski for their expert clinical assistance with these challenging cases.

R. D. is a visiting Fellow from I Department of Cardiology, Medical University of Gdansk, Poland. All authors drafted the article and approved the final version. All authors had full access to all of the data (including statistical reports and tables) in the study and can take responsibility

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