Aim
Transcatheter aortic valve implantation (TAVI) is a mainstay in the management of severe aortic valve stenosis in elderly patients, but there is uncertainty on their long-term effectiveness. We aimed to assess the long-term outcome of patients undergoing TAVI with the Portico valve.
Methods
We retrospectively collected the data on patients in whom TAVI with Portico was attempted from 7 high-volume centres. Only patients theoretically eligible for 3 or more years of follow-up were included. Clinical outcomes, including death, stroke, myocardial infarction, reintervention for valve degeneration and hemodynamic valve performance were systematically assessed.
Results
A total of 803 patients were included, with 504 (62.8%) women, mean age of 82 years, median EuroSCORE II of 3.1%, and 386 (48.1%) subjects at low/moderate risk. The median follow-up was 3.0 years (3.0; 4.0). The composite of death, stroke, myocardial infarction, and reintervention for valve degeneration occurred in 37.5% (95% confidence interval: 34.1–40.9%), with all-cause death in 35.1% (31.8–38.4%), stroke in 3.4% (1.3–3.4%), myocardial infarction in 1.0% (0.3–1.5%), and reintervention for valve degeneration in 1.1% (0.6–2.1%). The mean aortic valve gradient at follow-up was 8.1 ± 4.6 mmHg, and at least moderate aortic regurgitation was present in 9.1% (6.7–12.3%). Independent predictors of major adverse events or death were: peripheral artery disease, chronic obstructive pulmonary disease, estimated glomerular filtration rate, atrial fibrillation, prior pacemaker implantation, EuroSCORE II, and reduced left ventricular ejection fraction (all p < 0.05).
Conclusions
Portico use is associated with favorable long-term clinical outcomes. Clinical outcomes were largely impacted by baseline risk factors and surgical risk.
Background
The transfemoral approach drives most of the advantages of transcatheter aortic valve implantation (TAVI) over surgical aortic valve replacement (SAVR). Alternative accesses for TAVI are associated with higher complication rates, but are still considered in approx. 5% of cases due to peripheral arterial disease (PAD). Percutaneous transluminal angioplasty (PTA) can still allow transfemoral TAVI in selected cases with severe calcific PAD; however, ancillary techniques for calcium management are often needed.
Case Summary
Orbital atherectomy was selected to facilitate transfemoral TAVI in two patients with different degrees and aspects of calcific PAD. Pre-procedural computed tomography analysis was key to choose the most appropriate technique for calcium management. We describe our experience with a step-by-step procedural approach to orbital atherectomy-assisted transfemoral TAVI.
Discussion
PAD is not uncommon in patients affected by severe symptomatic aortic valve stenosis. Orbital atherectomy can still allow transfemoral TAVI in selected cases with severe calcific PAD. A meticulous patient selection and a standardized, step-wise procedural execution are mandatory to optimize outcomes.
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