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Title: Vascular access selection and its influence on the results of transcatheter aortic valve implantation procedures
Abstract:
Background Aortic stenosis (AS) is the most common valvular heart disease in the adult population and its frequency significantly increases with age. For many years, surgical aortic valve replacement (SAVR) was the only effective treatment option. Since the first percutaneous valve implantation in 2002, transcatheter aortic valve implantation (TAVI) has become a valuable method in the treatment of non-operative patients as well as an alternative to classic surgical valve replacement. Due to the best clinical results, the most widespread and preferred access to TAVI is via the femoral artery. It can be obtained fully percutaneous (PA - percutaneous access) or by surgical unveiling of the artery and its subsequent puncture (SA - surgical access). In cases where the use of femoral access is not possible, an alternative approach should be considered. Most frequently chosen is through the carotid or subclavian artery or surgical apical access (TA). Objectives The objectives of the doctoral dissertation are to determine the relationship between the choice of access and its influence on transcatheter aortic valve implantation, periprocedural complications and the subsequent results of the procedure. Methods The study was retrospective and covered the period from November 2008 to December 2019. Study group consisted of patients qualified by Heart Team, to invasive ; treatment with TAVI method. The analysis was performed by comparing the three subgroups depending on the access method used (PA, SA, TA groups). Results In the first publication, "Computed tomography guided tailored approach to transfemoral access in patients undergoing transcatheter aortic valve implantation”, the differences between the TAVI procedure performed using PA and SA access were assessed. The analyzed group included 158 patients, mean age 79.6 ± 8.43 years, 39% were male, baseline median aortic valve area (AVA) was 0.80 [0.60; 0.90] cm , mean gradient 45.00 [38.00; 55.00] mmHg, maximum 70.00 [60.75; 94.00]. The PA group consisted of 92 patients (58.2%), 36% were male. The radiation dose during the procedure was significantly higher in the PA group compared to SA 614.0 [410.0-1104.0] vs 405.0 [240.5-658.0] mGy (p <0.001). The dose of contrast used was also higher in the PA group (154.7 ± 50.6 ml vs 138.9 ± 69.2 ml, p = 0.04). Hemorrhagic complications were most common and occurred in 11 patients in the PA group and 5 in the SA group (12.4% vs 8.6%, p = 0.48). In both groups, the majority of bleeding was access site-related. There was one pericardial tamponade associated with aortic root rupture in each group. Three bleeding episodes were associated with perioperative blood loss, two (2.2%) in the PA group and one (1.5%) in the SA group. In terms of ; other serious complications, no statistically significant differences were found. The median valve prothesis gradient were 9.00 mmHg [6.00; 11.5] in the SA group and 8.00 mmHg [6.00; 11.0] in the PA group (p = 0.588). The mean value of the effective orifice area of the valve prosthesis was 2.01 cm2 (SD = 0.25) and 2.10 cm2 (SD = 0.31), respectively (p = 0.526). The median hospitalization time was similar in both groups and amounted to 6 days [4.0-8.0], (p = 0.62) There was one in-hospital death in each group, p = 1.00. There were no deaths in any group during the 30-day follow-up.The 12-month mortality in the whole group was 3.2%, 3.3% in the PA group, and 3.0% in the SA group, p = 0.89. In the second manuscript, "Twelve-month outcomes of transapical transcatheter aortic valve implantation in patients with severe aortic valve stenosis," the early and midterm results of transcatheter aortic valve implantation through the transapical access are presented. There were 61 patients in the study group. The median age was 80.0 years [76.00-84.0], 55.7% of the group were male. The median AVA was 0.70 cm2 [0.60-0.90], the median of the maximum and mean gradient was 82.0 mm Hg [59.5-93.5] /49.0 [36.061.0]. The procedure was successful in 59 patients (96.7%). In most cases, only mild regurgitation was found (90.2%); the peak and mean valve prothesis gradient median was 1 ; 5 mm Hg [10.5-20.0] / 9 [6.0-12.0], respectively. One stroke and one myocardial infarction occurred perioperatively. In 6.6% of cases, implantation of a pacemaker was necessary due to conduction disturbances. Hemorrhagic complications were the most common and occurred in 9 cases (14.8%). The hospitalization time in the TA group was much longer than in the femoral approach group and was 15 days [10-20]. Six patients died during hospitalization (9.8%). The 30-day mortality was 18.0% and the 12-month 24.6%. Factors most strongly associated with mortality were a history of the cerebrovascular event (CVE) - a stroke or a transient ischemic attack (TIA), level of estimated glomerular filtration ratio (eGFR), AVA, the right ventricle systolic pressure (RVSP) and the concentration of the N-terminal prohormone of the natriuretic peptide type B (NT-proBNP). In the third paper, "Complete transcatheter treatment of multiple heart valve diseases", a case of a patient with a multivalvular heart disease, including severe aortic stenosis, is presented. Due to numerous contradictions, including the history of chest radiation, it was impossible to treat the patient according to the European Society of Cardiology's main recommendations and perform classical aortic, mitral and tricuspid valve surgery using sternotomy. In this situation, the patient was disqualified from cardiac ; surgery and successfully underwent transcatheter interventions on these valves. In the TAVI procedure, percutaneous access through the femoral artery was used. At a later stage, percutaneous access through the femoral vein was used to treat severe mitral and tricuspid regurgitation and these valves were repaired with the MitraClip system (Abbott, USA). Conclusions Fully percutaneous femoral access is associated with a significantly higher dose of radiation and a significantly higher dose of contrast used during the TAVI procedure than access obtained by the surgical unveiling of the artery. Nevertheless, PA is associated with the same effectiveness and similar results of the TAVI procedure as SA. In the group of patients with a high surgical risk, when the femoral approach for TAVI cannot be used, the transapical approach gives good hemodynamic results of the TAVI procedure, with a significant clinical improvement and an acceptable complication rate. In the periprocedural period, bleeding was the most common complication in all types of vascular access. The lowest number of bleeding complications occurred in the SA group while the highest in the TA group. Full percutaneous femoral access has not been shown to reduce hospitalization time compared to the surgical unveiling of the artery. The longest hospitalization time was observed in the TA group. In the study ; group, in-hospital 30-day and 12-month mortality in the PA and SA groups was comparable. The 30-day and 12-month mortality in the TA group was higher compared to PA and SA group, but TA was the only chance for effective treatment in very vulnerable group. A history of the cerebral vascular incident, impaired renal function, aortic valve area, elevated NT-proBNP values , and increased systolic pressure in the right ventricle is associated with increased 12-month mortality in patients undergoing TAVI with the use of the transapical approach.
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Rada Dyscypliny Nauki medyczne
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Nov 20, 2023
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Nov 20, 2023
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