The self-expandable valve is deployed without burst pacing, by the retracting the outer sheath of the delivery catheter. Recently reported 2-year outcomes showed continued encouraging results.
At 2 years, the primary endpoint of all-cause mortality was reduced from Predictors of mortality — Risk factors for early and late mortality were identified in a study of patients undergoing TAVR with CoreValve.
Intraprocedural mortality was 0. Mortality was 5. Importantly, no structural failures of the transcatheter valves have been seen in studies with a follow-up of more than 1 year [ 73 - 74 ].
In addition to baseline and procedural factors, the learning-curve phenomenon and the improvements in valve prosthesis and delivery catheters have also been associated with a substantial improvement in the results obtained with TAVI. Three-year follow-up data have been published and are consistent with lasting improvement in cardiac symptoms [ 72 ]. The most frequent etiology of procedural stroke is likely to be atheroembolism from the ascending aorta or the aortic arh.
Other several factors include manipulation of a wire, positioning of device, performance of the balloon aortic valvuloplasty, air embolism, dissection of the arc vessels and inadequate blood flow to brain during rapid pacing. Reported 30 day stroke rate was 3. Additionaly Kahlert et al observed that using diffusion-weighed MRI has underlined this issue, demonstrating multiple embolic cerebral lesion in all patients after TAVI. Although most of these lesions were clinically silent, silent cerebral infarcts are associated with subtle cognitive change.
Efforts have been directed towards prevention of stroke. Procedural anticoagulation to reach a target activated clotting time over s is suggested. Empiric dual antiplatelet therapy is recommended for 3 to 6 months followed by long-term daily low dose aspirin.
Additionally less traumatic valve delivery system and embolic protection devices Embrella embolic deflector system currently under devolepment might lower the risk of stroke.
However some authors have suggested that stroke risk might be lower with transapical access, this has not been a universal finding. Vascular Complication: Common vascular complication arterial dissection, closure device failure, arterial stenosis, haematoma in the accsess site. Artery avulsion, vessel perforation, annulus rupture represent more severe complications which are fatal if not rapidly treated. Small vessel diameter, severe atherosclerosis, bulky calcification, and tortusosity are the main determinats of vascular complications.
In the future delivery catheter and sheath size will likely decrease which should be associated with reductions in the risk of vascular injury. Coronary obstruction and myocardial infarction: Coronary ostia obstruction especially of the left main coronary artery might occur if an obstructive portion of the valve frame or the sealing cuff is placed directly over a coronary ostium however this is very rare but potentially fatal event [ 77 ].
Some cases may require immediate coronary angioplasty or coronary artery bypass graft operation. Additionally myocardial infarction was associated with an increased cardiac mortality at midterm follow up.
Heart Block: High grade atrioventricular block and consecutive pacemaker implantation are frequent especially in CoreValve complications following TAVI.
Potential risk factors include aggressive over sizing, low implantation of the prosthesis, small annulus diameter, using CoreValve and the presence of preexisting infranodal block such as RBBB [ 79 , 80 ]. Cardiogenic Schock and low cardiac output: This complication may be induced by ischemia, rapid pacing, volume depletion, anesthesia and interruption in cardiac output during valve implantation.
Vasopresor agents and intraaortic balloon support to maintain adequate perfusion pressure are often helpful. Rarely elective femoral cardiopulmonary bypass is an option for patients at hemodynamic instability. Causes of paravalvular regurgitation include a heavily calcified annulus,large annulus size, an undersized prosthesis, device failure and inadequate balloon aortic valvuloplasty. Redilatation or implantation of a second, overlapping transcathater valve can often correct the problem.
Acute Kidney Injury: Angiographic contrast injection, hypotension, atheroembolism, periprocedural blood transfusion might contribute to acute renal failure. Additionally need for hemodialysis has ranged from 1. Predictors of acute kidney injury include hypertension, decrease baseline renal function, previous myocardial infarction, high logistic EuroSCORE and chronic obstructive pulmonary disease [ 83 ].
Other Complication: Other significant and very rare complications include aortic rupture, aortic dissection, periaortic hematoma, ventricular or aortic embolization of valve, structural valve failure, cardiac tamponade and acute mitral regurgitation due to mitral valve apparatus damage [ 73 - 74 ]. Valve-in-valve — A valve-in-valve procedure involves catheter-based valve implantation inside an already implanted bioprosthetic valve. This approach may provide an alternative to replacement of a degenerated surgically-implanted valve, or a means of salvaging suboptimal implantation of a catheter-based valve during the initial implantation procedure.
In the future when it is a safer and more reliable procedure and further refinement of the device i. In , Theodore Tuffier was the first to attempt opening AS using his finger. Russel Brock and then Bailey used dilatators for stenotic aortic valves. Today more than patients have aortic valve surgery per year and surgery for AS is more common than it is for aortic insufficiency [ 84 ].
Aortic valve surgery has been improved with the developments of new technologies in cardiopulmonary bypass techniques and valve industry. AVR is the treatment of choice for patients with severe degenerative AS, offering both symptomatic relief and a potential for improved long term survival [ 85 ].
The surgery should immediately be programmed if the patient becomes symptomatic. Despite LV dysfunction, the risk of aortic valve replacement for AS was satisfactory and related to meanaortic gradient and additional coronary artery disease, and long-term survival was related to also coronary disease and cardiac output [ 86 ].
On the other hand, elderly patients stay longer in the hospitals and intensive care units during the postoperative period [ 87 ]. Although the surgery for the asymptomatic patients is preferred due to sudden death, surgery for asymptomatic octogenarians is controversial.
The complex cardiac procedures have high risks for elderly patients. The mortality rate of valve surgery and risk of sudden death without surgery have to be carefully considered. AVR usually performed under general anesthesia using conventional techniques of open heart surgery with median sternotomy. Minimally invasive surgery has continued to be an evolving concept after the first publication of Cosgrove in [ 91 ] Minimally invasive procedures are associated with acceptable mortality and morbidity rates even in high risk patients.
The major advantages of minimally access surgeries are improved cosmesis with reduced insicion size, decreased surgical trauma, less pain, better respiratory function and early return to work [ 92 ]. These procedures can be performed through different approaches. These are upper mini sternotomy, transverse sternotomy and right parasternal or anterolateral mini thoracotomy, using port access technique or not.
Although mini sternotomy is the most common approach, the outcomes after right anterior thoracotomy have satisfactory results [ 93 ]. The arterial cannulation sites are either aorta or femoral artery. The venous cannulation sites are right atrium, femoral vein or percutanous supeior vena cava with femoral vein.
The incisions differ from 5 to 10 cm and small incisions may provide low infection rates [ 94 ]. This procedure has advantages such as less 1 surgical trauma, decreased pain and faster recovery. It reduces blood transfusions and shortens the length of hospital and ICU stay [ 95 ].
It is a safe operation and results lower incidence of atelectasis inthe cardiac ICU [ 96 ]. Port access aortic surgery also allows patients to be extubated earlier [ 97 ]. Avoidance of full sternotomy for patients prompts a comfortable postoperative period. Although the number of the aortic valve procedures increase worldwide, the ideal valve choice is still a debate. There are several options for valves. These are mechanical valve prosthesis, stented and stentless bioprosthetic valves, aortic homograft and pulmonary autograft.
The use of these valves differs from patient to patient due to comorbidities and anticoagulant needs. The bioprosthetic valves are good alternatives for elderly patients and women who want to be pregnant because long term anticoagulation use is not required.
The other situation for the patients undergoing AVR is the injurious effects of Cardiopulmonary bypass to the life organs. This results as a systemic inflammatory response and this may affect the post-operative course of the patients. The Ross procedure is another surgical technique for aortic valve replacement. This is more commonly used in pediatric cases but also good alternative for especially young adult patients and women want have child. In this operation the patient's own pulmonary valve and main pulmonary artery are used as an autograft and they are implanted to the aortic position, with reimplantation of coronary arteries.
The primary indication for the Ross procedure is to provide a permanent valve replacement among younger patients who will grow potentially. Other possible indications include complex left ventricular outflow obstructive disease, native or prosthetic valve endocarditis, and adult aortic insufficiency with a dilated aortic annulus [ 98 ]. One of the most commonly seen complications of Ross procedure is autograft regurgitation and sinus or ascending aortic dilatation, which can usually be corrected with a valve-sparing root replacement.
There were just 2 early deaths. Recent years aortic valve repair also become popular when valve morphology is amenable to repair. But this is a limited procedure among patients who have aortic regurgitation AR without aortic stenosis.
Aortic valve repair is commonly indicated commonly in patients with a dilated aortic annulus without any degeneration of the leaflets [ ]. Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution 3. Help us write another book on this subject and reach those readers. Login to your personal dashboard for more detailed statistics on your publications. Edited by Elena Aikawa. Edited by Dan Simionescu. We are IntechOpen, the world's leading publisher of Open Access books.
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Downloaded: Introduction There is a trend towards a worldwide aging in the last decades and diseases which are common in the elderly people would take important place in clinical practice.
Claveau D et al. Complications associated with nitrate use in patients presenting with acute pulmonary edema and concomitant moderate or severe aortic stenosis. Ann Emerg Med Oct; Ann Emerg Med Oct In acute pulmonary edema patients with aortic stenosis, nitroglycerin may not be so bad. Comment In patients with hard-to-manage acute pulmonary edema who have known aortic stenosis or a suggestive murmur, judicious use of carefully titrated nitroglycerin may not be as risky as we thought.
Patients with hemodynamically significant AS are challenging to manage in the resuscitation phase. Avoid excessive tachycardia , maintain sinus rhythm , optimize preload , and treat hypotension aggressively with phenylephrine. The evolving epidemiology of valvular aortic stenosis.
Calcific aortic stenosis. Nature Reviews Disease Primers. Natural history of valvular aortic stenosis. Br Heart J. Natural history of moderate aortic stenosis.
J Am Coll Cardiol. Spontaneous course of aortic valve disease. Eur Heart J. Can severe aortic stenosis be identified by emergency physicians when interpreting a simplified two-view echocardiogram obtained by trained echocardiographers?
Critical ultrasound journal. A practical approach to cardiac anesthesia. Horak J, Weiss S. Emergent management of the airway: New pharmacology and the control of comorbidities in cardiac disease, ischemia, and valvular heart disease.
Crit Care Clin. Influence of phenylephrine bolus administration on left ventricular filling dynamics in patients with coronary artery disease and patients with valvular aortic stenosis. Award Winners. Editor's Forum. Leadership Reports. Leader Spotlights. Advancing EM. Published by Elsevier Inc. All rights reserved. Abstract Study objective: We evaluate the incidence of complications associated with the use of nitrates in patients presenting with acute pulmonary edema and concomitant moderate or severe aortic stenosis compared with patients without aortic stenosis.
Substances Vasodilator Agents Nitroglycerin.
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