Objective: The clinical utility of transcatheter aortic valve replacement (TAVR) without contrast medium in patients with advanced-stage chronic kidney disease (CKD) remains unexplored. We evaluated the feasibility and clinical utility of zero-contrast TAVR in patients with CKD.
Methods: We retrospectively analyzed patients who underwent TAVR between February 2014 and November 2019. We defined zero-contrast TAVR as TAVR performed without contrast medium under transesophageal echocardiographic (TEE) guidance. In zero-contrast TAVR, annulus sizing and other aortic valve complexes were assessed, and valve positioning during deployment was performed under 3D-TEE guidance. We performed an assessment of the aortic valve by TEE just after inducing anesthesia. The calcification of the aortic valve was assessed by non-contrast computed tomography (CT). The access site was assessed by preprocedural ultrasound and intravascular ultrasound during the procedure. The incidence of acute kidney injury (AKI) and other clinical outcomes were compared between TAVR with contrast and zero-contrast TAVR groups. All definitions of the clinical endpoints used in this study were in accordance with the Valve Academic Research Consortium-3 definitions.
Results: Among the 555 patients included in this study, 34 patients (6.1%) underwent zero-contrast TAVR. Although the incidence of AKI in the zero-contrast TAVR group was numerically higher than that in the contrast TAVR group (11% vs. 4%; P = 0.06), stage 2–4 AKI was not recognized in both groups. There were no significant differences in device success (100% vs. 93%; P = 0.28) and 30-day mortality rates (3% vs. 0.5%; P = 0.11) between patients in the zero-contrast TAVR and TAVR with contrast groups. In the zero-contrast TAVR group, post-estimated glomerular filtration rate (eGFR) showed no difference compared to pre-eGFR (19.9 mL/min/1.73 m2 [13.5–22.3] vs. 20.3 mL/min/1.73 m2 [14.8–28.4]; P = 0.21). When compared between patients with and without preoperative contrast CT, the incidence of AKI in patients with preprocedural contrast CT was numerically higher than that without contrast CT (27% vs. 4%; P = 0.09). No significant difference in major vascular complications was observed between these groups (0% vs. 4%; P = 1.00).
Conclusion: In patients with CKD, zero-contrast TAVR even without preoperative contrast CT may be feasible in terms of high procedural success rate and low incidence of AKI after TAVR.
Objective: Recently, the number of structural heart disease (SHD) procedures has increased, leading to increased radiation exposure doses of physicians. Information about SHD physicians’ exposure is insufficient to elucidate their degree of exposure. Physicians’ radioprotection is therefore poor or sometimes overly cautious. This study uses quantitative evaluation with a physical simulation to elucidate the exposure dose sustained by physicians during SHD procedures.
Methods: The reported Monte Carlo system was used for dose estimation while using statistical sampling to simulate particle interactions in matter. The simulation geometry resembled an actual SHD procedure. Body models were posturally transformed to simulate a physician’s posture for the procedure faithfully and correctly.
Results: Doses for the left eye lens in the upper body were about 1.5 times higher than doses for the right eye lens under all fluoroscopic directions. Doses for the left-hand skin were twice those for the right side. Hand skin doses varied depending on the direction. The same applied to doses for abdominal skin.
Conclusion: The results of this study suggest that physicians’ exposures differ significantly depending on the fluoroscopic directions. Physicians should understand the dose differences and endeavor to reduce risks posed by self-exposure.
Objective: Transcarotid access for transcatheter aortic valve replacement (TAVR) is a minimally invasive alternative approach if femoral access becomes unfavorable; however, it remains off-label use in Japan.
Case Presentation: An 85-year-old female patient with severe aortic valve stenosis presented to our hospital and was diagnosed with acute heart failure. The Society of Thoracic Surgery score and the European System for Cardiac Operative Risk Evaluation 2 were 9.5% and 11.2%, respectively. Computed tomography revealed a small aortic annulus (annulus axis diameter: 18.5 mm × 22.8 mm, perimeter: 67.5 mm, area: 359 mm2), small aortic roots (Valsalva: noncoronary cusp, 22.7 mm; right coronary cusp, 22.8 mm; left coronary cusp, 24.3 mm; sinotubular junction: 18.5 mm × 22.8 mm), and a shaggy aorta with bilateral subclavian artery stenoses. Optimal medical therapy did not work well; therefore, we performed balloon aortic valvuloplasty (BAV). However, BAV did not improve aortic stenosis and worsened aortic regurgitation. The heart team decided to perform transcarotid TAVR owing to the presence of almost no plaque in the left common carotid artery (CCA), and brain magnetic resonance angiography revealed good communications between the anterior and posterior communicating arteries. On the 10th hospital day, transcarotid TAVR was performed, and Sapien 3 20-mm valve was directly implanted during the 30-min clamp time of the left CCA. The procedure was successful, and the clinical course following TAVR was good. Finally, she was discharged to her home on the 24th hospital day.
Conclusion: We experienced a successful transcarotid TAVR case. Transcarotid access is a feasible approach in a case requiring an alternative approach.