Transcatheter aortic valve implantation in obese patients: Overcoming technical challenges and maintaining adequate hemodynamic performance using new generation prostheses
Introduction
Transcatheter aortic valve implantation (TAVI) has been proposed as a safe and effective therapy to treat patients with aortic valve stenosis (AVS) at increased risk for conventional surgical aortic valve replacement. Although obese patients may present challenges in terms of vascular access and fluoroscopic visualization, the feasibility of TAVI in this peculiar group of patients has been previously investigated and proven [1], [2], [3]. The recent introduction of second-generation TAVI prostheses with added features of valve full repositionability, retrievability, optimized trackability and aortic annulus sealing may enhance TAVI performance reducing operative time and complications rate, maintaining adequate valve hemodynamics.
In the present manuscript we present our results with 2 new generation TAVI prostheses focusing on the perioperative clinical and hemodynamic outcomes in obese patients.
Section snippets
Data collection
A series of 172 consecutive patients undergoing trans-femoral TAVI with new generation prostheses (Direct Flow Medical, DFM®, Santa Rosa, California, USA and LOTUS®, Boston Scientific Corporation, Marlborough, Massachusetts, USA) were included. Two groups were identified according to their body mass index (BMI): group NO with BMI < 30 kg/m2 and group O with BMI ≥ 30 kg/m2.
All patients were treated by our TAVI team during the period March 2013–October 2015.
Perioperative data were prospectively
Results
Table 1 summarizes the preoperative findings. A total of 125 patients were included in group NO and 47 in group O. Obese patients had a higher risk profile (euro-SCORE II, systemic hypertension, and diabetes mellitus).
Anatomical features of the aortic unit and the iliac-femoral access were comparable in the 2 groups (Table 1).
Table 2 reports intraoperative data. A trans-femoral approach was possible in all patients, independently by their body habitus, and no conversion to conventional
Discussion
Although obesity is a recognized risk factor for cardiovascular disease, overweight and obese patients who undergo cardiac surgery, including aortic valve replacement, have a survival advantage over underweight, normal weight, and morbidly obese patients (obesity paradox) [7].
At times of stress, such as that experienced during surgical interventions, improved survival of obese patients could be attributed to high metabolic reserves and body fat.
In reality, the presence of obesity in patients
Limitations
In consideration of the limited sample size, we cannot draw definitive conclusions concerning the impact of obesity on follow-up outcomes. Moreover, our echocardiographic follow-up was limited to a part of the overall cohort.
Conclusions
Second generation TAVI prostheses allow for safe and effective procedures in obese patients. In spite of patient ´s body habitus, agile prosthesis placement will lead to optimized hemodynamics. Finally our clinical follow-up confirms the benefits of TAVI in both groups. Although no statistically significant differences were noted, obese patients seemed to have a trend for increased follow-up mortality and especially MACCEs. These findings may derive from the additional comorbidities that are
Authors contribution
SK, HA: Data Collection, designing, revising; GD: Data collection and analysis, Designing, writing, revising; GEA-MD-JO-AO-UK-AB-BL-HI: data collection, reading, revising.
Authorship declaration
All authors listed meet the authorship criteria according to the latest guidelines of the International Committee of Medical Journal Editors, and all authors are in agreement with the manuscript.
Disclosures
Drs. D'Ancona, Stephan Kische, and Hüseyin Ince have received proctors' fees from Direct Flow Inc.
Conflict of interest
The authors report no relationships that could be construed as a conflict of interest.
References (10)
- et al.
PRAGMATIC-Plus Researchers. Effect of body mass index on short- and long-term outcomes after transcatheter aortic valve implantation
Am. J. Cardiol.
(2013) - et al.
FRANCE 2 Registry Investigators. Effect of body mass index on 30- and 365-day complication and survival rates of transcatheter aortic valve implantation
Am. J. Cardiol.
(2013) - et al.
Valve Academic Research Consortium-2. Updated standardized endpoint definitions for transcatheter aortic valve implantation: the Valve Academic Research Consortium-2 consensus document
J. Thorac. Cardiovasc. Surg.
(2013) - et al.
Prospective multicenter evaluation of the direct flow medical transcatheter aortic valve
J. Am. Coll. Cardiol.
(2014) - et al.
1-year outcomes with the fully repositionable and retrievable lotus transcatheter aortic replacement valve in 120 high-risk surgical patients with severe aortic stenosis: results of the REPRISE II study
JACC Cardiovasc. Interv.
(2016)
Cited by (9)
Effect of BMI on patients undergoing transcatheter aortic valve implantation: A systematic review and meta-analysis
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2017, American Journal of CardiologyCitation Excerpt :Several studies have explored the perioperative complications in obese versus nonobese in TAVI patients. Previous reports varied in the results but suggested that major and minor vascular complications, stage 1 acute kidney injury, major/life-threatening bleeding, and minor stroke were more observed in obese TAVI,7–9 but other studies reported similar perioperative complications.10 Smith et al., in their large series of 1,066 SAVR patients from a single institution, reported that there was no association of perioperative complications (analyzed as a continuous variable, an increase of 1 kg/m2).11
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2022, Singapore Medical Journal
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Authors have equally contributed to the manuscript.
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This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.