In the past Tsuyoshi Kaneko has collaborated on articles with Jenna Stuebe and Sameer A. Hirji. One of their most recent publications is Case reportTransjugular Approach in Valve-in-Valve Transcatheter Mitral Valve Replacement: Direct Route to the Valve. Which was published in journal The Annals of Thoracic Surgery.

More information about Tsuyoshi Kaneko research including statistics on their citations can be found on their Copernicus Academic profile page.

Tsuyoshi Kaneko's Articles: (20)

Case reportTransjugular Approach in Valve-in-Valve Transcatheter Mitral Valve Replacement: Direct Route to the Valve

With the recent emergence of transcatheter valve replacement, high-risk cases of structural valve deterioration after mitral bioprosthesis can be treated with valve-in-valve transcatheter mitral valve replacement (TMVR). The transapical approach has become the principal access for TMVR, but we report an alternative direct access for TMVR—transjugular transseptal route—in an 81-year-old woman with a degenerated mitral bioprosthesis.

Original articleAdult cardiacA Pragmatic Preoperative Prediction Score for Nonhome Discharge After Cardiac Operations

BackgroundTargeted rehabilitation of patients at risk for nonhome discharge (NHD) after an operation is an appealing area for quality improvement. We sought to identify the primary predictors of NHD after cardiac operations to generate a robust preoperative prediction tool for those at greatest risk.MethodsThe medical records of 5,253 patients undergoing cardiac operations between January 1, 2012, and March 31, 2016, were reviewed. Two models of NHD were created: a preoperative model using only preoperative predictors and a postoperative model using the same preoperative predictors and including postoperative adverse outcomes and hospital length of stay. We also determined whether NHD also reduced 30-day hospital readmission.ResultsA multivariable logistic regression model allowed robust identification of NHD using only preoperative variables of age, sex, marital status, obesity, comorbidities, addictions, psychiatric disease, and planned operation (area under the curve = 0.820, r2 = 0.349). Postoperative factors associated with NHD, including hospital length of stay and the occurrence of a neurologic event, were included and improved model performance (area under the curve = 0.860, r2 = 0.439), with integrated discrimination improvement of 7.5%. We observed an overall all-cause readmission rate of 12%. Patients with NHD had a higher readmission rate (16% vs 11%; p < 0.0001), as did patients with longer hospital stays, postoperative atrial fibrillation, neurologic event, or infection (all p < 0.0001).ConclusionsWe identified preoperative risk factors for NHD after cardiac operations and developed a pragmatic NHD prediction score with high accuracy. Addition of postoperative risk factors for NHD only modestly improved prediction. NHD does not decrease the readmission rate after cardiac operations.

Original articleAdult cardiacMechanical Versus Bioprosthetic Aortic Valve Replacement in Patients Aged 50 Years and Younger

BackgroundThis study evaluated outcomes in younger patients, specifically aged 50 years and younger, after mechanical aortic valve replacement (mAVR) and bioprosthetic AVR (bAVR).MethodsFrom 1994 to 2016, 643 patients underwent AVR (411 mAVR and 232 bAVR) at age 50 or younger. Concomitant coronary artery bypass grafting and mitral valve procedures were also included. Propensity score-matching methods resulted in 170 evenly matched patient pairs. Primary end points were operative mortality and long-term survival. Secondary end points were stroke, major bleeding, and redo AVR. Median observation time was 8.1 years (range, 0 to 23.6 years).ResultsOverall, mean age was 41.9 years, and 29.3% were women, with an increasing trend toward use of bAVR. Mean age in the matched patients was 43.3 years for both cohorts (p = 0.68). Operative mortality, stroke, atrial fibrillation, reoperation for bleeding, and readmission rates within 30 days were all similar between the two groups. bAVR patients were at higher risk for redo AVR (13% vs 1.6%, p < 0.001), and mAVR patients were at higher risk for major bleeding events (8.5% vs 2.2%, p = 0.006). However, when adjusted, there were no differences in midterm and long-term survival between unmatched and matched cohorts.ConclusionsThe increased risk of reoperation for bAVR and major bleeding incidents for mAVR was not reflected in midterm and long-term survival differences between the two groups. Our results suggest that bAVR may be an acceptable prosthesis choice for some patients aged 50 years and younger, although the results should be taken with caution.

Original articleEducationDebunking the July Effect in Cardiac Surgery: A National Analysis of More Than 470,000 Procedures

BackgroundRecent studies in noncardiac surgery have described worse outcomes in the first month of training. However, the “July effect” in the context of cardiac surgery outcomes is not well understood. We examined whether patient outcomes after cardiac surgery were affected by procedure month or academic year quartile.MethodsUsing the National Inpatient Sample, we isolated all coronary artery bypass grafting (CABG), surgical aortic valve replacement (AVR), mitral valve repair or replacement (MV), and isolated thoracic aortic aneurysm (TAA) replacement procedures between 2012 and 2014. For each procedure, overall trends in in-hospital mortality and hospital complications were compared by academic year quartiles (ie, between the first academic year quartile vs the fourth quartile) and by procedure month. Outcomes between teaching and nonteaching hospitals were also compared.ResultsOverall, 301,105 CABG, 111,260 AVR, 54,985 MV, and 2,655 TAA procedures met inclusion criteria. In-hospital mortality for each procedure did not vary by procedure month or academic year quartile, even after risk adjustment (all P > .05). Teaching status did not influence risk-adjusted mortality for CABG and isolated TAA replacement (both P > .05). However, teaching hospitals had significantly lower adjusted mortality than nonteaching hospitals for AVR and MV surgery (both P < .01).ConclusionsThe July effect is not evident for cardiac surgery despite preexisting notions. Teaching hospitals performed at least equivalent, if not better, for major cardiac surgery procedures. These findings highlight the pivotal role of hospital support systems to ensure the safe transition of resident classes without compromising on patient outcomes.

Case ReportsGastric tube-to-tracheal fistula closed with a latissimus dorsi myocutaneous flap

AbstractA gastric tube-to-airway fistula is a very rare complication after esophageal reconstruction. A patient with a gastric tube-to-tracheal fistula that developed more than 9 years after surgery for cancer of the cervical esophagus was treated with transposition of a pedicled latissimus dorsi myocutaneous flap. Careful perioperative respiratory management helped save the patient’s life.

Acquired cardiovascular diseaseThe “no-dissection” technique is safe for reoperative aortic valve replacement with a patent left internal thoracic artery graft

ObjectiveManagement of a patent left internal thoracic artery graft during reoperation is controversial. The “no-dissection” technique avoids dissection and clamping of the left internal thoracic artery graft, and myocardial protection is achieved using adjunctive systemic hypothermia and hyperkalemia. We compared the postoperative outcomes after isolated reoperative aortic valve replacement in patients with previous coronary artery bypass grafting with a patent left internal thoracic artery graft using a no-dissection technique with the outcomes of patients with previous coronary artery bypass grafting without a left internal thoracic artery graft.MethodsThe outcomes were analyzed for patients who underwent isolated reoperative aortic valve replacement with previous coronary artery bypass grafting from January 1, 2002, to June, 30, 2011. Patency of the left internal thoracic artery was confirmed using either coronary angiography or computed tomography angiography. The patent left internal thoracic artery group did not undergo dissection or clamping of the left internal thoracic artery graft, and myocardial protection was obtained using systemic hypothermia and hyperkalemia. The no left internal thoracic artery group underwent isolated aortic valve replacement with previous coronary artery bypass grafting but had no left internal thoracic artery graft.ResultsA total 174 patients were identified for the patent left internal thoracic artery group and 26 for the no left internal thoracic artery group. The perfusion and crossclamp times were similar. No differences were seen between the 2 groups in operative mortality (6.9% vs 7.7%, P = 1.00). The complication rates were similar, and the peak creatine kinase-MB values within 24 hours of surgery were not significantly different between the 2 groups (median, 27.4 vs 29 μ/mL; P = .72).ConclusionsReoperative aortic valve replacement in patients with previous coronary artery bypass grafting and a patent left internal thoracic artery graft can be performed safely without dissection or clamping of the left internal thoracic artery using systemic hyperkalemia and hypothermia. We believe this method prevents unnecessary injury during dissection of the left internal thoracic artery graft.

Acquired cardiovascular diseaseReoperative aortic valve replacement in the octogenarians—minimally invasive technique in the era of transcatheter valve replacement

ObjectiveReoperative aortic valve replacement (re-AVR) in octogenarians is considered high risk and therefore might be indicated for transcatheter AVR. The minimally invasive technique for re-AVR limits dissection and might benefit this patient population. We report the outcomes of re-AVR in high-risk octogenarians who might be considered candidates for transcatheter AVR to assess the safety of re-AVR and minimally invasive operative techniques.MethodsWe identified 105 patients, aged ≥80 years, who underwent open re-AVR at our institution from July 1997 to December 2011. Patients requiring concomitant coronary bypass surgery and/or other valve surgery were excluded. The outcomes of interest included operative mortality, postoperative complications, and midterm postoperative survival.ResultsOf the 105 patients, 51 underwent minimally re-AVR through upper hemisternotomy (Mre-AVR) and 54 standard full sternotomy (Fre-AVR). The mean patient age was 82.8 ± 3.8 years. No significant differences were found in the patient risk factors. Postoperatively, 6 patients (5.7%) underwent reoperation for bleeding, 4 (3.8%) experienced permanent stroke, 4 (3.8%) developed new renal failure, and 22 (21.0%) had new-onset atrial fibrillation. Overall, the operative mortality was 6.7%, and the 1- and 5-year survival was 87% and 53%, respectively. When Mre-AVR and Fre-AVR were compared, the operative mortality was 9.2% in the Fre-AVR group and 3.9% in the Mre-AVR group (P = .438). Kaplan-Meier analysis showed a survival benefit at both 1 year (79% ± 11.7% vs 92% ± 7.8%) and 5 years (38% ± 17.6% vs 65% ± 15.7%, P = .028) favoring Mre-AVR. Cox regression analysis identified heparin-induced thrombocytopenia, reoperation for bleeding, older age, full sternotomy, and an infectious complication as predictors of mortality.ConclusionsOctogenarians who undergo re-AVR are thought to be high-risk surgical candidates. The present single-center series revealed acceptable in-hospital outcomes and operative mortality. Mre-AVR was associated with better survival compared with Fre-AVR and might benefit this population.

Acquired cardiovascular diseaseMitral valve repair versus replacement in the elderly: Short-term and long-term outcomes

ObjectiveTo compare the short-term and long-term outcomes of mitral valve repair (MVP) versus mitral valve replacement (MVR) in elderly patients.MethodsAll patients, age 70 years or greater, with mitral regurgitation who underwent MVP or MVR with or without coronary artery bypass graft (CABG), tricuspid valve surgery, or a maze procedure between 2002 and 2011 were retrospectively identified. Patients with a rheumatic cause or who underwent concomitant aortic valve or ventricular-assist device procedures were excluded.ResultsOverall, 556 patients underwent MVP and 102 patients underwent MVR. The mean age of the patients in the MVR group was 78 years versus 77 years for those in the MVP group (P < .02). The patients in the MVR group had a better mean left ventricular ejection fraction than those in the MVP group (60% vs 55%, P = .04). The incidence of concomitant CABG, tricuspid valve operations, and atrial fibrillation ablation procedures was similar in both groups, but perfusion time was significantly longer for the MVR group (median 177 minutes vs 146 minutes for MVP, P = .001). Postoperatively, patients in the MVR group had a higher incidence of stroke (6% vs 2%, P < .10) and significantly longer intensive care unit stay (median 86 hours vs 55 hours, P = .001) and hospital stay (9 days vs 8 days, P < .01). Operative mortality of patients was significantly higher for the MVR group (8.8% vs 3.6%, P = .03) and remained significant long-term on Kaplan-Meier analysis. Cox regression analysis of all 658 patients and propensity-matched analysis of 96 patients also confirmed these results.ConclusionsElderly patients with mitral regurgitation who undergo MVP have better postoperative outcomes, lower operative mortality, and improved long-term survival than those undergoing MVR. MVP is a safe and more effective option for the elderly with mitral regurgitation.

Adult: Mitral ValveOutcomes of repeat mitral valve replacement in patients with prior mitral surgery: A benchmark for transcatheter approaches

AbstractObjectivesWith the emergence of transcatheter mitral valve-in-valve/ring replacement for deteriorated bioprostheses or failed repair, comparative clinical benchmarks for surgical repeat mitral valve replacement (re-MVR) are needed. We present in-hospital and survival outcomes of a 24-year experience with re-MVR.MethodsFrom January 1992 to June 2015, 520 adult patients underwent re-MVR; 273 had undergone prior mitral valve repair (pMVP) and 247 had undergone prior MVR (pMVR). A benchmark cohort of isolated re-MVR was defined based on potential eligibility for transcatheter mitral valve-in-valve/ring replacement, resulting in 73 pMVPs with previous annuloplasty rings and 74 pMVRs with previous bioprosthetic valves for comparison.ResultsFor the entire cohort, mean age was 64 ± 12 years for pMVP patients and 63 ± 15 years for pMVR patients (P = .281), which was similar for the benchmark cohort. Overall operative mortality was 14 out of 273 (5%) for pMVP versus 23 out of 247 (9%) for pMVR (P = .087). There were 3 operative deaths (4.1%) in both groups of the benchmark cohort (P = 1.0). For the benchmark cohort, median time to reoperation was 9.8 years for pMVP and 9.1 years for pMVR. Cox proportional hazard analysis showed that chronic kidney disease (hazard ratio [HR], 2.47; 95% CI, 1.77-3.44), endocarditis (HR, 1.49; 95% CI, 1.07-2.07), pMVR (HR, 1.45; 95% CI, 1.12-1.89), early reoperation ≤ 1 year (HR, 1.49; 95% CI, 1.02-2.17), and age (HR, 1.04/y; 95% CI, 1.03-1.05) were associated with decreased survival after re-MVR.ConclusionsA re-MVR is a high-risk operation, but in carefully selected patients such as our benchmark population, it can be performed with acceptable results. Patients undergoing pMVP also have better long-term survival compared with patients undergoing pMVR. These results will serve as a benchmark for transcatheter mitral valve-in-valve/ring replacement.

AATS Aortic Symposium: Proximal AortaProximal aortic surgery in the elderly population: Is advanced age a contraindication for surgery?

AbstractObjectiveThe study objective was to describe the clinical outcomes of elderly patients undergoing ascending aortic surgery.MethodsPatients aged 70 years or older who underwent ascending aortic surgery between January 2002 and December 2013 were examined. Of 415 included patients, 285 were elderly patients (age 70-79 years) and 130 were very elderly (age ≥80 years). Logistic regression and Cox proportional hazards models were used to evaluate operative mortality and long-term survival, respectively.ResultsSurgical indications included aortic aneurysm (63.1%), calcified aorta with need for other cardiac procedure (26.4%), and type A dissection (10.5%). Compared with elderly patients, the very elderly patients had a higher burden of comorbidities and operative mortality (13% vs 7%, P < .04). The very elderly patients were also more likely to be discharged to a rehabilitation facility than home (P < .001). However, risk-adjusted operative mortality and 30-day readmissions rates were similar (P > .05). Kaplan–Meier estimates of survival at 1 and 5 years were 85.6% and 72.6% for elderly patients versus 79.2% and 57.1% for the very elderly patients. Age was a strong risk variable for late mortality in the unadjusted and adjusted analyses.ConclusionsAfter adjusting for these comorbidities, the cause of aortic disease, and the type of procedure, age was not an independent predictor of operative mortality, but was strongly associated with reduced late survival. Thus, advanced age alone should not be an absolute contraindication for ascending aortic surgery.

AdultRisk of reoperative valve surgery for endocarditis associated with drug use

AbstractBackgroundWe aimed to quantify incidence and operative risks associated with reoperative valve surgeries (RVS) in patients with drug-associated infective endocarditis in a multi-center setting.MethodsWe formed a registry of patients with drug-associated infective endocarditis who underwent valve surgeries at 8 US centers between 2011 and 2017. Outcomes of first-time valve surgery (FVS) and RVS were compared. Multivariable logistic regression models related RVS to 30-day mortality. Poisson regression models were fitted to evaluate temporal trends in overall case volume and proportions of patients undergoing RVS.ResultsThe cohort consisted of 925 patients with drug-associated infective endocarditis who underwent a valve surgery, of which 652 were FVS and 273 were RVS. Patients undergoing FVS had fewer comorbidities than those undergoing RVS. Overall case volume increased from 108 in 2012 to 229 cases in 2017 (P < .001). The proportion of redo valve cases increased from 19% in 2012 to 28% in 2017 (P < .001). The 30-day mortality in RVS was higher compared with FVS (8.1% vs 4.8%; P = .049). An increase in unadjusted mortality rates were observed as the number of prior cardiac surgeries increased, from 4.8% in FVS to 11.8% in ≥3 RVS. Multivariable model demonstrated that RVS was associated with an increased risk of 30-day mortality (odds ratio, 2.22; 95% confidence interval, 1.22-4.06; P = .010).ConclusionsAn increasing proportion of valve surgery for drug-associated infective endocarditis is for RVS. Despite being young and harboring few comorbidities, the RVS cohort is still susceptible to increased risk of 30-day mortality compared with those undergoing FVS.

OutcomesPresented at the Academic Surgical Congress 2016Race-based differences in duration of stay among universally insured coronary artery bypass graft patients in military versus civilian hospitals

BackgroundDuration of stay for coronary artery bypass graft operation outcomes differs for black versus white patients, with differences often attributed to insurance. We examined black versus white differences in duration of stay among TRICARE-covered patients undergoing coronary artery bypass graft.MethodsPatients aged 18–64 years with TRICARE who underwent isolated coronary artery bypass graft (ICD-9CM 36.10–36.20) between 2006–2010 and who identified as black or white race were identified. Negative binomial regression, stratified by sex and military versus civilian facility, examined the duration of stay controlling for patient- and hospital-level factors.ResultsOf 3,496 eligible patients, 2,904 underwent coronary artery bypass graft at 682 civilian and 592 at 11 military hospitals. Patients (mean age 56.2 years) were predominantly white (88.9%), male (88.7%), married (88.2%), and retired (87%). Black patients demonstrated longer duration of stay (8.6 vs 7.5 days, P > .001), and overall duration of stay was longer at military facilities (8.1 vs 7.5 days, P = .013). Among the men, mean duration of stay was 14% longer for black patients at civilian hospitals (95% confidence interval 1.07–1.22) with no race-based differences at military facilities.ConclusionAmong coronary artery bypass graft patients with TRICARE coverage, black, male patients demonstrated greater duration of stay at civilian facilities. Further work should examine care at military hospitals to elucidate factors that drive the apparent mitigation of race-related variability in duration of stay.

Cardiac Surgery Presented at the Academic Surgical Congress 2018Minimally invasive versus full sternotomy aortic valve replacement in low-risk patients: Which will stand against transcatheter aortic valve replacement?☆

AbstractBackgroundMinimally invasive aortic valve replacement using upper-hemisternotomy has been associated with improved results compared to full sternotomy aortic valve replacement. Given the likely expansion of transcatheter aortic valve replacement to low-risk patients, we examine contemporary outcomes after full sternotomy and minimally invasive aortic valve replacement in low-risk patients using our 15-year experience.MethodsTwo thousand ninety-five low-risk patients (Society of Thoracic Surgeons Predicted Risk of Mortality score <4) underwent elective isolated aortic valve replacement, including 1,029 (49%) minimally invasive and 1,066 (51%) full sternotomy, from 2002 to 2015.ResultsCompared to minimally invasive aortic valve replacement patients, full sternotomy aortic valve replacement patients had a greater burden of comorbidities, including diabetes, stroke, congestive heart failure, and predicted risk of mortality (all P ≤ .05). Operative mortality, stroke, and reoperation rates for bleeding were similar. There was a clinical trend toward shorter median intensive care unit stay and significantly shorter hospital length of stay among minimally invasive aortic valve replacement patients. Adjusted survival analysis identified age, chronic kidney disease, prior sternotomy, and congestive heart failure as predictors of decreased survival (all P ≤ .05), while type of intervention approach was nonsignificantly different.ConclusionIn low-risk patients, minimally invasive aortic valve replacement results in similar mortality, stroke, reoperation rates for bleeding, and midterm survival (after adjusting for confounders), but shorter hospital length of stay and a trend (P = .075) toward shorter intensive care unit stay, compared to full sternotomy aortic valve replacement. Therefore, minimally invasive aortic valve replacement should stand as a benchmark against transcatheter aortic valve replacement in these patients.

The determination by gas chromatography with atomic emission detection of total sulfur in fuels used as forensic evidence

AbstractIn Japan, taxed diesel fuel from non-taxed fuel oil-A is illegally produced by removing coumarin, which is added as a non-taxed marker. The coumarin is removed using concentrated sulfuric acid and this produces a high viscosity and hazardous material, called “sulfuric acid pitch”, as a by-product. This compound has a detrimental effect on the environment and is hazardous to humans. The actions have been associated with organized crime with the illegally gained taxes becoming financial bases. To discriminate legal and diesel oil from illegal product, the peak area ratio RSC, the ratio of total sulfur to carbon (>C14), was used. RSC is calculated by the total areas of sulfur and carbon (>C14) from the gas chromatogram obtained by gas chromatography-atomic emission detection (GC-AED). Sulfur in legal diesel fuels is strictly regulated by a maximum limit, which was 50 ppm (and is now 10 ppm), but in the preparation of illegal diesel oil, in which coumarin is eliminated, sulfur cannot be removed. Therefore, the RSC of fuel oil-A and illegal fuel oil is over 15, whereas those for legal fuel oil and diesel fuel are under 2.0. Furthermore, these ratios do not change in weathering experiments. GC-AED was applied to an actual arson case and was found to be effective for the determination of total sulfur in trace amounts of accelerants detected in fire debris at the arson scene, and hence was effective for the characterization of the ignitable liquids used.

A quick discrimination of vegetable oil by solid-phase microextraction method

AbstractA trace amount of vegetable oil was picked up with solid-phase microextraction (SPME) fiber and identified using a gas chromatograph–mass spectrometer (GC–MS). Unsaponifiable constituents such as sterols could be detected by an injection of the SPME fiber, with the fiber touching the vegetable oil and then leading directly into the port of the GC–MS. After thermal desorption of unsaponifiable constituents, the remaining triacylglycerols or oil that was freshly added to the fiber were recovered with a little organic solvent, and the profiles of the fatty acids that had been constructing the acylglycerols were determined using a base-catalyzed trans-esterification method which produced fatty acid methyl esters. The simple and rapid techniques that make up this method make it possible to significantly reduce the preparation time and as well as the required sample volume. When urgent discrimination is required with high accuracy, this technique could serve as a useful and powerful tool for identification of vegetable oil.

Adaquate fixation of plates for stability during mandibular reconstruction

SUMMARYPurposeTo determine the most appropriate plate fixation for dispersing the stress around screws in mandibular reconstruction.Material and methodsForty-eight three-dimensional reconstructed mandibular models with Central (C) or right Lateral (L) defects were created and divided into three groups, fixed with: (1) two screws on each side, (2) three screws on the left side with the third (middle one) located distally, or (3) three screws on the left side with the third (middle one) located proximally. A 300 N vertical load was applied to the left molar region. The maximum stress was calculated using a finite element method and statistically evaluated.ResultsStress was concentrated around the screw at the distal end of the mandibular halves on the loaded side (‘crucial screw’). For the C defect, stress concentrated around the ‘crucial screw’ was greater when there were only two screws for fixation (20.55 MPa) than when there were three screws (16.17 MPa; p=0.022). No significant difference was found between the two groups with three screws for fixation. For the L defect on the other hand, stress on the ‘crucial screw’ was relatively greater when there were three screws for fixation (18.9 MPa) than when there were only two screws for (12.83 MPa; p=0.051). No significant difference was found between the two groups with three screws for fixation. As for the reconstruction plate, the stresses on the plates were not different among the various screw groups for fixation nor among the C and L defects.ConclusionThis paradoxical result is explained by plate bowing. Thus in large defects screw positions should take into consideration the potential for plate bowing.

Current ReadingsCurrent Readings: Status of Robotic Cardiac Surgery

Robotic surgery has been applied to various fields in cardiac surgery. Despite excellent results published in the literature, critics have questioned procedure reproducibility, increased cost, and the real patient benefit. We reviewed 5 recent articles to show that robotic cardiac surgery likely will play an important role in the new era of cardiac surgery.

StructuralImpact of Aortic Root Anatomy and Geometry on Paravalvular Leak in Transcatheter Aortic Valve Replacement With Extremely Large Annuli Using the Edwards SAPIEN 3 Valve

AbstractObjectivesThe aim of this study was to determine factors affecting paravalvular leak (PVL) in transcatheter aortic valve replacement (TAVR) with the Edwards SAPIEN 3 (S3) valve in extremely large annuli.BackgroundThe largest recommended annular area for the 29-mm S3 is 683 mm2. However, experience with S3 TAVR in annuli >683 mm2 has not been widely reported.MethodsFrom December 2013 to July 2017, 74 patients across 16 centers with mean area 721 ± 38 mm2 (range: 684 to 852 mm2) underwent S3 TAVR. The transfemoral approach was used in 95%, and 39% were under conscious sedation. Patient, anatomic, and procedural characteristics were retrospectively analyzed. Valve Academic Research Consortium–2 outcomes were reported.ResultsProcedural success was 100%, with 2 deaths, 1 stroke, and 2 major vascular complications at 30 days. Post-dilatation occurred in 32%, with final balloon overfilling (1 to 5 ml extra) in 70% of patients. Implantation depth averaged 22.3 ± 12.4% at the noncoronary cusp and 20.7 ± 9.9% at the left coronary cusp. New left bundle branch block occurred in 17%, and 6.3% required new permanent pacemakers. Thirty-day echocardiography showed mild PVL in 22.3%, 6.9% moderate, and none severe. There was no annular rupture or coronary obstruction. Mild or greater PVL was associated with larger maximum annular and left ventricular outflow tract (LVOT) diameters, larger LVOT area and perimeter, LVOT area greater than annular area, and higher annular eccentricity.ConclusionsTAVR with the 29-mm S3 valve beyond the recommended range by overexpansion is safe, with acceptable PVL and pacemaker rates. Larger LVOTs and more eccentric annuli were associated with more PVL. Longer term follow-up will be needed to determine durability of S3 TAVR in this population.

StructuralLeft Ventricular Hypertrophy Does Not Affect 1-Year Clinical Outcomes in Patients Undergoing Transcatheter Aortic Valve Replacement

AbstractObjectivesThe aim of this study was to evaluate the association between pre-procedural left ventricular hypertrophy (LVH) patterns and clinical outcomes after transcatheter aortic valve replacement (TAVR).BackgroundThe association between pre-procedural LVH pattern and severity and clinical outcomes after TAVR is uncertain.MethodsPatients (n = 31,199) across 422 sites who underwent TAVR from November 2011 through June 2016 as part of the Society of Thoracic Surgeons/American College of Cardiology TVT (Transcatheter Valve Therapies) Registry linked with the Centers for Medicare and Medicaid Services database were evaluated by varying LVH patterns, according to sex-specific cutoffs for left ventricular mass index and relative wall thickness. The association between LVH pattern (concentric remodeling, concentric LVH, and eccentric LVH) and outcomes (rates of mortality, myocardial infarction [MI], stroke, new dialysis requirement) at 1-year follow-up were evaluated using multivariate hazard models.ResultsThere were no significant associations between concentric remodeling (death: adjusted hazard ratio [HR]: 1.03; 95% confidence interval [CI]: 0.93 to 1.15; MI: HR: 1.05; 95% CI: 0.76 to 1.46; stroke: HR: 1.11; 95% CI: 0.89 to 1.39; new dialysis: HR: 0.86; 95% CI: 0.64 to 1.15), concentric LVH (death: HR: 1.04; 95% CI: 0.95 to 1.15; MI: HR: 1.12; 95% CI: 0.82 to 1.52; stroke: HR: 1.14; 95% CI: 0.92 to 1.40; new dialysis: HR: 1.17; 95% CI: 0.90 to 1.52), or eccentric LVH (death: HR: 0.98; 95% CI: 0.87 to 1.10; MI: HR: 1.07; 95% CI: 0.71 to 1.63; stroke: HR: 1.01; 95% CI: 0.78 to 1.32; new dialysis: HR: 1.25; 95% CI: 0.92 to 1.70) and outcomes at 1 year compared with patients without LVH.ConclusionsIn a contemporary cohort of patients who underwent TAVR, pre-procedural LVH according to left ventricular mass index and relative wall thickness was not associated with adverse outcomes at 1-year follow-up. TAVR is likely to benefit patients with severe aortic stenosis regardless of the presence of LVH.

StructuralOutcomes Following Subclavian and Axillary Artery Access for Transcatheter Aortic Valve Replacement: Society of the Thoracic Surgeons/American College of Cardiology TVT Registry Report

AbstractObjectivesThe aim of this study was to analyze the frequency and outcomes of patients who underwent transsubclavian or transaxillary (TAx) transcatheter aortic valve replacement (TAVR) using the balloon-expandable SAPIEN 3 prosthesis compared with traditional alternative access, transapical (TA) and transaortic (TAo).BackgroundThe transsubclavian and TAx approaches for TAVR are rapidly growing alternatives in the setting of hostile iliofemoral arteries, yet few data exist.MethodsThe Society of Thoracic Surgeons/American College of Cardiology TVT (Transcatheter Valve Therapy) Registry was queried for all patients undergoing TAx TAVR with the SAPIEN 3 prosthesis from June 2015 to February 2018. Secular trends over time were evaluated. Logistic regression analyses used to assess risk-adjusted outcomes. Propensity score matching was used to compare TAx access with TA and TAo access.ResultsIn total, 3,628 patients (5.7%) underwent nontransfemoral access with the SAPIEN 3. Overall, TAx TAVR accounted for 1,249 of these patients (34.4%). There has been rapid recent growth in TAx TAVR (from 20.2% in the third quarter of 2015 to 49.0% in the fourth quarter of 2017; p < 0.001 for trend) and a concomitant decrease in TA and TAo access (from 61.9% in the third quarter of 2015 to 35.3% in the fourth quarter of 2017; p < 0.001 for trend). The median number of TAx TAVR cases per hospital during the study period was 2, and 78.2% of centers performed ≤5 TAx TAVR procedures. The device success rate was 97.3%, and the major vascular complication rate was 2.5%. After propensity matching, TAx access had lower 30-day mortality (5.3% vs. 8.4%; p < 0.01), shorter lengths of intensive care unit and hospital stay, but a higher stroke rate (6.3% vs. 3.1%; p < 0.05) compared with TA and TAo access.ConclusionsTAx access has become the most frequent alternative access route for balloon-expandable TAVR procedures. Outcomes following TAx TAVR appear positive despite the relatively early experience of most centers performing these cases.

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