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OBJECTIVES Obesity may increase the risk of vascular complications in transfemoral (TF) transcatheter aortic valve replacement (TAVR) procedures. The transcarotid (TC) approach has recently emerged as an alternative access in TAVR. We sought to compare vascular complications and early clinical outcomes in obese patients undergoing TAVR either by TF or TC vascular access. METHODS Multicentre registry including obese patients undergoing TF- or TC-TAVR in 15 tertiary centres. All patients received newer-generation transcatheter heart valves. For patients exhibiting unfavourable ileo-femoral anatomic characteristics, the TC approach was favoured in 3 centres with experience with it. A propensity score analysis was performed for overcoming unbalanced baseline covariates. The primary end point was the occurrence of in-hospital vascular complications (Valve Academic Research Consortium-2 criteria). RESULTS A total of 539 patients were included, 454 (84.2%) and 85 (15.8%) had a TF and TC access, respectively. In the propensity-adjusted cohort (TF: 442 patients; TC: 85 patients), both baseline and procedural valve-related characteristics were well-balanced between groups. A significant decrease in vascular complications was observed in the TC group (3.5% vs 12% in the TF group, odds ratio: 0.26, 95% CI: 0.07–0.95, P = 0.037). There were no statistically significant differences between groups regarding in-hospital mortality (TC: 2.8%, TF: 1.5%), stroke (TC: 1.2%, TF: 0.4%) and life-threatening/major bleeding events (TC: 2.8%, TF: 3.8%). CONCLUSIONS In patients with obesity undergoing TAVR with newer-generation devices, the TC access was associated with a lower rate of vascular complications. Larger randomized studies are warranted to further assess the better approach for TAVR in obese patients.

Vàlvula aòrtica bicúspide; Talla del bicúspide; SAPIEN 3/Ultra Válvula aórtica bicúspide; Talla del bicúspide; SAPIEN 3/Ultra Bicuspid aortic valve; Bicuspid sizing; SAPIEN 3/Ultra Severe aortic stenosis patients with bicuspid anatomy have been excluded from the major transcatheter aortic valve replacement (TAVI) randomized clinical trials. As a result, there is no official recommendation on bicuspid TAVI. A panel of bicuspid experts was created to fill this gap. In this consensus statement, an algorithm is proposed to guide the choice of surgery or TAVI within this complex patient population, depending on aortic dilatation, age, surgical risk score, and anatomy. A step-by-step guide for sizing and positioning of the SAPIEN 3/Ultra TAVI bioprostheses is presented. Annular sizing remains the primary strategy in most bicuspid patients. However, some anatomies may require sizing at the supra-annular level, for which patients the panel recommends the circle method, a dedicated sizing and positioning approach for SAPIEN 3/Ultra. The consensus provides valuable pre-operative insights on the interactions between SAPIEN 3/Ultra and the bicuspid anatomy; understanding the valve–anatomy relationship is critical to avoid complications and to optimize outcomes for patients. The journal’s Rapid Service Fee was supported by Edwards Lifesciences.

Estenosis aórtica; Lactante; Cirugía de Ross Aortic stenosis; Infant; Ross procedure Estenosi aòrtica; Lactant; Cirurgia de Ross Introducción y objetivos La estenosis valvular aórtica severa en edad pediátrica supone un auténtico reto quirúrgico. Las opciones terapéuticas son altamente complejas, especialmente en niños menores de un año de edad. La cirugía de Ross está indicada en aquellos casos donde la reparación quirúrgica o la valvuloplastia con balón no han sido factibles. El objetivo del estudio es comparar los resultados postoperatorios y en el seguimiento de los pacientes menores de un año con la totalidad de pacientes intervenidos de Ross/Ross-Konno en nuestro centro. Métodos Se recogieron de manera consecutiva todos los pacientes intervenidos en nuestro centro mediante estos dos procedimientos durante los últimos 10 años. Durante ese periodo, se intervinieron a 11 pacientes (cinco Ross y seis Ross-Konno) de los cuales tres corresponden a pacientes menores de un año. Resultados La mortalidad hospitalaria es del 9,1% (un paciente) con una supervivencia a 10 años del 90,9%. El porcentaje de reoperaciones en el seguimiento es del 72,7% siendo mayor en los pacientes menores de un año (100 vs. 62,5%). Sólo un paciente requirió una reintervención sobre el autoinjerto en edad adulta. La necesidad de intervención sobre el tracto de salida derecho es del 64,6% a 10 años. Conclusiones La mortalidad postoperatoria y supervivencia a los 10 años de los pacientes intervenidos durante el primer año de vida no difiere del resto de pacientes de mayor edad, aunque la tasa de reintervenciones en el seguimiento es mayor en este subgrupo de pacientes. Introduction and objectives Severe aortic valve stenosis in pediatric population represents a real surgical challenge. Therapeutic options are highly complex, especially in children under one year of age. Ross procedure is indicated in those cases where surgical repair or balloon valvuloplasty has not been feasible. The aim of the study is compare the postoperative outcomes and in the follow-up of patients under one year with all the patients who underwent Ross / Ross-Konno procedure in our centre. Methods Consecutive patients operated in our centre with these two procedures for the last ten years were collected. During this period, 11 patients were operated (5 Ross and 6 Ross-Konno) of which 3 corresponded to patients under one year of age. Results Hospital mortality is 9,1% (1 patient) with a 10-year survival of 90,9%. The reoperations percentage is 72,7%, higher in patients less than 1-year-old (100% vs. 62,5%). Only one patient required an autograft reoperation in the adulthood. The right ventricle outflow tract reoperation rate is 64,6% at 10 years. Conclusions Postoperative mortality and survival at 10 years of patients operated on during the first year of life does not differ from the rest of older patients, although the rate of reoperations in the follow-up is higher in this subgroup of patients.

ObjectivesTo determine the risk of mortality and need for aortic valve replacement (AVR) in patients with low-flow low-gradient (LFLG) aortic stenosis (AS).MethodsA longitudinal multicentre study including consecutive patients with severe AS (aortic valve area [AVA] < 1.0 cm2) and normal left ventricular ejection fraction (LVEF). Patients were classified as: high-gradient (HG, mean gradient ≥ 40 mmHg), normal-flow low-gradient (NFLG, mean gradient < 40 mmHg, indexed systolic volume (SVi) > 35 ml/m2) and LFLG (mean gradient < 40 mmHg, SVi ≤ 35 ml/m2).ResultsOf 1,391 patients, 147 (10.5%) had LFLG, 752 (54.1%) HG, and 492 (35.4%) NFLG. Echocardiographic parameters of the LFLG group showed similar AVA to the HG group but with less severity in the dimensionless index, calcification, and hypertrophy. The HG group required AVR earlier than NFLG (p < 0.001) and LFLG (p < 0.001), with no differences between LFLG and NFLG groups (p = 0.358). Overall mortality was 27.7% (CI 95% 25.3–30.1) with no differences among groups (p = 0.319). The impact of AVR in terms of overall mortality reduction was observed the most in patients with HG (hazard ratio [HR]: 0.17; 95% CI: 0.12–0.23; p < 0.001), followed by patients with LFLG (HR: 0.25; 95% CI: 0.13–0.49; p < 0.001), and finally patients with NFLG (HR: 0.29; 95% CI: 0.20–0.44; p < 0.001), with a risk reduction of 84, 75, and 71%, respectively.ConclusionsParadoxical LFLG AS affects 10.5% of severe AS, and has a lower need for AVR than the HG group and similar to the NFLG group, with no differences in mortality. AVR had a lower impact on LFLG AS compared with HG AS. Therefore, the findings of the present study showed LFLG AS to have an intermediate clinical risk profile between the HG and NFHG groups.

BackgroundThe Toronto Aortic Stenosis Quality of Life Questionnaire (TASQ) is a validated instrument for assessing quality of life (QoL) in patients with severe aortic stenosis (AS). In this study, we evaluated health status outcomes, based on the TASQ, in patients with severe AS undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR).MethodsThe TASQ registry was a prospective observational registry. Patients with severe AS from nine centres in Europe and one in Canada underwent either SAVR or transfemoral TAVR. Patients completed the TASQ, Kansas City Cardiomyopathy Questionnaire and Short Form-12 V.2 prior to the intervention, predischarge, and at 30-day and 3-month follow-ups. Primary end point was the TASQ score.ResultsIn both the TAVR (n=137) and SAVR (n=137) cohorts, significant increases were observed in all three scores. The overall TASQ score improved as did all but one of the individual domains at 3 months after the intervention (pConclusionsThe TASQ captured changes in QoL among patients with severe AS who were treated with TAVR or SAVR. QoL improved substantially after either intervention, as indicated by changes in the TASQ overall score at 3 months.Trial registration numberNCT03186339.

Reemplaçament de la vàlvula aòrtica; Qualitat de vida; Qüestionari Reemplazo de la válvula aórtica; Calidad de vida; Cuestionario Aortic valve replacement; Quality of life; Questionnaire Aims There is no quality of life tool specifically developed for patients with severe aortic stenosis (AS) to assess how this chronic condition and its treatment affect patients. The Toronto Aortic Stenosis Quality of Life Questionnaire (TASQ) has been developed to overcome this gap. The results of the validation of the TASQ in patients undergoing treatment for severe AS are presented. Methods and results Prospective study at 10 centres in Europe and Canada, which enrolled 274 patients with severe symptomatic AS undergoing surgical or transcatheter aortic valve replacement. Mean TASQ score at baseline was 71.2 points and increased to 88.9 three months after aortic valve implantation (P < 0.001). Increases were seen for the emotional impact (32.0 to 39.0; P < 0.001), physical limitations (14.8 to 22.0; P < 0.001), and physical symptoms (8.5 vs. 11.0; P < 0.001) domains. Internal consistency was good/excellent for overall TASQ score (α = 0.891) and for the physical limitation, emotional impact, and social limitation domains (α = 0.815–0.950). Test–retest reliability was excellent or strong for the overall TASQ (intraclass correlation coefficient of 0.883) and for the physical symptoms, physical limitation, emotional impact, and social limitation domains (intraclass correlation coefficient of 0.791–0.895). Responsiveness was medium overall (Cohen's d = 0.637) and medium/large for physical symptoms, emotional impact, and physical limitations (0.661–0.812). Sensitivity to change was significant for physical symptoms, physical limitations (both P < 0.001), emotional impact (P = 0.003), and social limitations (P = 0.038). Conclusions The TASQ is a new, brief, self‐administered, and clinically relevant health‐specific tool to measure changes in quality of life in patients with AS undergoing an intervention. This work was supported by a research grant provided by Edwards Lifesciences (Nyon, Switzerland) to the Institute for Pharmacology and Preventive Medicine (Cloppenburg, Germany).

Estenosi aòrtica; Implant transcatèter de pròtesis valvulars aòrtiques; TAVI Estenosis aórtica; Implante transcatéter de prótesis valvulares aórticas; TAVI Aortic stenosis; Transcatheter implant of aortic valve prostheses; TAVI L’estenosi aòrtica (EAo) és una malaltia crònica progressiva, la prevalença de la qual s’incrementa amb l’edat fins a arribar a un 7-8% de la població més gran de 85 anys. La seva letalitat és elevada, amb una supervivència mitjana de 2-3 anys des de l’aparició dels símptomes. Tradicionalment, el tractament d’elecció de l’estenosi aòrtica ha estat quirúrgic (pròtesi valvular), però aquesta opció no es pot dur a terme en un percentatge elevat de pacients a causa de les contraindicacions o per inoperabilitat, de manera que fins fa uns anys només se’n feia un tractament conservador. Aquests últims anys, s’ha desenvolupat una nova alternativa per als pacients no candidats a cirurgia o d’alt risc quirúrgic, que és l’implant transcatèter de pròtesi valvular aòrtica (TAVI). Atès que es tracta d’una tecnologia relativament nova, indicada en subgrups específics de malalts, sobre la qual existeixen evidències clares d’eficàcia i seguretat, i atès que presenta un elevat impacte, tant organitzatiu com econòmic, es va considerar convenient crear un grup de treball per revisar i prioritzar les indicacions d’aquesta tècnica, i definir els requisits que havien de complir els centres hospitalaris per poder dur-la a terme amb la qualitat adequada. Això va donar lloc a la redacció d’un document sobre les Recomanacions d’indicacions per a la implantació de TAVI a Catalunya 2016, a la instrucció administrativa que en regulava l’ús i a la creació d’un registre per a l’auditoria. Actualment, els grans avenços en la tècnica i les dades de la literatura sobre l’expansió de l’ús que se’n fa aconsellen la revisió del document previ. Aquest document es basa en les guies de pràctica clínica més actuals i en les dades actualitzades de la literatura, alhora que s’ha mirat d’adaptar a la realitat socioeconòmica de Catalunya.

Pròtesi valvular; Cateterisme cardíac; Planificació sanitària Prosthetic valve; Cardiac catheterization; Health planning Prótesis valvular; Cateterismo cardíaco; Planificación sanitaria L'objecte d'aquesta instrucció és establir l'ordenació del procediment d'implant transcatèter de pròtesis valvulars aòrtiques al CatSalut. The purpose of this Instruction is to set the arrangement procedure transcatheter implant prosthetic aortic valve in the CatSalut. El objeto de esta Instrucción es establecer la ordenación del procedimiento de implante transcatéter de prótesis valvulares aórticas en el CatSalut.

Estenosi aòrtica; Implant transcatèter de pròtesis valvulars aòrtiques; TAVI Estenosis aórtica; Implante transcatéter de prótesis valvulares aórticas; TAVI Aortic stenosis; Transcatheter implant of aortic valve prostheses; TAVI L’estenosi aòrtica (EAo) és una malaltia crònica progressiva, la prevalença de la qual s’incrementa amb l’edat, arribant a un 7-8% de la població major de 85 anys. Encara que el tractament d’elecció és quirúrgic (pròtesi valvular), aquest no es pot realitzar en un percentatge elevat de pacients degut a contraindicacions o inoperabilitat, de manera que fins fa uns anys només es realitzava tractament conservador. Darrerament s’ha desenvolupat una nova alternativa per als pacients no candidats a cirurgia, que és l’implant transcatèter de pròtesis valvulars aòrtiques (TAVI, transcatheter aortic-valve implantation), que es pot fer per via percutània (generalment transfemoral) o mitjançant una minitoracotomia (via transapical).