International Society For Minimally Invasive Cardiothoracic Surgery

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Lower Volume High Quality Outcomes: Veterans Affairs Heart Team Experience With Tavr And Minimally Invasive Surgical Aortic Valve Replacement
Andrew D. Wisneski1, Norah E. Liang1, Sue Wang2, Kendrick A. Shunk1, Curtis J. Wozniak1, Joseph Yang1, Jeffrey Zimmet1, Liang Ge1, Elaine E. Tseng1.
1University of California San Francisco/San Francisco VA Medical Center, San Francisco, CA, USA, 2Brigham and Women's Hospital, Boston, MA, USA.

Background: Aortic valve disease is prevalent in the United States (US) veteran population. Transcatheter aortic valve replacement (TAVR) and minimally invasive surgical aortic valve replacement (MIAVR) are minimally invasive approaches predominantly performed at higher-volume cardiac centers. The study aim was to evaluate our experience with minimally invasive techniques at a Veterans Affairs Medical Center (VAMC), since outcomes from lower-volume US federal facilities are relatively unknown.
Methods: This study examines retrospective data from 228 consecutive patients who underwent treatment for isolated aortic valve disease with MIAVR or TAVR via intent to treat at a VAMC between January 2011 and July 2017. Perioperative outcomes were analyzed using Stata Version 15.
Results: Operative mortality was 1.1% for MIAVR and 0.7% for TAVR (p=0.79, χ2). Median length of hospital stay was 10 days (IQR:7-14) for MIAVR and 4 days for TAVR (3-6; p<0.001, Mann-Whitney). Post-operative new onset atrial fibrillation occurred in 52% of MIAVR patients and 5.2% of TAVR patients (p<0.001, χ2). Stroke occurred in 2.2% of MIAVR patients and 3.0% of TAVR patients (p=0.71, χ2). In patients who underwent MIAVR, 5.4% required placement of a permanent pacemaker post-operatively, compared to 14% of TAVR patients (p=0.04, χ2). Mild paravalvular leak (PVL) affected 2.2% of MIAVR and 28% of TAVR patients, with moderate PVL reported in 2.2% of MIAVR and 3% of TAVR patients (p<0.001, χ2). Kaplan-Meier survival curves and freedom from late structural valve deterioration (SVD) are shown in Figure 1. SVD defined as mean gradient ≥20mmHg.
Conclusions: The VAMC heart team offers MIAVR and TAVR to veterans with isolated aortic valve disease, and has achieved excellent outcomes despite relatively lower case volumes. Both offer excellent hemodynamic results, with low mortality in a complex population.


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