Original Article
Transcatheter aortic valve implantation: Is anatomy still the limiting factor?
Implantação percutânea de válvula aórtica: a anatomia é (ainda) o factor limitante?
Olga Sousa
, Marta Ponte, Daniel Caeiro, Mónica Carvalho, Daniel Leite, João Rocha, Nuno Bettencourt, José Ribeiro, Pedro Braga, Vasco Gama
Corresponding author
Serviço de Cardiologia, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "281" "paginaFinal" => "286" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Olga Sousa, Marta Ponte, Daniel Caeiro, Mónica Carvalho, Daniel Leite, João Rocha, Nuno Bettencourt, José Ribeiro, Pedro Braga, Vasco Gama" "autores" => array:10 [ 0 => array:4 [ "nombre" => "Olga" "apellidos" => "Sousa" "email" => array:1 [ 0 => "olga-sousa@sapo.pt" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Marta" "apellidos" => "Ponte" ] 2 => array:2 [ "nombre" => "Daniel" "apellidos" => "Caeiro" ] 3 => array:2 [ "nombre" => "Mónica" "apellidos" => "Carvalho" ] 4 => array:2 [ "nombre" => "Daniel" "apellidos" => "Leite" ] 5 => array:2 [ "nombre" => "João" "apellidos" => "Rocha" ] 6 => array:2 [ "nombre" => "Nuno" "apellidos" => "Bettencourt" ] 7 => array:2 [ "nombre" => "José" "apellidos" => "Ribeiro" ] 8 => array:2 [ "nombre" => "Pedro" "apellidos" => "Braga" ] 9 => array:2 [ "nombre" => "Vasco" "apellidos" => "Gama" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Serviço de Cardiologia, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Implantação percutânea de válvula aórtica: a anatomia é (ainda) o factor limitante?" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1660 "Ancho" => 1368 "Tamanyo" => 243977 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Anatomical requirements of the devices.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Transcatheter aortic valve implantation (TAVI) has been shown to be effective and safe in the treatment of patients with severe aortic stenosis and high surgical risk.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–8</span></a> The latest generation prostheses available in Europe are the Medtronic CoreValve (Medtronic Inc., Minneapolis, MN) and the Edwards Sapien XT (Edwards Lifesciences Inc., Irvine, CA). The Medtronic CoreValve is a self-expanding device, available in 26-mm, 29-mm and 31-mm sizes, and can be implanted via a transfemoral, transaxillary/subclavian or transaortic approach. The Edwards Sapien XT is a balloon-expandable valve, available in 23-mm, 26-mm and 29-mm sizes, to be implanted via a transfemoral or transapical approach. Despite rapid advances in these devices, anatomical constraints remain, particularly with regard to the diameter of the aortic annulus (for all approaches) and of the iliofemoral arteries (for transfemoral approach), which can limit patient access to this treatment. Our objective was to determine the proportion of patients referred for TAVI who were anatomically suitable for the technique using the latest devices and the various approaches available.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Methods</span><p id="par0010" class="elsevierStylePara elsevierViewall">We retrospectively analyzed 145 consecutive patients referred to our center for TAVI between March 2007 and October 2011. All patients were assessed by transesophageal echocardiography (TEE) and multidetector computed tomography (MDCT). The aortic annulus diameter obtained by TEE in long-axis view of the left ventricle at 120–140° (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>) was used whenever possible. Minimum iliofemoral diameters were determined by MDCT for the entire segment proximal to the head of the femur, the diameter selected being that of the artery with the most favorable anatomy (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>). The proportion of patients considered suitable for the various devices and approaches was determined according to their respective anatomical requirements (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The aortic annulus diameters required for the Medtronic CoreValve are 20–23<span class="elsevierStyleHsp" style=""></span>mm for the 26-mm, 23–27<span class="elsevierStyleHsp" style=""></span>mm for the 29-mm, and 26–29<span class="elsevierStyleHsp" style=""></span>mm for the 31-mm valve. A further requirement is that the diameter of the ascending aorta be ≤40<span class="elsevierStyleHsp" style=""></span>mm for the 26-mm, and ≤43<span class="elsevierStyleHsp" style=""></span>mm for the 29-mm and 31-mm prostheses. An 18F introducer is used for transfemoral access, which requires a minimum iliofemoral diameter of 6<span class="elsevierStyleHsp" style=""></span>mm. Alternatively, the prosthesis can be delivered via the subclavian artery (also requiring a minimum diameter of 6<span class="elsevierStyleHsp" style=""></span>mm) or directly via the ascending aorta.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The required aortic annulus diameters for the Edwards Sapien XT are 18–22<span class="elsevierStyleHsp" style=""></span>mm for the 23-mm, 21–25<span class="elsevierStyleHsp" style=""></span>mm for the 26-mm, and 24–27<span class="elsevierStyleHsp" style=""></span>mm for the 29-mm valve (the latter is currently available only for a transapical approach). Transfemoral access using the new Edwards eSheath delivery system with a dynamic expansion mechanism requires a minimum iliofemoral diameter of 5.3<span class="elsevierStyleHsp" style=""></span>mm for 23-mm/16F systems and 6<span class="elsevierStyleHsp" style=""></span>mm for 26-mm/18F systems. Alternatively, the device can be implanted using a transapical approach.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The proportion of patients anatomically suitable for the various devices and approaches was compared using the McNemar test.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0030" class="elsevierStylePara elsevierViewall">The study population consisted of 145 patients, of whom 70 were male (48.3%), with a mean age of 78<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>7.1 years. Mean aortic annulus diameter was 22.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.4<span class="elsevierStyleHsp" style=""></span>mm and mean minimum iliofemoral diameter was 7.7<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.5<span class="elsevierStyleHsp" style=""></span>mm (<a class="elsevierStyleCrossRefs" href="#fig0020">Figures 4 and 5</a>).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Of the 145 patients, 129 (89%) were suitable for Medtronic CoreValve prostheses via transfemoral access and 136 (93.8%) were suitable for transaxillary or transaortic approaches; with regard to Edwards Sapien XT devices, 119 patients (82.1%) were suitable for transfemoral and 141 (97.2%) for transapical approaches. Of nine patients who were anatomically unsuitable for Medtronic CoreValve prostheses, seven could be treated with Edwards Sapien XT devices, while of four unsuitable for Edwards prostheses, two were treatable by CoreValve devices. Only two patients (1.4%) were anatomically unsuitable for TAVI using any device or approach (<a class="elsevierStyleCrossRef" href="#fig0030">Figure 6</a>). A similar proportion of patients were suitable for CoreValve or Edwards devices (93.8% vs. 97.2%, p=0.1797). Assessment on the basis of multiple devices increased the proportion of the study population with suitable anatomy from 93.8% to 98.6% (p=0.016) for the Medtronic CoreValve, and from 97.2% to 98.6% (p=0.5) for the Edwards Sapien XT. The proportion of patients treatable by transfemoral access on the basis of multiple devices was 93.8%, significantly higher than the 89% with Medtronic CoreValve (p=0.016) and the 82.1% with Edwards Sapien XT (p<0.001) valves. The proportion of patients anatomically suitable for TAVI on the basis of multiple devices and multiple access approaches was 98.6%, compared to 93.8% (p=0.0156) with multiple devices via transfemoral access only.</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Of the 145 patients assessed, 72 had undergone TAVI up to October 2011; of these, 71 were implanted with Medtronic CoreValve devices (60 via transfemoral, nine via subclavian/transaxillary and two via transaortic approaches) and one patient was treated with an Edwards Sapien XT valve.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">The study considered only two anatomical criteria – aortic annulus diameter and iliofemoral artery diameter – since these dictate the eligibility of patients for TAVI and the approach to adopt. Nevertheless, there are other anatomical aspects that need to be considered, including the presence of severe left ventricular hypertrophy, small sinuses of Valsalva, and excessive calcification or tortuosity of the iliofemoral arteries.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> These factors are not absolute exclusion criteria but they will affect procedure success and complication rate, as well as increasing risk, and should thus be assessed on a case-by-case basis.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Determining aortic annulus diameter is an essential step in evaluating candidates for TAVI, since it may immediately exclude a patient from the procedure or dictate the type of device to be implanted. It must therefore be measured accurately, since it determines the choice of the most appropriate prosthesis in each case to minimize the risk of paravalvular leak and device migration.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> There is currently no gold standard exam for annulus measurement, which can be performed by transthoracic echocardiography (TTE), TEE, MDCT or calibrated aortography,<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a> but the few studies comparing the different methods have conflicting results. One limitation of two-dimensional echocardiography is that measurements are based on a single view and assume that the aortic annulus is circular. However, MDTC studies have demonstrated that the annulus is often oval, with significant differences between minimum and maximum diameters.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> In general, the aortic annulus diameter is greater when assessed by MDTC than by TEE, and the latter is in turn greater than that assessed by TTE.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,12–14</span></a> In current clinical practice, the eligibility of patients for TAVI and the choice of prosthesis size are generally based on TEE measurement since it is the standard technique and has shown good results.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,13</span></a> Recent studies on three-dimensional (3D) imaging have shown a good correlation between measurements obtained by 3D TEE and those assessed by MDCT, which makes echocardiographic assessment a more viable option in these patients.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15,16</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Another essential step in evaluating these patients is assessment of the peripheral arterial system, which determines the approach to adopt. This can be performed by MDTC, peripheral angiography or magnetic resonance imaging with gadolinium.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> MDTC is a non-invasive technique that provides good quality images of the vascular system through cross-sectional views and 3D reconstructions, which help in procedure planning.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Nearly all patients (98.6%) in our study population were considered anatomically suitable for TAVI based on all the prostheses and approaches available. Another important finding was that most patients (93.8%) could be treated via transfemoral access, the preferred approach for any percutaneous procedure.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Although each device was able to treat a large number of patients, assessment on the basis of multiple devices further extended the range of treatable patients. Replacement valves are now more similar in terms of anatomical requirements compared to earlier devices. Nevertheless, there are still important structural differences between them, which can prompt the choice of one over another according to individual patient characteristics. Marked angulation of the ascending aorta or aortic arch may be more suited to anterograde (transapical) delivery of the prosthesis,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> as would a markedly sigmoid septum<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>; in cases of low ostial implantation of the coronary arteries, it is safer to use a self-expanding prosthesis.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> As more experience is gained of the various devices and approaches, it will be possible to tailor the choice of prosthesis and approach to individual patients.</p><p id="par0070" class="elsevierStylePara elsevierViewall">A study published in 2010 of 100 candidates for TAVI demonstrated that 89% were suitable for CoreValve and 88% for Edwards devices,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> but when assessed for transfemoral access only, 84% were treatable with CoreValve and 28% with Edwards prostheses. The study assessed anatomical suitability based on the devices available at that time (26-mm and 29-mm CoreValve with 18F transfemoral access, and 23-mm and 26-mm Edwards Sapien, with 22F and 24F femoral access, respectively).</p><p id="par0075" class="elsevierStylePara elsevierViewall">Recent years have seen rapid developments in percutaneous aortic valve prostheses, with new sizes and smaller-profile delivery systems, with the result that a greater number of patients are now considered anatomically suitable for the technique.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Besides anatomical features, other factors affect eligibility for TAVI and mean that many patients will be poor candidates. Moderate to severe mitral regurgitation or low ejection fraction with no contractile reserve, although they should be assessed on a case-by-case basis, are generally exclusion criteria. In addition, many of these patients are elderly and frail in poor general health, or have major comorbidities that will affect their short-term survival. Since current devices have fewer anatomical constraints, such clinical aspects are now the main factors affecting patient access to percutaneous treatment. Even so, ongoing technological advances in this area are likely to lead to a new generation of devices that will overcome the remaining anatomical limitations, simplify the procedure and minimize complications.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Up until October 2011, 72 of the 145 patients assessed at our center had undergone TAVI. We cannot be certain that 98.6% were anatomically suitable for the technique at the time of referral to our center, since in most cases not all the devices considered in this study were on the market. For example, the Edwards Sapien XT prosthesis was only available in our center from July 2011 and the transapical approach was only implemented in 2012. In addition, some of these patients are on the waiting list for the procedure. Lastly, despite being anatomically suitable for TAVI, many patients present the clinical characteristics mentioned above (frailty, poor general health and comorbidities) which make them poor candidates for the technique.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0090" class="elsevierStylePara elsevierViewall">In this population, 98.6% of the patients were considered anatomically suitable for TAVI using the devices and approaches currently available, and 93.8% could be treated via transfemoral access. Rapid advances in these devices have overcome most of the initial anatomical constraints, significantly extending the range of candidates for the treatment. At present, clinical rather than anatomical characteristics appear to be the main factor affecting access to percutaneous treatment for most patients with severe aortic stenosis and high surgical risk.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Ethical disclosures</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Protection of human and animal subjects</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Confidentiality of data</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data and that all the patients included in the study received sufficient information and gave their written informed consent to participate in the study.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Right to privacy and informed consent</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:2 [ "identificador" => "xres251748" "titulo" => array:5 [ 0 => "Abstract" 1 => "Introduction" 2 => "Methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec239346" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres251747" "titulo" => array:5 [ 0 => "Resumo" 1 => "Introdução" 2 => "Métodos" 3 => "Resultados" 4 => "Conclusões" ] ] 3 => array:2 [ "identificador" => "xpalclavsec239347" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:3 [ "identificador" => "sec0030" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Right to privacy and informed consent" ] ] ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflicts of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-04-15" "fechaAceptado" => "2012-08-09" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec239346" "palabras" => array:4 [ 0 => "Transcatheter aortic valve implantation" 1 => "Anatomy" 2 => "Aortic annulus" 3 => "Iliofemoral arteries" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec239347" "palabras" => array:4 [ 0 => "Implantação percutânea válvula aórtica" 1 => "Anatomia" 2 => "Anel aórtico" 3 => "Artérias iliofemorais" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Despite rapid advances in transcatheter aortic valve prostheses, anatomical constraints remain that can limit access to this treatment for patients with severe aortic stenosis. The objective of this study was to determine the proportion of patients anatomically suitable for this technique using the different devices and approaches available.</p> <span class="elsevierStyleSectionTitle">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We retrospectively analyzed 145 consecutive patients referred to our center for transcatheter aortic valve implantation. Aortic annulus diameter was measured by transesophageal echocardiography and minimum iliofemoral diameter was determined by multidetector computed tomography. We determined the proportion of patients anatomically suitable for current devices (26-mm, 29-mm and 31-mm Medtronic CoreValve for transfemoral, transaxillary or transaortic approaches, and 23-mm, 26-mm and 29-mm Edwards Sapien XT for transfemoral or transapical approaches).</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The Medtronic CoreValve was suitable for 89% of patients via transfemoral access and 93.8% via transaxillary or transaortic approaches, while the Edwards Sapien XT was suitable for 82.1% of patients via transfemoral and 97.2% via transapical approaches. Only 1.4% of patients were anatomically unsuitable for all devices and approaches.</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In this population, most patients were anatomically suitable for transcatheter aortic valve implantation if assessed on the basis of multiple devices and multiple access approaches.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span class="elsevierStyleSectionTitle">Introdução</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Apesar de a rápida evolução das próteses valvulares aórticas percutâneas, persistem restrições anatómicas que podem limitar o acesso dos doentes com estenose aórtica severa a este tratamento. O objetivo deste estudo foi determinar a proporção de doentes anatomicamente adequados para os diferentes dispositivos e acessos, numa população candidata a este tratamento.</p> <span class="elsevierStyleSectionTitle">Métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Análise retrospetiva de 145 doentes consecutivos referenciados ao nosso centro para implantação de válvula aórtica percutânea. A dimensão do anel aórtico foi determinada por ecocardiograma transesofágico e o diâmetro mínimo das artérias iliofemorais foi obtido por tomografia computadorizada multidetetores. Foi determinada a proporção de doentes anatomicamente adequados para as próteses actualmente disponíveis (Medtronic CoreValve de 26, 29 e 31<span class="elsevierStyleHsp" style=""></span>mm por acesso transfemoral, transaxilar ou transaórtico; Edwards Sapien XT de 23, 26 e 29<span class="elsevierStyleHsp" style=""></span>mm por acesso transfemoral ou transapical).</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Dos doentes avaliados, 89% eram adequados para as próteses Medtronic CoreValve por via transfemoral e 93,8% eram adequados para abordagem subclávia ou transaórtica. Em relação às próteses Edwards Sapien XT, 82,1% eram adequados para acesso transfemoral e 97,2% eram adequados para a via transapical. Apenas 1,4% dos doentes não apresentavam anatomia viável para esta técnica considerando todos os dispositivos e abordagens possíveis.</p> <span class="elsevierStyleSectionTitle">Conclusões</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Nesta população, a maioria dos doentes foi considerada anatomicamente adequada para tratamento percutâneo, numa estratégia multi-dispositivo e multi-abordagem.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Sousa O, et al. Implantação percutânea de válvula aórtica: a anatomia é (ainda) o fator limitante? Rev Port Cardiol. 2013. <span class="elsevierStyleInterRef" href="doi:10.1016/j.repc.2012.08.009">doi:10.1016/j.repc.2012.08.009</span>.</p>" ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1070 "Ancho" => 1583 "Tamanyo" => 109231 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Measurement of aortic annulus diameter by transesophageal echocardiography.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 3091 "Ancho" => 1583 "Tamanyo" => 312600 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Measurement of minimum iliofemoral diameters by multidetector computed tomography.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1660 "Ancho" => 1368 "Tamanyo" => 243977 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Anatomical requirements of the devices.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 993 "Ancho" => 1660 "Tamanyo" => 127687 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Aortic annulus diameters in the study population measured by transesophageal echocardiography.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 972 "Ancho" => 1674 "Tamanyo" => 81668 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Minimum iliofemoral diameters in the study population measured by multidetector computed tomography.</p>" ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 1340 "Ancho" => 2618 "Tamanyo" => 151893 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Anatomical suitability of the study population for different devices and approaches.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:16 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Percutaneous transcatheter implantation of an aortic valve prosthesis for calcific aortic stenosis: first human description" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 5 | 11 |
| 2024 October | 32 | 27 | 59 |
| 2024 September | 35 | 22 | 57 |
| 2024 August | 31 | 25 | 56 |
| 2024 July | 30 | 26 | 56 |
| 2024 June | 28 | 17 | 45 |
| 2024 May | 36 | 18 | 54 |
| 2024 April | 37 | 22 | 59 |
| 2024 March | 37 | 22 | 59 |
| 2024 February | 28 | 22 | 50 |
| 2024 January | 33 | 20 | 53 |
| 2023 December | 22 | 25 | 47 |
| 2023 November | 35 | 20 | 55 |
| 2023 October | 27 | 13 | 40 |
| 2023 September | 29 | 20 | 49 |
| 2023 August | 33 | 15 | 48 |
| 2023 July | 38 | 13 | 51 |
| 2023 June | 35 | 14 | 49 |
| 2023 May | 39 | 28 | 67 |
| 2023 April | 29 | 5 | 34 |
| 2023 March | 43 | 20 | 63 |
| 2023 February | 26 | 27 | 53 |
| 2023 January | 40 | 15 | 55 |
| 2022 December | 43 | 20 | 63 |
| 2022 November | 47 | 29 | 76 |
| 2022 October | 41 | 29 | 70 |
| 2022 September | 47 | 31 | 78 |
| 2022 August | 43 | 37 | 80 |
| 2022 July | 47 | 35 | 82 |
| 2022 June | 39 | 27 | 66 |
| 2022 May | 35 | 38 | 73 |
| 2022 April | 41 | 27 | 68 |
| 2022 March | 27 | 28 | 55 |
| 2022 February | 36 | 19 | 55 |
| 2022 January | 47 | 19 | 66 |
| 2021 December | 29 | 28 | 57 |
| 2021 November | 46 | 35 | 81 |
| 2021 October | 46 | 29 | 75 |
| 2021 September | 38 | 26 | 64 |
| 2021 August | 47 | 27 | 74 |
| 2021 July | 33 | 21 | 54 |
| 2021 June | 34 | 24 | 58 |
| 2021 May | 35 | 45 | 80 |
| 2021 April | 40 | 26 | 66 |
| 2021 March | 69 | 20 | 89 |
| 2021 February | 63 | 11 | 74 |
| 2021 January | 41 | 14 | 55 |
| 2020 December | 24 | 10 | 34 |
| 2020 November | 51 | 14 | 65 |
| 2020 October | 35 | 14 | 49 |
| 2020 September | 52 | 7 | 59 |
| 2020 August | 30 | 9 | 39 |
| 2020 July | 65 | 6 | 71 |
| 2020 June | 45 | 13 | 58 |
| 2020 May | 51 | 8 | 59 |
| 2020 April | 39 | 10 | 49 |
| 2020 March | 59 | 9 | 68 |
| 2020 February | 95 | 10 | 105 |
| 2020 January | 43 | 6 | 49 |
| 2019 December | 40 | 3 | 43 |
| 2019 November | 29 | 3 | 32 |
| 2019 October | 33 | 3 | 36 |
| 2019 September | 37 | 10 | 47 |
| 2019 August | 31 | 5 | 36 |
| 2019 July | 55 | 10 | 65 |
| 2019 June | 48 | 8 | 56 |
| 2019 May | 49 | 5 | 54 |
| 2019 April | 26 | 14 | 40 |
| 2019 March | 33 | 9 | 42 |
| 2019 February | 57 | 9 | 66 |
| 2019 January | 38 | 6 | 44 |
| 2018 December | 63 | 24 | 87 |
| 2018 November | 100 | 6 | 106 |
| 2018 October | 140 | 13 | 153 |
| 2018 September | 53 | 12 | 65 |
| 2018 August | 47 | 6 | 53 |
| 2018 July | 23 | 3 | 26 |
| 2018 June | 40 | 6 | 46 |
| 2018 May | 71 | 5 | 76 |
| 2018 April | 60 | 2 | 62 |
| 2018 March | 84 | 7 | 91 |
| 2018 February | 48 | 2 | 50 |
| 2018 January | 43 | 4 | 47 |
| 2017 December | 67 | 7 | 74 |
| 2017 November | 57 | 9 | 66 |
| 2017 October | 45 | 7 | 52 |
| 2017 September | 46 | 12 | 58 |
| 2017 August | 40 | 10 | 50 |
| 2017 July | 30 | 10 | 40 |
| 2017 June | 51 | 7 | 58 |
| 2017 May | 56 | 9 | 65 |
| 2017 April | 31 | 9 | 40 |
| 2017 March | 99 | 18 | 117 |
| 2017 February | 126 | 2 | 128 |
| 2017 January | 64 | 5 | 69 |
| 2016 December | 66 | 13 | 79 |
| 2016 November | 53 | 9 | 62 |
| 2016 October | 79 | 14 | 93 |
| 2016 September | 157 | 9 | 166 |
| 2016 August | 30 | 2 | 32 |
| 2016 July | 33 | 9 | 42 |
| 2016 June | 34 | 4 | 38 |
| 2016 May | 22 | 3 | 25 |
| 2016 April | 65 | 1 | 66 |
| 2016 March | 79 | 21 | 100 |
| 2016 February | 103 | 28 | 131 |
| 2016 January | 94 | 19 | 113 |
| 2015 December | 88 | 19 | 107 |
| 2015 November | 98 | 19 | 117 |
| 2015 October | 112 | 20 | 132 |
| 2015 September | 97 | 10 | 107 |
| 2015 August | 90 | 20 | 110 |
| 2015 July | 105 | 8 | 113 |
| 2015 June | 73 | 6 | 79 |
| 2015 May | 78 | 9 | 87 |
| 2015 April | 74 | 12 | 86 |
| 2015 March | 67 | 3 | 70 |
| 2015 February | 75 | 9 | 84 |
| 2015 January | 78 | 10 | 88 |
| 2014 December | 115 | 12 | 127 |
| 2014 November | 73 | 7 | 80 |
| 2014 October | 76 | 11 | 87 |
| 2014 September | 72 | 12 | 84 |
| 2014 August | 56 | 9 | 65 |
| 2014 July | 62 | 14 | 76 |
| 2014 June | 53 | 6 | 59 |
| 2014 May | 82 | 9 | 91 |
| 2014 April | 73 | 6 | 79 |
| 2014 March | 89 | 28 | 117 |
| 2014 February | 104 | 16 | 120 |
| 2014 January | 105 | 17 | 122 |
| 2013 December | 73 | 17 | 90 |
| 2013 November | 85 | 19 | 104 |
| 2013 October | 76 | 12 | 88 |
| 2013 September | 76 | 20 | 96 |
| 2013 August | 98 | 23 | 121 |
| 2013 July | 70 | 27 | 97 |
| 2013 June | 17 | 6 | 23 |
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