Contrast agent is a potential risk factor for acute kidney injury (AKI). Little is known about the incidence of contrast-induced nephropathy (CIN) after trans-apical aortic valve implantation (TA-AVI) and on the impact of contrast exposure during preoperative computed tomography (CT) scan and cardiac catheterization. A total of 270 consecutive high-risk patients received TA-AVI for symptomatic aortic valve stenosis during a 3-year period. Different preoperative, peri-procedural, and postoperative variables were analyzed by uni- and multivariate logistic regression concerning incidence of early (99 ml (OR=2.3, p=0.038), new thrombocytopenia (OR=4.4, p=0.005) and pathological leucocyte count (OR=2.8, p=0.009) were independent risk factors for this event. Early (within 1-7 days before TA-AVI) preoperative CT and cardiac catheterization did not significantly increase incidence of RRT or AKI. Short-term and long-term survival was explicitly lower in the AKI and in the RRT groups (p<0.001 each). GFR improves after TA-AVI. Postoperative AKI and RRT depend on the amount of intra-operative contrast agent. These results strongly support the need for intra-operative tools to reduce contrast-agent exposition during TA-AVI.

The precise sizing of the aortic annulus is crucial in order to select the most appropriate valve size for transcatheter aortic valve implantation (TAVI). Owing to the closed heart situation in TAVI, sizing has to be performed based on preoperative imaging when compared with direct sizing during conventional procedures. The aim of the study was to evaluate valve sizing performed either by CT-scan or by echocardiography by comparing these imaging-based measurements with direct intraoperative sizing. Prior to the standard conventional aortic valve replacement, 26 patients underwent cardiac CT-scan and echocardiographic examination. Maximal annular diameter was measured by echocardiography at end-diastole and end-systole, including the leaflet calcifications. The CT-scan maximal, minimal and mean diameters were measured as well as the ‘effective’ diameter (CT_eff). CT_eff represents the diameter of a circle with the exact same area as the measured area of the annular circumference reconstructed from the CT-data set. Direct intraoperative diameters were measured after decalcification using metric sizers. CT_eff and end-systolic echocardiographic diameters showed best agreement with intraoperative direct sizing (intraop) in the Bland–Altman analysis [mean difference for transoesophageal echocardiography (TEE) vs intraop 0.5 mm (limits of agreement −2.5–3.5); mean difference for transthoracic echocardiography (TTE) vs intraop 0.38 mm (limits of agreement −3.28–4.03) and CT_eff vs intraop −0.56 (limits of agreement −3.16–2.05)]. In patients with an oval-shaped annulus, CT_eff demonstrated the best agreement with intraop [mean difference −0.32 (limits of agreement −2.29 to 1.66)]. Both the ‘effective’ CT diameter and end-systolic TEE values are the most reliable approaches for preoperative aortic annulus sizing. In patients with a pronounced oval-shaped annulus, the ‘effective’ CT diameter seems to be the method of choice. Therefore, aortic annulus measurement using ‘effective’ CT diameters should be included into current recommendations for TAVI sizing.

Background—: Transapical aortic valve implantation has evolved to a reproducible therapeutic option for high-risk patients. The aim of the present study was to evaluate our learning experience over 4 years and to analyze outcome-related risk factors. Methods and Results—: A total of 299 patients who received transapical aortic valve implantation between February 2006 and January 2010 with the Edwards SAPIEN transcatheter prosthesis were analyzed according to early experience (EE; patients 1 to 150) and recent experience (RE; patients 151 to 299). Patients consistently demonstrated high risk scores, and major perioperative parameters were comparable between the 2 groups. RE patients had a significantly higher logistic EuroSCORE (RE 33.2±17.2, EE 29.4±14; P =0.039) but a significantly lower STS (Society of Thoracic Surgeons) score (RE 11.4±7.5, EE 13.5±7.8; P =0.019). Use of contrast dye (EE 104±78 mL, RE 93±46 mL) and the need to perform a balloon redilation were significantly reduced in the RE group. Thirty-day mortality decreased from 11.3% to 6.0%, and 1-year mortality improved significantly from 30.7% (EE) to 21.5% in the RE patients ( P =0.047). Multivariate logistic regression analysis revealed reduced vital capacity (1+ as the only independent predictors of 30-day mortality. Classic variables such as age, logistic EuroSCORE >30%, and STS score >15% failed to predict mortality. Conclusions—: Recent results with transapical aortic valve implantation indicate a progressive improvement in outcomes despite an unchanged patient risk profile, which reflects a significant learning curve that includes a better understanding of optimal patient selection. Classic surgical risk factors fail to predict outcome, which indicates the need for new transapical aortic valve implantation–specific risk scores.