title: Does minimalist transfemoral transcatheter aortic valve replacement produce better survival in patients with severe chronic obstructive pulmonary disease?
abstract: OBJECTIVE
  To compare outcomes after minimalist and standard transfemoral transcatheter aortic valve replacement (TF-TAVR) in patients with severe chronic obstructive pulmonary disease (COPD).
  
  
  BACKGROUND
  TF-TAVR is increasingly performed with conscious sedation and transthoracic echocardiography guidance (minimalist). The safety/efficacy of this technique in patients with severe COPD is unknown.
  
  
  METHODS
  We compared demographics, 30-day outcomes and 1-year survival of patients with severe COPD (FEV1% ≤50) who underwent minimalist vs. standard TF-TAVR between 2008 and 2015 at our institution.
  
  
  RESULTS
  Of 88 patients with severe COPD, 46 underwent minimalist and 42 underwent standard TF-TAVR. There were no differences on baseline characteristics, except for more history of coronary artery bypass grafting (45.5% vs. 20.6%, P = 0.03) and less history of cerebrovascular disease (16.7% vs. 45.5%, P = 0.03) in the standard TF-TAVR. Seventeen minimalist TF-TAVR patients (41.0%) were transferred directly to the general medical ward with telemetry monitoring (without ICU stay); all standard TF-TAVR patients went to the ICU. Minimalist TF-TAVR patients had shorter procedure time (97 vs. 129 min, P < 0.001), ICU time (21.8 vs. 29.8 hr, P = 0.001) and length of stay (2 vs. 5 days, P = 0.001). There were no differences in procedure complications and 30-day mortality between groups. In our multivariate analysis, minimalist TF-TAVR (HR 0.28, 95%CI 0.08-0.97) and previous coronary revascularization (HR 0.24, 95%CI 0.09-0.65) were associated with increased 1-year survival. In contrast, moderate paravalvular leak (HR 7.73, 95%CI 1.94-30.84) was associated with decreased 1-year survival.
  
  
  CONCLUSIONS
  In patients with severe COPD, Minimalist TF-TAVR results in less resource utilization and improved 1-year survival compared to standard approach. Our findings should be validated in a larger cohort of patients with severe COPD. © 2016 Wiley Periodicals, Inc.
authors.affiliation: Structural Heart and Valve Center, Divisions of Cardiology, Emory University, Atlanta, Georgia.
authors.forename: Jose F
authors.initials: JF
authors.lastname: Condado
authors.affiliation: Department of Medicine, Emory University, Atlanta, Georgia.
authors.forename: Moosa N
authors.initials: MN
authors.lastname: Haider
authors.affiliation: Structural Heart and Valve Center, Divisions of Cardiology, Emory University, Atlanta, Georgia.
authors.forename: Stamatios
authors.initials: S
authors.lastname: Lerakis
authors.affiliation: Structural Heart and Valve Center, Divisions of Cardiology, Emory University, Atlanta, Georgia.
authors.forename: Patricia
authors.initials: P
authors.lastname: Keegan
authors.affiliation: Structural Heart and Valve Center, Divisions of Cardiology, Emory University, Atlanta, Georgia.
authors.forename: Hope
authors.initials: H
authors.lastname: Caughron
authors.affiliation: Department of Cardiothoracic Surgery, Emory University, Atlanta, Georgia.
authors.forename: Vinod H
authors.initials: VH
authors.lastname: Thourani
authors.affiliation: Structural Heart and Valve Center, Divisions of Cardiology, Emory University, Atlanta, Georgia.
authors.forename: Chandan
authors.initials: C
authors.lastname: Devireddy
authors.affiliation: Department of Cardiothoracic Surgery, Emory University, Atlanta, Georgia.
authors.forename: Bradley
authors.initials: B
authors.lastname: Leshnower
authors.affiliation: Structural Heart and Valve Center, Divisions of Cardiology, Emory University, Atlanta, Georgia.
authors.forename: Kreton
authors.initials: K
authors.lastname: Mavromatis
authors.affiliation: Department of Cardiothoracic Surgery, Emory University, Atlanta, Georgia.
authors.forename: Eric L
authors.initials: EL
authors.lastname: Sarin
authors.affiliation: Structural Heart and Valve Center, Divisions of Cardiology, Emory University, Atlanta, Georgia.
authors.forename: James
authors.initials: J
authors.lastname: Stewart
authors.affiliation: Department of Cardiothoracic Surgery, Emory University, Atlanta, Georgia.
authors.forename: Robert
authors.initials: R
authors.lastname: Guyton
authors.affiliation: Department of Cardiothoracic Surgery, Emory University, Atlanta, Georgia.
authors.forename: Jessica
authors.initials: J
authors.lastname: Forcillo
authors.affiliation: Structural Heart and Valve Center, Divisions of Cardiology, Emory University, Atlanta, Georgia.
authors.forename: Ateet
authors.initials: A
authors.lastname: Patel
authors.affiliation: Department of Cardiothoracic Surgery, Emory University, Atlanta, Georgia.
authors.forename: Amy
authors.initials: A
authors.lastname: Simone
authors.affiliation: Structural Heart and Valve Center, Divisions of Cardiology, Emory University, Atlanta, Georgia.
authors.forename: Peter C
authors.initials: PC
authors.lastname: Block
authors.affiliation: Structural Heart and Valve Center, Divisions of Cardiology, Emory University, Atlanta, Georgia.
authors.forename: Vasilis
authors.initials: V
authors.lastname: Babaliaros
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000150:complications / Q000401:mortality / Q000601:surgery*; D006328:Cardiac Catheterization / Q000379:methods*; D017548:Echocardiography, Transesophageal; D005260:Female; D005263:Femoral Artery; D005500:Follow-Up Studies; D005845:Georgia / Q000453:epidemiology; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D029424:Pulmonary Disease, Chronic Obstructive / Q000150:complications* / Q000175:diagnosis / Q000401:mortality; D012189:Retrospective Studies; D012720:Severity of Illness Index; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D065467:Transcatheter Aortic Valve Replacement / Q000379:methods*; D016896:Treatment Outcome
keywords: chronic obstructive pulmonary disease; minimalist; transcatheter aortic valve replacement; transfemoral