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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\u003Cp id=\u0022p-1\u0022\u003EAs data increase on the benefits of transcatheter aortic valve replacement, several issues remain to be addressed including the choice of anesthesia (local or general), whether or not cerebral embolic protection during the procedure is beneficial, and the comparative benefits of self-expanding and balloon-expandable transcatheter aortic valve replacement.\u003C\/p\u003E\u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Etranscatheter aortic valve replacement\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ETAVR\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ecerebral embolic protection\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eimaging modalities\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Einterventional techniques \u0026amp; devices\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ethrombotic disorders\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Evalvular disease\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\u003Cp id=\u0022p-2\u0022\u003EAs more data accumulate on the use of transcatheter aortic valve replacement (TAVR), a number of issues have emerged. Among them are the use of conscious sedation vs general anesthesia (GA) for patients undergoing TAVR, the need for embolic neuroprotection for TAVR, the differences between self-expanding and balloon expandable TAVR, and the next generation of TAVR devices that are striving to improve upon the current generation to arrive at an ideal technology.\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\u003Ch2 class=\u0022\u0022\u003EAnesthesia for Patients Undergoing TAVR\u003C\/h2\u003E\u003Cp id=\u0022p-3\u0022\u003ERon Waksman, MD, Medstar Washington Hospital Center, Georgetown University, Washington, DC, USA, examined the different options in anesthesia for patients undergoing TAVR, specifically comparing local anesthesia with monitored anesthesia care (MAC) to GA. Although no randomized data are available that compare these 2 options, data from clinical experience show a number of benefits of MAC compared with GA including shorter procedure duration, shorter time spent in the intensive care unit, and shorter hospital stays (\u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E) [Ben-Dor I et al. \u003Cem\u003ECardiovasc Revasc Med\u003C\/em\u003E. 2012].\u003C\/p\u003E\u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/16659\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/16659\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/16659\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \u003Cp id=\u0022p-4\u0022 class=\u0022first-child\u0022\u003EStudies Comparing MAC vs GA\u003C\/p\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-7\u0022\u003EDespite these positive outcomes with MAC, Dr Waksman noted that real-world experience shows that about 95% of TAVR in the United States (and 30% in Europe) is performed with GA [Bufton KA et al. \u003Cem\u003EJ Cardiothorac Vasc Anesth\u003C\/em\u003E. 2013]. However, he said the trend is moving toward a simpler approach to TAVR using MAC instead of GA, and he encouraged conscious sedation for all patients if feasible.\u003C\/p\u003E\u003Cp id=\u0022p-8\u0022\u003EHe cautioned, however, against being too aggressive with using MAC and cited data from a study by Rouen et al [\u003Cem\u003EHeart\u003C\/em\u003E. 2014] in which high-surgical-risk patients with severe aortic stenosis underwent a simplified transfemoral TAVR with only local anesthesia and fluoroscopic guidance without the presence of an anesthesiologist. He emphasized the need to always have an anesthesiologist in the room in case a conversion from MAC to GA is needed, citing data showing the rate of conversion ranges from 11% to 25% depending on the series and most commonly for arrhythmias and hypotension (\u003Ca id=\u0022xref-table-wrap-2-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T2\u0022\u003ETable 2\u003C\/a\u003E).\u003C\/p\u003E\u003Cdiv id=\u0022T2\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/16660\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/16660\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/16660\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 2.\u003C\/span\u003E \u003Cp id=\u0022p-9\u0022 class=\u0022first-child\u0022\u003EReasons for Conversion From MAC to GA\u003C\/p\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\u003Ch2 class=\u0022\u0022\u003EEmbolic Neuroprotection\u003C\/h2\u003E\u003Cp id=\u0022p-12\u0022\u003EHighlighting that embolic strokes remain a devastating complication after TAVR despite improvements in patient selection, devices, and procedural techniques, Susheel Kodali, MD, Columbia University Medical Center, New York, New York, USA, talked about the potential need for cerebral embolic protection during TAVR. He emphasized that although the risk of stroke after TAVR is reduced with increased operator experience, the need for cerebral protection may extend beyond reduction in stroke risk to protection against silent infarcts that occur frequently after TAVR, which are associated with severe adverse neurologic and cognitive effects and place a person at a 5-times higher risk of stroke than persons without silent infarcts [Sacco RL et al. \u003Cem\u003EStroke.\u003C\/em\u003E 2013]. He described evidence of the benefit of embolic protection during TAVR from 2 recently presented randomized clinical trials\u2014CLEAN-TAVI [\u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT01833052\u0026amp;atom=%2Fspmdc%2F15%2F10%2F19.atom\u0022\u003ENCT01833052\u003C\/a\u003E; Linke A et al. TCT 2014] and DEFLECT III [\u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT02070731\u0026amp;atom=%2Fspmdc%2F15%2F10%2F19.atom\u0022\u003ENCT02070731\u003C\/a\u003E; Lansky AJ et al. ACC 2015]\u2014both of which showed that embolic protection significantly reduced diffusion-weighted magnetic resonance imaging lesion number and total volume.\u003C\/p\u003E\u003Cp id=\u0022p-13\u0022\u003EHe emphasized, however, that magnetic resonance imaging is not sufficient to determine the true benefit of embolic protection during TAVR and said that demonstration of clinical improvement will be necessary. He said that cerebral protection with TAVR will become the standard of care in the future if additional studies can confirm consistent reductions in neuroimaging stroke lesions that are correlated with improvement in clinical neurologic end points.\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-4\u0022\u003E\u003Ch2 class=\u0022\u0022\u003ESelf-Expanding vs Balloon Expandable TAVR\u003C\/h2\u003E\u003Cp id=\u0022p-14\u0022\u003EPresenting the clinical results on self-expanding vs balloon expandable TAVR, James Hermiller, MD, St Vincent Medical Group, Indianapolis, Indiana, USA, emphasized that there are no data on hard end points such as mortality showing any real differences between the 2 platforms. Both platforms have good effective orifice area and durability, neither is associated with late or intermediate failures, and both have a very good delivery profile. Balloon-expandable TAVR may be better in several niche settings, he said, including in patients who need a permanent pacemaker and those with a horizontal aorta. In addition, early paravalvular leak is better initially with balloon technology but over time may become similar to self-expanding TAVR. A better role for self-expanding TAVR is for valve-in-valve placement and for patients with annular rupture.\u003C\/p\u003E\u003Cp id=\u0022p-15\u0022\u003EBecause of the lack of hard evidence on the differences between the 2 platforms, Dr Hermiller said that the choice to use one platform or the other in many circumstances comes down to what the operator is comfortable with. Overall, he emphasized that, despite the debate over one platform vs the other, he thinks both platforms are valuable.\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-5\u0022\u003E\u003Ch2 class=\u0022\u0022\u003EWhat the Future Holds\u003C\/h2\u003E\u003Cp id=\u0022p-16\u0022\u003EDavid Zhao, MD, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA, briefly described the next generation of TAVR devices and the rapidly evolving technology that is addressing needed improvements to develop the ideal TAVR device with these characteristics:\u003C\/p\u003E\u003Cul class=\u0022list-unord \u0022 id=\u0022list-1\u0022\u003E\u003Cli id=\u0022list-item-1\u0022\u003E\u003Cp id=\u0022p-17\u0022\u003EControllable and predictable deployment\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-2\u0022\u003E\u003Cp id=\u0022p-18\u0022\u003ECoronary accessibility and anatomic directional positioning\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-3\u0022\u003E\u003Cp id=\u0022p-19\u0022\u003EDurability\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-4\u0022\u003E\u003Cp id=\u0022p-20\u0022\u003ELower cost, delivery profile, and permanent pacemaker implantation rate\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-5\u0022\u003E\u003Cp id=\u0022p-21\u0022\u003ELow stroke\/thrombotic risk\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-6\u0022\u003E\u003Cp id=\u0022p-22\u0022\u003EMinimal flow obstruction during deployment\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-7\u0022\u003E\u003Cp id=\u0022p-23\u0022\u003EMinimal or no rapid pacing\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-8\u0022\u003E\u003Cp id=\u0022p-24\u0022\u003EMinimal pre- and post-balloon dilatation\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-9\u0022\u003E\u003Cp id=\u0022p-25\u0022\u003EMinimal paravalvular leak\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-10\u0022\u003E\u003Cp id=\u0022p-26\u0022\u003EMinimal valve preparation and loading\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-11\u0022\u003E\u003Cp id=\u0022p-27\u0022\u003ERetrievable and repositionable\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-12\u0022\u003E\u003Cp id=\u0022p-28\u0022\u003ESuitable for aortic stenosis and aortic regurgitation\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-13\u0022\u003E\u003Cp id=\u0022p-29\u0022\u003ESuperb hemodynamics\u003C\/p\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-30\u0022\u003EMany of the next-generation devices address some of the issues needed to develop an ideal valve, such as Edwards CENTERA, Medtronic CoreValve Evolut R, Direct Flow, and Boston Scientific Lotus, but, to date, not one addresses all issues in a single device.\u003C\/p\u003E\u003Cp id=\u0022p-31\u0022\u003ESuch a device, he thinks, will be developed in the future. Dr Zhao emphasized that the one issue that has not been addressed at all is the issue of cost and said that lowering the cost of TAVR will remain unaddressed until there are 3 or 4 different valves in competition with each other.\u003C\/p\u003E\u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2015 SAGE Publications\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/15\/10\/19.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzll8d\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzll8d\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}