Objectives We describe the first use of caval-aortic access and closure to enable transcatheter aortic valve replacement (TAVR) in patients who lacked other access options. Caval-aortic access refers to percutaneous entry into the abdominal aorta from the femoral vein through the adjoining inferior vena cava. Background TAVR is attractive in high risk or inoperable patients with severe aortic stenosis. Available transcatheter valves require large introducer sheaths, which risk major vascular complications or preclude TAVR altogether. Caval-aortic access has been successful in animals. Methods We performed a single center retrospective review of procedural and 30-day outcomes of prohibitive-risk patients undergoing TAVR via caval-aortic access. Results Between July 2013 and January 2014, 19 patients underwent TAVR via caval-aortic access. 79% were women. Caval-aortic access and tract closure was successful in all 19; TAVR was successful in 17. Six patients suffered modified VARC-2 major vascular complications, two (11%) of whom required intervention. Most (79%) required blood transfusion. There were no deaths attributable to caval-aortic access. Through 111 (39–229) days of follow up, there were no post-discharge complications related to tract creation or closure. All patients had persistent aorto-caval flow immediately post procedure. Of 16 who underwent repeat imaging after the first week, 15 (94%) had complete closure of the residual aorto-caval tract. Conclusions Percutaneous transcaval venous access to the aorta allows TAVR in otherwise ineligible patients, and may offer a new access strategy for other applications requiring large transcatheter implants.

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Three-dimensional CT image case planning provides a comprehensive and customized patient-specific LAA assessment that appears to be accurate and may possibly facilitate reducing the early WATCHMAN implantation learning curve.

Keywords3D print; computer aided design; LVOT obstruction; transcatheter mitral valve replacement EVOLUTION OF CATHETER-BASED STRUCTURAL INTERVENTIONS HAS GIVEN PATIENTS LESS INVASIVE alternatives to surgery; however, the current generation of transcatheter heart valves (THV) are not specifically designed for mitral position implantation and have intrinsic geometry that may make mitral implantation suboptimal. Operators are faced with unique challenges with valve deliverability, embolism, and notably left ventricular outflow tract (LVOT) obstruction. Therefore, understanding the suitability of prosthesis delivery and implantation individualized to each heart is of paramount importance.Successful transcatheter mitral valve replacement (TMVR) depends on accurate sizing of the mitral annulus (Figure 1) and avoidance of LVOT obstruction. Incorporation of computeraided design and generation of 3-dimensional-printed heart models allows for ex vivo device bench testing in patient-specific anatomy (Figures 1 and 2). Modeling of proposed THV at different angles/depths of deployment into the LV allows estimation of LVOT obstruction of neo-LVOT/LVOT (Figure 3). We now aim to describe the utility of cardiac computed tomography ( Table 1) and ex vivo THV fit testing with 3-dimensional models to predict LVOT obstruction in TMVR.

The coronavirus disease‐2019 (COVID‐19) pandemic has strained health care resources around the world, causing many institutions to curtail or stop elective procedures. This has resulted in an inability to care for patients with valvular and structural heart disease in a timely fashion, potentially placing these patients at increased risk for adverse cardiovascular complications, including CHF and death. The effective triage of these patients has become challenging in the current environment, as clinicians have had to weigh the risk of bringing susceptible patients into the hospital environment during the COVID‐19 pandemic against the risk of delaying a needed procedure. In this document, the authors suggest guidelines for how to triage patients in need of structural heart disease interventions and provide a framework for how to decide when it may be appropriate to proceed with intervention despite the ongoing pandemic. In particular, the authors address the triage of patients in need of transcatheter aortic valve replacement and percutaneous mitral valve repair. The authors also address procedural issues and considerations for the function of structural heart disease teams during the COVID‐19 pandemic.