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Ann Thorac Surg 2011;92:1315-1323. doi:10.1016/j.athoracsur.2011.05.077
© 2011 The Society of Thoracic Surgeons
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Original Articles: Adult Cardiac

Analysis of Survival in 300 High-Risk Patients up to 2.5 Years After Transapical Aortic Valve Implantation

Axel Unbehaun, MD, Miralem Pasic, MD, PhD*, Thorsten Drews, MD, Stephan Dreysse, MD, Marian Kukucka, MD, Roland Hetzer, MD, PhD, Semih Buz, MD

Deutsches Herzzentrum Berlin, Berlin, Germany

Accepted for publication May 18, 2011.

* Address correspondence to Dr Pasic, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, D-13353 Berlin, Germany (Email: pasic{at}dhzb.de).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 
Background: Midterm results after transapical aortic valve implantation are still unknown in a large group of patients. We report our institutional experience in 300 high-risk patients.

Methods: Since April 2008, transapical aortic valve implantation was performed in 300 patients (mean age, 80 ± 8 years). The mean logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) was 39% ± 19% and the mean Society of Thoracic Surgeons (STS) score was 19% ± 16%. Eighteen patients were in cardiogenic shock preoperatively. Follow-up was up to 31 months with a total of 3,500 months of follow-up.

Results: Technical success of the procedure was 99.7% (299 of 300 patients). The 30-day mortality rate in all patients without cardiogenic shock was 3.9%. The overall 30-day mortality for the whole group of 300 patients was 4.7%. The mortality of the last 100 patients dropped to 2.0%. The cumulative survival was 83% at 1 year, 76% at 1.5 years, and 65% at 2 years and beyond. In patients with lower risk scores, cumulative survival reached 78% at 2 years and beyond.

Conclusions: The outcome of transapical aortic valve implantation in very high-risk patients was very favorable not only early after the procedure but also later on. Preoperative risk scores were not indicators for early mortality but were for later mortality. Survival was mainly influenced by noncardiac (renal, pulmonary, and vascular) comorbidities as well as by signs of advanced cardiac failure.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 

Drs Pasic, Unbehaun, Drews, Buz, and Dreysse disclose that they have financial relationships with Edwards Lifesciences.

 

Transcatheter aortic valve implantation has been introduced as an alternative to conventional aortic valve replacement for high-risk patients in an increasing number of cardiac centers, mostly in Europe [1–4]. The early outcomes are encouraging, with reported 30-day mortality rates between 5% and 12% in centers with increased experience [5–11]. The midterm and long-term results in a larger patient population are still lacking. In the recent literature there are only 2 reports from 1 Canadian group about midterm survival up to 3 years after transapical aortic valve implantation in only 71 patients [12] and after transfemoral aortic valve implantation in only 55 patients [13]. Therefore more knowledge about this aspect of this new and promising procedure is needed, especially in a larger group of patients.

Our recently published articles regarding transapical aortic valve implantation focused on early results [11]—on problems and complications we met during our learning curve and the way to manage them [14]. We used this hybrid method as a treatment option for several specific complex cases [15–17]. The outcomes of our patients during the later postoperative period were not known at that time.

The primary aim of this study was to analyze the later survival of 300 patients treated by transapical aortic valve implantation in our institution and to identify factors that predict survival during follow-up of up to 31 months.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 Acknowledgments
 References
 
Patients
Between April 2008 and October 2010, 300 consecutive patients (mean age, 80 ± 8 years; range, 36 to 99 years) with severe aortic valve stenosis underwent transapical aortic valve implantation. There were 97 men (32.3%) and 203 women (67.7%). The mean logistic EuroSCORE for the whole group was 39% ± 19%, with a range from 6% to 97%. The mean STS score for the whole group was 19% ± 16%, with a range from 1% to 90%. All patients' baseline characteristics are given in Table 1. The institutional review board at our institution approved this prospective study, and all patients or their representatives gave informed consent. The mean follow-up period was 11.7 ± 8.7 months (range, 0 to 31 months), with a total of 3,500 months of follow-up. The information about death was also obtained from the official state administrative office. The follow-up regarding death or survival was 100%.


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  		Table 1 Preoperative Characteristics in 300 Patients
 
The risk for conventional aortic valve replacement was evaluated by a team of experienced cardiac surgeons. Both risk scores (ie, the logistic EuroSCORE and the STS score) were calculated in an always-reproducible manner by an experienced cardiac surgeon after thoroughly reviewing the whole diagnostic and clinical workup. Patients were considered for the transapical procedure if the logistic EuroSCORE was at least 20%, if the STS score was 10% or higher, or if there were specific pathologic conditions with high risk for conventional aortic valve operations (for instance porcelain aorta). According to our institutional "no exclusion policy" [11], no patient was excluded regardless of a very high-risk profile, a poor left ventricular performance, or even the presence of cardiogenic shock.

Methods
The preoperative diagnostic workup as well as the routine postoperative examinations are described in detail elsewhere [11,14]. All procedures were performed in our special hybrid operating room with a monoplane angiography system (Siemens Artis zee, Siemens AG, München, Germany). All valve implantations were performed by the same team consisting of 5 surgeons, 2 cardiologists, and 2 anesthesiologists with expertise in echocardiography dedicated to this program. The elective use of cardiopulmonary bypass was considered in patients with cardiogenic shock or poor left ventricular function (left ventricular ejection fraction [LVEF], 10% to 20%). Elective coronary artery stent implantation was considered in patients with concomitant coronary artery disease. Only the most relevant coronary artery stenosis was treated [11]. Concomitant atrioventricular valve pathologic conditions were not treated simultaneously (except for grade IV tricuspid valve insufficiency) but were treated later by surgical procedures if necessary.

All procedures were performed with general anesthesia. The principal surgical technique that has been described in detail by Walther and colleagues [18] was applied in the first 20 patients. After that we performed valve implantation in a modified way according to the "Berlin addition" technique, which has been described in detail elsewhere [19]. Balloon-expandable transcatheter stent–prosthetic xenograft valves of 23-mm or 26-mm diameter with their delivering system (Edwards SAPIEN THV, Edwards Lifesciences LLC, Irvine, CA,) were used in all patients.

Statistical Analysis
Continuous variables are expressed as mean ± SD and maximal and minimal absolute numbers. Statistical analyses of the risk scores between survivors and nonsurvivors were carried out with the Student's t test. The cohort of 300 patients was arbitrarily divided into subgroups dependent on age, LVEF, logistic EuroSCORE, and STS score. The Kaplan-Meier survival functions for the whole group and subgroups were calculated. A Gehan test was used to analyze differences between 2 survival functions. A Cox proportional hazards model was used to investigate possible risk factors for mortality. A univariable approach for all possible risk factors was evaluated. Proportional hazard assumptions were checked. For several parameters, multivariable Cox proportional hazards models with all combinations were performed. The best model was chosen according to Akaike's information criterion. The distribution of age, logistic EuroSCORE, and STS score were analyzed. Q-Q plots and box-whisker plots were generated. A regression analysis of logistic EuroSCORE and STS score was performed, and the correlation coefficient is given. To evaluate differences between the first, second, and third 100 consecutive patients in age, logistic EuroSCORE, and STS score, a Kruskal-Wallis-test followed by Mann-Whitney tests were performed. The data were evaluated by SPSS software, version 18.01 (SPSS Inc, Chicago, IL). A p value less than 0.05 was considered to be significant.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 Acknowledgments
 References
 
Overall Outcome
The 30-day survival for the whole group of 300 patients, including patients with cardiogenic shock, was 95.3% (the overall early mortality = 4.7% [14 patients died]). The mean logistic EuroSCORE of all patients who died during the first month was 43% ± 20%. The mean STS score of all patients who died during the first month was 21% ± 14%. The mean logistic EuroSCORE and STS score of all patients who survived the first postoperative month were 38% ± 19% and 19% ± 16%, respectively. There was no statistical significance between the logistic EuroSCORE values of the 2 groups (p = 0.350) and no statistical significance between the STS scores (p = 0.585).

The risk scores were significantly higher in the group of patients who died during the follow-up: logistic EuroSCORE (survivors versus nonsurvivors) 36% ± 17% versus 48% ± 21% (p = 0.001); STS score (survivors versus nonsurvivors) 17% ± 14% versus 27% ± 20% (p = 0.001).

The causes of early deaths were septicemia in 1 patient with preoperative methicillin-resistant Staphylococcus aureus infection, acute myocardial failure in 5 patients, multiorgan failure in 4 patients, basilar vein thrombosis in 1 patient, abdominal complications in 2 patients, and leg ischemia related to severe peripheral arterial disease and type II heparin-induced thrombocytopenia in 1 patient.

The overall survival at 1, 6, 12, 18, 24, and 30 months was 95.3% ± 1.2%, 85.8% ± 2.1%, 82.5% ± 2.4%, 75.8% ± 3.2%, 64.6% ± 4.7%, and 64.6% ± 4.7%, respectively. Only 4 patients have so far reached a follow-up of 30 months. The Kaplan-Meier survival function is given in Figure 1 . Excluding the 18 patients with cardiogenic shock, the 30-day mortality rate was 3.9%; 11 of 282 patients died. The survival for all 282 patients without cardiogenic shock at 1, 6, 12, 18, 24, and 30 months was 96.1% ± 1.2%, 87.8% ± 2.0%, 84.7% ± 2.3%, 77.6% ± 3.2%, 65.5% ± 4.9%, and 65.5% ± 4.9%, respectively.


Figure 1
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  		Fig 1. Kaplan-Meier-survival function for whole cohort of 300 patients.

 
Survival in Different Subgroups
The analysis revealed a significantly better survival in subgroups with lower risk scores. The Kaplan-Meier survival functions are shown in Figure 2 . The survival for all 128 patients with a logistic EuroSCORE less than 30% at 1, 6, 12, 18, 24, and 30 months was 96.9% ± 1.5%, 92.7% ± 2.3%, 92.7% ± 2.3%, 86.7% ± 4.0%, 78.1% ± 6.0%, and 78.1% ± 6.0%, respectively. The survival was significantly better compared with the subgroup of 70 patients with a logistic EuroSCORE greater than 50% (p = 0.001). The survival for all 111 patients with an STS score less than 10% at 1, 6, 12, 18, 24, and 30 months was 96.4% ± 1.8%, 90.5% ± 2.9%, 89.1% ± 3.1%, 89.1% ± 3.1%, 78.4% ± 6.5%, and 78.4% ± 6.5%, respectively. Survival was significantly better compared with the subgroup of 78 patients with an STS score greater than 25% (p = 0.007).


Figure 2
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  		Fig 2. Kaplan-Meier-survival functions for different subgroups. (A) Survival in groups with different logistic EuroSCOREs. (B) Survival in groups with different Society of Thoracic Surgeons (STS) scores. (C) Survival in groups with different ages. (D) Survival in groups with different left ventricular ejection fraction (LVEF). (EuroSCORE = European System for Cardiac Operative Risk Evaluation.)

 
There was no statistically significant difference in the survival of different age groups (Fig 2). A significantly better survival was found in the subgroup of 145 patients with LVEF greater than 50% (Fig 2). The survival for these patients at 1, 6, 12, 18, 24, and 30 months was 96.6% ± 1.5%, 91.3% ± 2.4%, 86.3% ± 3.2%, 84.4% ± 3.6%, 72.3% ± 6.7%, and 72.3% ± 6.7%, respectively.

The overall 30-day mortality rate was 6.0% for the first and second consecutive 100 patients. It dropped to 2.0% for the last 100 patients. The 6-month survival rate was 84.0% ± 3.7% and 79.0% ± 4.1% for the first and second 100 patients, respectively. It increased to 95.6% ± 2.1% in the last 100 patients. The survival was significantly better for the last 100 patients (p = 0.026 for the first versus third 100 patients; p = 0.005 for the second versus third 100 patients). There were no significant differences in age (p = 0.100), but the differences in STS scores (p = 0.001) between the 3 groups of consecutive 100 patients were significant (Fig 3 ).


Figure 3
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  		Fig 3. (A, left side) Box-whisker plots of age, logistic EuroSCORE, and STS score (A, right side) for all 300 patients. Box-whisker plots of age (B), logistic EuroSCORE (C), and STS score (D) for the first, second, and third consecutive 100 patients. p values from the Kruskal-Wallis-test and Mann-Whitney tests are given. (EuroSCORE = European System for Cardiac Operative Risk Evaluation; STS = The Society of Thoracic Surgeons; age is given in years; logistic EuroSCORE and STS score are given in %.)

 
Distribution of Age, Logistic EuroSCORE, and STS Score
Box-whisker plots (Fig 3) and Q-Q plots (Fig 4 ) indicate an asymmetric (ie, nongaussian) distribution of age, logistic EuroSCORE, and STS score in our cohort of 300 patients. More than one third of the patients were in the low-risk score groups with a logistic EuroSCORE less than 30% (128 [43%] patients) or an STS score less than 10% (111 [37%] patients). In contrast, about one fourth of the patients were in the very high-risk group with a logistic EuroSCORE greater than 50% (70 [23%] patients) or an STS score greater than 25% (78 [26%] patients). There was a weak correlation between logistic EuroSCORE and STS score (correlation coefficient 0.641).


Figure 4
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  		Fig 4. Q-Q plots of logistic EuroSCORE (A), STS score (B), and age (C) for all 300 patients indicating nongaussian distribution for all 3 parameters. (D) X-Y plot of both risk scores for all 300 patients and linear line fitting. (EuroSCORE = European System for Cardiac Operative Risk Evaluation; STS = The Society of Thoracic Surgeons; y=f(x) = regression equation; R² = coefficient of determination.)

 
Predictors of Survival
Eleven parameters were found to be predictive for later survival in the univariable statistical analysis of 31 relevant preoperative parameters: logistic EuroSCORE, STS score, N-terminal protein B–type natriuretic peptide (NT-proBNP), New York Heart Association class, presence of cardiogenic shock, glomerular filtration rate, presence of renal failure, forced expiratory volume in 1 second, presence of peripheral arterial disease, chronic atrial fibrillation, and mean transvalvular gradient (Table 2). The results from the multivariable analysis are given in Table 3.


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  		Table 2 Predictive Factors of Cumulative Survival (Univariable Cox Regression Analysis)
 

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  		Table 3 Predictive Factors of Cumulative Survival (Multivariable Cox Regression Analysis)
 
Procedural Course
During the same procedure, 10 patients received a second valve implanted within the first valve ("valve in valve") after redilatation of the first valve because of a paravalvular leak and relevant regurgitation. In another 6 patients redilatation was performed because of relevant paravalvular regurgitation without implanting a second valve. Simultaneous with aortic valve implantation, additional elective procedures were performed in 43 (14.3%) patients, including elective coronary artery stent implantation in 31 (10.3%) patients, off-pump bypass grafting of the left internal thoracic artery to the left anterior descending artery in 1 (0.3%) patient, and a tricuspid valve repair in 2 (0.7%) patients. Elective femorofemoral cardiopulmonary bypass was applied in 13 (4.3%) patients with severe cardiogenic shock or poor left ventricular function (LVEF, 10%-20%), or both. The mean fluoroscopy time for valve implantation was 8.7 ± 5.1 minutes (range, 2.5 to 33.0 minutes). The mean dose area product for valve implantation was 7,487 ± 6,242 µGy/m2 (range, 776 to 70,118 µGy/m2). The mean dosage of the contrast agent iopromide for aortic valve implantation in the whole group was 104 mL ± 52 mL (range, 30 to 441 mL).

Procedural and Postoperative Complications
For the first 194 patients all problems, complications, and solutions have been published elsewhere [14]. Procedural success of valve implantation was 99.7% with 1 conversion to a conventional operation because of annulus rupture. Intraprocedural obstruction of the left main stem occurred in 2 (0.7%) patients. Cardiopulmonary bypass was applied in 4 (1.3%) patients on an emergency basis to control hemodynamic instability. In the early postoperative course there were 4 (1.2%) surgical revisions because of postoperative bleeding. Postoperative pacemaker implantations related to high-grade atrioventricular block were performed in 19 patients (7.0% of 271 patients without previous pacemaker implantation) between the first and the 61st days after transapical aortic valve implantation. Three (1.0%) patients experienced postoperative neurologic deficits that resolved in further follow-up visits. Three (1.0%) patients underwent conventional aortic valve replacement in a further follow-up (endocarditis in 2 patients and moderate to severe paravalvular regurgitation in 1 patient).


   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
Acknowledgments
 References
 
Short-Term Survival After Transapical Aortic Valve Implantation
We observed an overall 30-day mortality rate of 4.7% in a continuation of our excellent early results already achieved during our learning curve [11]. The 30-day mortality in patients without cardiogenic shock was 3.9%. We have considered our institutional learning curve to be about 200 procedures. After that and despite still high patient risk scores, the early mortality rate dropped to 2% and the 6-month survival advanced to 96% in the last 100 patients. Obviously the learning curve for this new hybrid method is a very sensitive phase and its effect on the early results has also been described by other authors [12]. Because transcatheter aortic valve implantation departs from standard surgical procedures, it requires new ways of thinking. A precisely coordinated team of surgeons, cardiologists, and anesthesiologists seems to be the most sensitive prerequisite to achieve excellent results, to avoid several types of complications, and to have a suitable solution ready if problems occur. Therefore the education and training of the team is crucial for favorable early results. We have never considered any patient to be too sick for transcatheter aortic valve implantation because that has been our institutional policy from the beginning of our experience [11,14]. The risk scores of our patients are higher than in other studies. None of the very high-risk patients evaluated was refused treatment regardless of comorbidities and clinical status, eg, profound shock (except patients with active endocarditis), if technically feasible in terms of annular size [11,14]. This is of course reflected in the higher STS scores and EuroSCOREs of our cohort and is in some measure an indicator of the patient referral pattern of our institution. We consider that transcatheter aortic valve implantation is currently the most appropriate therapy for such very high-risk patients.

Later Survival
The reported 1-year survival rate after transcatheter aortic valve implantation ranges between less than 70% and more than 80% in larger groups of patients [8, 10, 20, 21]. We observed a 1-year survival rate of 83% for the whole cohort and up to more than 90% for subgroups with lower risk scores. Contrary to short-term survival, both risk scores are strong predictors for midterm survival. Survival rates beyond 1 year after transcatheter aortic valve implantation remain unclear. There are only 2 reports from 1 Canadian group with a very limited number of patients and a follow-up of 3 years [12,13]. We observed a 2.5-year survival rate of 65% for the whole cohort and 78% in subgroups with lower risk scores. Concluding from early results, there is no doubt that transcatheter aortic valve implantation improves survival compared with only medical management of patients with severe aortic valve stenosis [20]. However whether there is superiority compared with conventional operations remains unclear. The recently reported survival rates after conventional aortic valve replacement in octogenarians are 87% at 1 year and 68% at 3 years [22] or 67% and 60% in subgroups of increased risk, respectively [23]. Comparing the results (despite a significant higher risk profile in our patients), transcatheter aortic valve implantation may significantly improve short-term survival. However midterm survival is determined by comorbidities after elimination of aortic valve stenosis regardless of surgical versus transcatheter treatment. One may speculate that the avoidance of paravalvular leaks during transcatheter valve deployment is a prerequisite to achieving similar results in the midterm follow-up. In this context, a reported high incidence of moderate- to high-grade regurgitation up to more than 20% after transfemoral aortic valve implantation [20, 21, 24, 25] gives reason to expect worse outcome compared with conventional aortic valve replacement. Applying our modified implantation technique [19], we observed more than trace regurgitation only as an exception after transapical valve deployment. We consider it a strong advantage of the transapical over the transfemoral approach at this time point in the development of the devices. A very low rate of strokes (1.0%) and vascular complications (0.7%) in our patients are further benefits of the short and antegrade approach.

Predictors of Later Survival
Most interestingly, age itself was not predictive of survival in our patients. It confirms that comorbidities rather than advanced age itself determine midterm survival. Similar to the results from other groups [8], we observed that later survival is negatively influenced by various noncardiac comorbidities, such as reduced pulmonary function, chronic renal failure, or advanced stages of peripheral arterial diseases. The combination of several comorbidities, as reflected by higher values of the applied risk scores (the logistic EuroSCORE and the STS score) was not different between 30-day survivors and nonsurvivors but was found to be a very sensitive predictor for survival during follow-up. It emphasizes that these polymorbid elderly patients have limited life expectancy despite complete elimination of aortic valve stenosis. During follow-up, survival has been determined by other emerging diseases.

Female sex was found to be an independent predictor of survival in the multivariable analysis. Whether this phenomenon reflects a general demographic effect or a specific procedure-related effect needs to be clarified in further studies. Contrary to the results from conventional aortic valve replacement, previous cardiac procedures seem not to influence early survival after transapical aortic valve implantation [15, 16, 26]. Our midterm analysis demonstrated no negative effect on midterm outcome as well. However, signs of preoperative advanced cardiac failure or the presence of cardiogenic shock are related to worse outcome. One may conclude from this that candidates for transcatheter aortic valve implantation should be treated electively rather than on an emergency basis or after a significant impairment of left ventricular function has already occurred.

Transapical or Transfemoral Approach?
Transapical and transfermoral approaches are 2 different therapeutic options for treating the same clinical problem, namely severe aortic stenosis in patients with increased risk from conventional procedures [4, 20]. Both procedures are competitive with conservative therapy or standard aortic valve replacement but they are also competitive between themselves (transfemoral versus transapical or transaxillary). The best treatment option evaluated in each patient should be chosen. In our institution we are able to offer all these options. Our "TAVI team" uses all approaches of transcatheter aortic valve implantation (transfemoral, transapical, right and left transaxillary), and currently we can perform implantation in the manner that is best for the patient.

It is frequently asked what the criteria are in deciding between a transapical and a transfemoral approach. The simplest way is to decide according to the condition of the vascular access (state, presence or absence of peripheral arterial disease, calcifications, diameter of the arteries). If the status of iliacofemoral arteries allows it, transfemoral implantation should be performed as the primary option. Transapical implantation is a more difficult technique than transfemoral implantation and needs a longer learning curve. In order to achieve excellent expertise in both techniques, we first used the transapical method of valve implantation (except in patients who had larger aortic valve annuli). In contrast, transapical implantation is a very simple and direct procedure. It has several advantages over the transfemoral (or transaxillary) route. The transapical approach is independent of the degree of the patient's peripheral arterial disease. Furthermore the advancing of the wire in an antegrade direction through the valve is very easy, rapid, and simple in comparison to the retrograde approach used with transfemoral implantation. It may reduce or eliminate cerebral embolization during this phase of the procedure. We also expect a lower rate of neurologic complications because the danger of embolization during manipulation in the aortic arch is reduced or eliminated by the transapical route. However, our main reason for the exclusive use of the transapical approach at the beginning of our project is the excellent and safe possibility of precise deployment of the new valve in the desired position by applying our modified valve implantation technique (Berlin addition [19]). The inflation of the balloon during valve deployment is performed slowly, not instantly, as described in the principal technique [18], allowing the valve position to be corrected if necessary. We think that in the future the transfemoral method will be performed more frequently. It could be the primary way of implantation if the results in terms of procedural success (eg, low rate of neurologic complications) could be matched to those of the transapical method. The advantage of the transfemoral method is it is a much easier way to implant a valve on an awake patient. Currently at our institution we perform the transfemoral method using local anesthesia. The main indication for a transapical aortic valve implantation is of course severe atherosclerotic peripheral disease in the inguinal and iliac region. It is important that the same team is educated to use all approaches of transcatheter aortic valve implantation (transfemoral, transapical, and transaxillary) to be able to decide intraoperatively and to perform the means of implantation that is best for the patient.

Further Perspectives
The analysis of our results showed favorable survival during the later follow-up after transapical aortic valve implantation in a group of very high-risk patients. Among others, reliable long-term results that exceed those we are familiar with for conventional aortic valve surgery are a prerequisite before broadening the indication of this procedure. In conclusion our experience with this new procedure is excellent, but compared with conventional aortic valve replacement it is still small. This new method should be validated by true long-term follow-up results and also by further randomized trials. Therefore we fully agree that the indication for this type of operation should be applied restrictively at present. Although our experience with this fascinating procedure is limited, the clinical impression is that the new method is becoming a real breakthrough. We believe that it will change the face of cardiac operations in the near future.


   Acknowledgments
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
References
 
Other members of the TAVI team are Dr Alexander Mladenow, Dr Christoph Klein, and Katrin Schäfer. We thank Julia Stein for the statistical analyses. We thank Anne Gale for editorial assistance.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 

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