ABSTRACT
Background
Despite the emergence of the transcaval (TCv) access route for transcatheter aortic valve implantation (TAVI) in the treatment of patients with hostile iliofemoral anatomy, the number of patients reported in clinical series of TCv TAVI has been relatively small (< 500 published cases). We assessed procedural and clinical outcomes in a prospective cohort of patients undergoing TAVI using TCv access at a clinical site without prior TCv TAVI experience.
Methods
A prospective TAVI database was used to identify all patients treated with TCv TAVI at our center. Baseline clinical and procedural data, and clinical outcomes at follow‐up were assessed. The Valve Academic Research Consortium (VARC) consensus document for standardized endpoints was used.
Results
Between February 2020 and July 2024, a total of 21 patients underwent TCv TAVI. The mean age of the cohort age was 76 ± 6 years, most were female (N = 13, 62%), and the mean STS score was 7.4 ± 5.8%. We achieved a technical and clinical success rate of 100% and 95%, respectively. The mean duration of in‐hospital stay was 3.4 ± 1.5 days. There was one central aortic complication in a patient who required balloon tamponade to treat bleeding into the retroperitoneum from the aorto‐caval tract and one peripheral vascular complication in a patient who required a direct thrombin injection to treat a femoral artery pseudoaneurysm. The rate of permanent pacemaker implantation was 20% (N = 4) and the incidence of stroke and/or death at 30 days was 0%. The mean follow‐up time of the cohort was 2.5 ± 1.4 years with a 1‐year Kaplan−Meier survival estimate of 89.6% (95% confidence interval of 64.3%–97.3%).
Conclusions
When performed by an experienced TAVI operator with peripheral vascular and structural training, with limited up‐front proctoring for procedures and input from imaging specialists, this series supports that TCv TAVI can achieve a high rate of procedural success with low risk of mortality and stroke.
Abbreviations
- AS
aortic stenosis
- ASD
atrial septal defect
- CT
computed tomography
- EF
ejection fraction
- FA
femoral artery
- IVC
inferior vena cava
- KM
Kaplan−Meier
- NG
nasogastric
- PDA
patent ductus arteriosis
- PSA
pseudoaneurysm
- SAVR
surgical aortic valve replacement
- SD
standard deviation
- SE
standard error
- STS
society of thoracic surgeons
- TAVI
transcatheter aortic valve implantation
- TAX
transaxillary
- TC
transcarotid
- TCv
transcaval
- TF
transfemoral
- TTE
transthoracic echocardiogram
- VARC
Valve Academic Research Consortium
1. Introduction
Transfemoral (TF) access is established as the optimal access site for TAVI in patients with severe symptomatic aortic stenosis (AS). However, approximately 5% of patients are precluded from TF TAVI due to unfavorable aortoiliofemoral anatomy [1, 2]. TCv TAVI has emerged as an alternative access site in a subset of these patients but presents a number of technical challenges related to achieving TCv access and management of the aortic puncture site. Studies to date of outcomes for TCv TAVI are limited to registries involving relatively small numbers of patients [3, 4, 5, 6, 7, 8, 9, 10, 11]. We sought to assess the procedural and clinical outcomes in a prospective cohort of patients undergoing TAVI using TCv access at our clinical site with no prior TCv TAVI experience.
2. Materials and Methods
2.1. Patient Selection and Data Collection
A prospective TAVI database was analyzed to identify patients treated with TCv TAVI for severe AS at the Mater Misericordiae University and Mater Private Hospitals.
Clinical and procedural data was entered prospectively at the time of the TAVI procedure. Follow‐up data was entered after each follow‐up interaction. All cases were initially reviewed in the structural heart clinic and then discussed at the multidisciplinary Heart Team meeting. Pre‐procedural planning included transthoracic echocardiography (TTE) and computed tomography (CT) to assess aortic valve anatomy and vascular anatomy. Specifically, a careful analysis of the infra‐renal abdominal aorta and inferior vena cava (IVC) was performed to assess the suitability for TCv access and to plan the interventional strategy.
Ethical approval for this study was obtained from the Research Ethics Committee, Mater Misericordiae University Hospital (Ref: 1/378/2410TMR).
2.2. Statistical Analysis
Continuous variables are presented as mean ± standard deviation (SD). Categorical data are presented as frequencies and percentages. Survival estimates were calculated using the Kaplan−Meier method. Greenwood's formula was used to compute standard errors (SEs) for the survival estimates and was performed using Stata version 18.
2.3. Definitions
The estimated risk of mortality from surgical aortic valve replacement (SAVR) was calculated based on the standard Society of Thoracic Surgeons (STS) and updated EuroSCORE II risk assessment tools [12, 13]. Definitions for background medical conditions are in keeping with the Valve Academic Research Consortium‐3 (VARC‐3) criteria [14]. Standard variable and outcome definitions for TAVI are consistent with those outlined in the VARC‐2 consensus document or VARC‐3 criteria wherever possible [14, 15].
Technical success was defined as successful TCv access, deployment of the valve, retrieval of the delivery system, and closure of the TCv access site. Clinical success was defined as technical success without major adverse cardiac events (death, stroke, valve embolization, cardiac arrest, perforation requiring pericardiocentesis, major vascular access complication including retroperitoneal hemorrhage or requirement for surgical repair of TCv access site, and conversion to SAVR) at 30 days.
TCv access and closure was executed using the methods outlined by Ledermann et al. [16].
3. Results
Between February 2020 and July 2024, 21 patients with severe symptomatic AS underwent TAVI using TCv access. This number represented 2.1% of all TAVI procedures performed at the study site during this period. During this same period, 94% of all TAVI cases were performed using TF access [17]. All cases were elective. Figure 1 demonstrates the enrollment cadence in the study.
Figure 1.
Enrollment cadence for TCv TAVI cases. [Color figure can be viewed at wileyonlinelibrary.com]
3.1. Baseline Patient Characteristics
Table 1 summarizes the baseline characteristics of the patient cohort. Most were female (N = 13, 62%). The mean age was 76 ± 6 years. The mean STS score of the cohort was 7.4 ± 5.8%. Most patients received a TAVI for treatment of senile calcific degeneration causing severe stenosis in a tricuspid aortic valve (n = 20, 95%). One patient (n = 1, 5%) required valve‐in‐valve TAVI for treatment of severe stenosis within a prior prosthetic TAVI valve.
Table 1.
Baseline patient characteristics.
| Clinical characteristics | N (%) |
|---|---|
| Female | 13 (62) |
| Age (mean ± SD) (years) | 76 ± 6 |
| BMI (mean ± SD) (Kg/m2) | 26.7 ± 6.4 |
| Comorbidities | |
| Hypertension | 17 (80) |
| Dyslipidaemia | 18 (85) |
| Diabetes mellitus | 6 (28) |
| Chronic lung disease | |
| Any | 14 (66) |
| Oxygen dependent | 0 (0) |
| Prior stroke | 0 |
| Prior TIA | 1 (5) |
| Peripheral arterial disease | 21 (100) |
| Atrial fibrillation/flutter | 10 (47) |
| Permanent pacemaker | 2 (10) |
| Renal impairment | |
| Moderate (CrCl 50−80 mL/min) | 9 (42) |
| Severe (CrCl < 50 mL/min) | 7 (33) |
| Coronary artery disease | |
| MI | 2 (9) |
| CABG | 6 (28) |
| PCI | 6 (28) |
| Previous valve procedure | |
| Surgical AVR (tissue) | 0 |
| TAVI | 1 (5) |
| STS risk score (%)—(mean ± SD) | 7.4 ± 5.8 |
| EuroSCORE II (mean ± SD) | 7.7 ± 5.0 |
Abbreviations: AVR, aortic valve replacement; BMI, body mass index; CABG, Coronary artery bypass graft; CrCl, Creatinine clearance; Euroscore, European System for Cardiac Operative Risk Evaluation; ICD, Implantable cardioverter‐defibrillator; Kg/m2, kilograms per meter squared; MI, Myocardial infarction; mL/min, milliliters per minute; PCI, percutaneous coronary intervention; SD, standard deviation; STS, Society of Thoracic Surgeons; TAVI, transcatheter aortic valve implantation; TIA, transient ischaemic attack.
3.2. Baseline Imaging Characteristics
Table 2 summarizes the baseline imaging characteristics of the cohort. The mean ejection fraction (EF) was 47 ± 11%, with 20% (n = 4) of patients having an EF ≤ 35%. The max and mean peak aortic valve gradients of the cohort were 78.8 ± 17 and 48.9 ± 9.9 mmHg respectively. The mean aortic valve area was 0.65 ± 0.1 cm2. The mean caval‐aortic distance and aortic lumen diameter at the TCv access point was 5.3 ± 4.2 mm and 18.8 ± 3.5 mm, respectively, as measured by CT.
Table 2.
Baseline imaging characteristics.
| ECHO | Mean ± SD |
|---|---|
| LVEF | 47 ± 12 |
| LVEF ≤ 35%—N (%) | 4 (20) |
| Mean AV gradient (mmHg) | 49 ± 9.8 |
| Peak AV gradient (mmHg) | 79 ± 17 |
| AV area (cm2) | 0.65 ± 0.1 |
| Computed tomography | |
|---|---|
| AV annulus perimeter (mm) | 75 ± 7 |
| AV annulus area (mm2) | 433 ± 80 |
| Aortic diameter at caval‐aortic access site (mm) | 18.8 ± 3.5 |
| Caval‐aortic distance at aortic access site | 5.3 ± 4.2 |
Abbreviations: AV, aortic valve; cm, centimetres; IVC, inferior vena cava; LVEF, left ventricular ejection fraction; mm, millimeters; mmHg, millimeters of mercury.
3.3. Procedural Characteristics
Table 3 summarizes the procedural characteristics of the cohort. All procedures were performed under general anaesthesia. The mean procedural time was 126 ± 48 min, with a trend toward lower procedure duration over time (Figure 2). The TAVI valve was delivered from the right common femoral vein in all but one case (n = 20, 95%). In the latter procedure, the TAVI valve was delivered from the left common femoral vein due to occlusion of the right common iliac vein. Figure 3 illustrates the pre‐procedural CT assessment and key components of a TCv interventional strategy.
Table 3.
Procedural characteristics.
| Procedural characteristics | N (%) |
|---|---|
| General anaesthesia | 21 (100) |
| Procedure time (mean ± SD) (min) | 126 ± 48 |
| IVC guide | |
| Renal IM | 20 (95) |
| Modified coronary AL 0.75 | 1 (5) |
| Aorta guide | |
| JR4 | 21 (100) |
| Aortic snare | |
| Gooseneck | 19 (95) |
| 15 mm | 2 (9) |
| 20 mm | 7 (33) |
| 25 mm | 9 (42) |
| 30 mm | 2 (9) |
| Ensnare | 1 (5) |
| Coronary balloon pre‐dilatation of caval‐aortic tract | 4 (20) |
| TAVI valve used | |
| Medtronic Evolut Pro | 8 (38) |
| Medtronic Evolut Pro Plus | 1 (5) |
| Edwards Sapien 3 Ultra | 10 (47) |
| Edwards Sapien 3 | 1 (5) |
| Edwards Sapien Resilia | 1 (5) |
| Fluoroscopy time ‐ (mean ± SD) (min) | 30 ± 14.5 |
| Air Kerma—(mean ± SD) (mGy) | 1907 ± 1545 |
Abbreviations: AL, Amplatz Left; IM, Internal Mammary; IVC, inferior vena cava; JR, Judkins right; mGy, milliGray; mm, millimeter; PDA, patent ductus arteriosus; SD, standard deviation.
Figure 2.
Change in duration of TCv TAVI procedure over time. [Color figure can be viewed at wileyonlinelibrary.com]
Figure 3.
Pre‐procedural CT assessment and key components of a TCv interventional strategy. (Image A) 3D volume rendered CT scan showing extensively diseased common femoral arteries precluding transfemoral access. (Images B, C) Pre‐procedural CT imaging detailing key vascular characteristics used in assessing suitability for TCv access and planning of interventional strategy. (Image B) CT Coronal image illustrates the relationship between the abdominal aorta (Ao) and inferior vena cava (IVC). Arrow indicates target site for TCv access to aorta. Image C Axial CT image showing distance between the IVC to the aorta (Ao) at proposed location of TCv access and the diameter of the abdominal aorta at that point. Images D, E and F: Procedural steps to successfully secure TCv access and closure. (Images D and E) demonstrate frontal (D) and orthogonal en‐face (E) fluoroscopic projections which facilitate alignment of guide catheter and gooseneck snare to ensure successful delivery of Astato wire into the lumen of the aorta. (Image F) Aortogram showing successful closure of the caval‐aortic tract with a PDA occluder device. [Color figure can be viewed at wileyonlinelibrary.com]
3.4. In‐Hospital Outcomes
A full list of procedural complications is shown in Table 4. The mean in‐hospital length of stay was 3.4 ± 1.5 days. Technical success was achieved in all cases. Clinical success was achieved in 20 patients (96%).
Table 4.
Procedural complications.
| Complication | N (%) |
|---|---|
| Minor vascular | |
| Pseudoaneurysm | 1 (5) |
| Major vascular | |
| Central aortic retroperitoneal hemorrhage | 1 (5) |
| New PPM | 4 (20) |
| Mortality | 0 (0) |
| Stroke | 0 (0) |
Abbreviations: PPM, permanent pacemaker; VARC, Valve Academic Research Consortium.
There was one patient with a central aortic complication. The patient developed severe hypotension following retraction of the TAVI delivery sheath into the IVC. The patent ductus arteriosus (PDA) occluder was deployed and balloon tamponade was performed with a 24 mm Amplatzer sizing balloon (used for atrial septal defect [ASD] closure procedures) across the aortic access site. Subsequent angiography showed complete occlusion of the aortic access site and cessation of bleeding (Figure 4). The patient required transfusion of two units of blood and placement of a nasogastric (NG) tube to treat gastroparesis, presumed to be related to the retroperitoneal hemorrhage. He was discharged home on Day 6. There was one minor peripheral vascular complication in a patient who required thrombin injection to treat a femoral artery (FA) pseudoaneurysm (PSA). Permanent pacemaker (PPM) insertion was required in four patients (20%). There was no death or stroke during the hospital stay.
Figure 4.
Fluoroscopic appearance and management of retroperitoneal hemorrhage following TCv access. Image (A) Pre‐procedural coronal CT image illustrating the relationship between the inferior vena cava (IVC) and abdominal aorta (Ao). Image (B) Aortogram demonstrating retroperitoneal hemorrhage (broken arrow) following deployment of the PDA occluder device and retraction of TAVI delivery sheath. Image (C) Balloon tamponade of the retroperitoneal hemorrhage with a 24 mm Aplazer sizing balloon in the abdominal aorta. Image (D) Aortogram demonstrating resolution of retroperitoneal hemorrhage and complete closure of aorto‐caval fistula post balloon tamponade to PDA occluder device. [Color figure can be viewed at wileyonlinelibrary.com]
3.5. Clinical Outcomes at Follow‐Up
There was no mortality, stroke or major complication between hospital discharge and 30‐day follow‐up. The mean follow‐up duration from the index procedure was 2.5 ± 1.4 years. There were four deaths at 2, 11, 32, and 46 months. The cause of death in one patient is unknown. In the remaining three cases, the cause of death was non‐cardiac: mechanical fall complicated by an intracranial hemorrhage, respiratory sepsis and unspecified sepsis. Figure 5 illustrates the Kaplan−Meier (KM) survival estimate for all patients. The KM estimate of survival at 1 year was 89.6%, with a 95% confidence interval of [64.3%, 97.3%]. Of the 14 of 21 (66%) patients with CT follow‐up at 30 days, complete closure of the TCv tract was documented in all patients.
Figure 5.
Kaplan−Meier survival curve for patients treated with TCv TAVI. [Color figure can be viewed at wileyonlinelibrary.com]
4. Discussion
In this study of 21 consecutive patients undergoing TCv TAVI at a site with no prior TCv TAVI experience, we achieved a technical and clinical success rate of 100% and 95%, respectively. The mean duration of in‐hospital stay was 3.4 ± 1.5 days. The incidence of stroke and death at 30 days was 0% and the 1‐year KM survival estimate for the cohort was 89.6%, with a 95% confidence interval of [64.3%, 97.3%].
4.1. Initiation of a TCv TAVI Program
The adoption of TCv access as an alternative access site for TAVI in patients with hostile iliofemoral anatomy has been limited. This is reinforced by a recent meta‐analysis of all published TCv TAVI studies by Salihu et al. [18]. Despite the hundreds of thousands of TAVI procedures that have been performed worldwide, only eight studies, including 467 patients, were eligible for inclusion in the analysis. In addition, almost all of the patients in this analysis came from three multicentre studies that included 388 patients, with the largest single center experience including 22 patients.
We initiated our TCv TAVI program in February 2020. An external proctor assisted with the first case that we performed. In addition, for the first three cases, image analysis of the pre‐procedural CT was kindly performed by a cardiovascular radiologist in the cardiovascular branch of the National Institutes of Health in Washington, DC, USA, to confirm anatomic suitability of the case and provide guidance for execution of the procedure.
The major inertia to initiating a TCv TAVI program is likely related to the comfort of the interventional cardiologist in establishing TCv access to the abdominal aorta, managing closure of the aortic access site, and treating possible bleeding complications at that site. Therefore, the training and clinic experience of the operator(s) is important in extrapolating outcomes from published series. In the current study, there was a single primary operator for all cases (IC). This operator was trained in peripheral vascular intervention and a broad range of structural heart procedures beyond TAVI (i.e., experienced in use of a broad range of closure devices including PDA occluders). This operator also had previous experience in the use of re‐entry tools such as the Outback LD re‐entry catheter (Cordis, Bridgewater, NJ) in the peripheral arterial tree, including re‐entry into the distal abdominal aorta for treatment of iliac occlusions.
This study demonstrates that within the context described above, a TCv TAVI program can be initiated successfully and achieve excellent clinical outcomes when performed by appropriately trained interventionalists, with minimal up‐front proctoring for procedures (1−2 cases) and input from imaging specialists (2−5 cases). For operators with less training in peripheral and non‐TAVI structural procedures, a higher number of proctored cases may be advisable.
4.2. Clinical Outcomes with TCv TAVI
Very high rates of technical success have been reported uniformly across all TCv TAVI studies. The 100% technical success rate achieved in the current study is consistent with the 98.5% technical success rate reported by Salihu et al. The use of general anaesthesia may have contributed to the high rate of technical success in this series, as a couple of the more prolonged procedures earlier in the experience may have been abandoned if patient comfort could not have been guaranteed.
In terms of acute procedural complications, the outcomes in the current study are comparable with prior studies. New pacemaker implantation and major vascular complications occurred in 20% (4 of 21) and 4.7% of patients (1 of 21), respectively. This compares with a new pacemaker implantation rate and major vascular complication rate of 15.4% and 8.7%, respectively, in the recent TCv TAVI meta‐analysis.
Management of aortic complications related to TCv access likely explains some of the inertia in the adoption of TCv TAVI by interventional cardiologists. The current study reinforces that this is an uncommon complication (n = 1, 4.7%). The 24 mm ASD sizing balloon used to tamponade the aortic puncture site can be delivered through a 10 Fr femoral arterial sheath and does provide assurance that any acute hemorrhage can be managed promptly. It has been our experience that most patients undergoing TCv TAVI have disease in the iliofemoral vessels that prohibits the delivery of a covered stent to occlude the aortic access site due to the typical femoral sheath diameter required for large caliber covered stent delivery. This consideration does need to be explained to the patient during consent for the TCv TAVI procedure.
The absence of stroke and/or death at 30 days in the current cohort is lower than previous reports. It should be highlighted that the mean STS score (predicting mortality at 30 days) in this cohort was 7.4 ± 5.9%, indicating that this cohort was at least in an intermediate‐to‐high risk category. In the recent TCv TAVI meta‐analysis, the rate of 30‐day all‐cause mortality and peri‐procedural stroke/transient ischaemic attack (TIA) was reported to be 6.1% and 3.3%, respectively. The STS score was not reported in all patients in this meta‐analysis, but ranged from 4.1% to 9.7%, with the largest single report contributing 238 patients to the meta‐analysis having a mean STS score of 5% (3.2−8.4).
Comparison of clinical outcomes between TCv TAVI and either TF TAVI or other alternate access TAVI is difficult since these patients are fundamentally different, both anatomically and clinically. Randomized comparison is impossible, since it would be unethical to randomize a patient who is suitable for TF TAVI to undergo alternative access TAVI. Propensity‐weighted analyses have been performed. Barbash IM et al. found that TCv TAVI (n = 20), when compared with other non‐TF access site TAVI (n = 165), was associated with a similar rate of death at 30 days (10% vs. 7.9%, p = 0.74), and a reduced risk of acute kidney injury and shorter hospital stay [10]. Lederman et al. compared a cohort of patients who underwent TCv TAVI (n = 238) with two groups who underwent TAVI using a transaxillary (TAX) approach (n = 106) or a TF approach (n = 7132). The 30‐day mortality rate in the TCv group (5.9%) was similar to the TAX group (6.6%), but higher than the TF group (1.7%). In contrast, the rate of stroke/TIA at 30 days was similar in the TCv (2.9%) and TF (2.1%) groups, but significantly lower than the TAX group (13.2%). A meta‐analysis by Abraham et al. compared transcarotid (TC) versus TF and other alternative access routes for TAVI [19]. The TC approach had higher mortality at 1 month (3.7% vs. 2.6%, p = 0.02) than the TF approach, but there was no significant difference in the risk of stroke (3% vs. 2.2%, p = 0.1). Yokoyama et al. performed a network meta‐analysis comparing clinical outcomes of TAVI from a variety of peripheral vascular access sites [20]. In the comparison between TC and TCv TAVI, there was no significant difference in 30‐day mortality (OR [95% CI] = 0.88 [0.35−2.2]) or stroke (OR [95% CI] = 1.5 [0.52−4.3]), but there was less risk of major vascular complication (OR [95% CI] = 0.18 [0.08–0.38], p < 0.001) associated with the TC approach.
The current study adds to the body of evidence reinforcing the safety of TCv TAVI. In particular, the lower risk of stroke with the TCv approach compared to either the subclavian or TAX approach appears to be real, and reflects our own clinical experience. The TC approach is well validated but acceptable outcomes are dependent on favorable anatomy and operator expertise. As a result, our bias has been to offer the TCv approach as the first‐line alternative access strategy where the anatomy of the abdominal aorta and IVC is favorable. Unfortunately, a high percentage of patients with hostile iliofemoral anatomy will also have unfavorable anatomy of the abdominal aorta for TCv access.
4.3. Technical Considerations—Room for Improvement?
The technique we employed for performing TCv TAVI in this series reflects that previously described by Lederman et al. in 2015. Unfortunately, the lack of a broader adoption of TCv TAVI appears to have hampered further iteration in technology to facilitate TCv TAVI from industry.
One of the simplest advances would be the availability of interventional wires such as the 300 cm long Astato XS 20 0.014” (Asahi Intecc Medical) with the insulation from the distal end pre‐removed. Removing this insulation manually by the operator using a blade, to facilitate electrification of the wire, adds some variability to the procedure that could be addressed by the manufacturers of the wire. In addition to removing the insulation from the end of the interventional coronary wire, we have also found it helpful to remove the insulation from the edges of the PlasmaBlade (Medtronic) in contact with the denuded wire to facilitate electrification of the tip of the interventional wire at the TCv access point.
The available lengths of coronary guide (65 cm), Navicross (90 cm) (Terumo Interventional Systems) and Finecross (130 cm) (Terumo Interventional Systems) catheters that are typically used to build the telescoping foundation for crossing the TCv access site result in long lengths of guide and catheter(s) outside the body. We typically place a Guardian Hemostasis valve (Teleflex) between each of the components of the telescoping system of guide and catheters to prevent movement at the junction points which hinders the forward push achieved at the wire tip in the IVC. A dedicated system including appropriate guide and catheter lengths together with connectors might help with the adoption of the TCv access site.
Finally, the availability of a dedicated closure device to achieve hemostasis at the aortic puncture site following TCv TAVI has been previously proposed by Lederman RJ. The ability to predictably achieve complete closure of the aortic puncture site acutely would help remove the one of the sources of major morbidity from the procedure and enhance the confidence with which operators would approach TCv TAVI.
5. Limitations
The data presented in this study should be interpreted within the inherent limitations of a registry‐based study and small sample size.
6. Conclusion
When performed by an experienced TAVI operator with peripheral vascular and structural training, with limited up‐front proctoring for procedures and input from imaging specialists, this series supports that TCv TAVI can achieve a high rate of procedural success with low risk of mortality and stroke.
Conflicts of Interest
The authors declare no conflicts of interest.
Acknowledgments
We acknowledge our structural clinical nurse specialists (Jamie Byrne, Barbara Moran, Niamh Mattimoe, Susan Groarke and Susi Gnanaraj) for their dedication to patient care and contributions to maintaining the Mater TAVI database.
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