Valve implantation and access-site handling

In a dedicated hybrid operating theatre, all TF valve implantations were performed with patients under conscious sedation. At least one of the operators was highly experienced (> 3 years of experience and > 40 TF implantations per year; 4 members of the team). Echo-guided arterial puncture was left to the operator’s discretion. Patients were treated with either a balloon-expandable (Edwards Lifesciences, Irvine, CA) or a self-expandable (Medtronic plc, Minneapolis, MN) valve. Per protocol, valves were advanced via their manufacturer-dedicated sheaths (e-sheath [Edwards Lifesciences] or InLine sheath [Medtronic] / sheathless). If the usual preoperative assessment suggested significant tortuosity, then the self-expandable valves were advanced via a guiding-sheath from Cook Medical (Bloomington, IN). Per protocol, a plug-based vascular closure device was used (MANTA). Device deployment depth was based on the stop-flow measurement. Until December 2019, 2.0 cm was added to the measured depth; after December 2019, this depth was reduced to 1 cm per a change in the manufacturer instructions.¹⁴ Any needed venous puncture was performed on the contralateral side. Anticoagulation and any other antiplatelet therapy other than acetylsalicylic acid were discontinued before the procedure. Anticoagulation was bridged in the following specific situations: atrial fibrillation with a Congestive Heart Failure, Hypertension, Age (≥ 75 Years) (doubled), Diabetes Mellitus, Stroke (doubled), Vascular Disease, Age (65-74) Years, Sex Category (Female) (CHA₂DS₂-VASc) score ≥ 8; mechanical heart valves (not in aortic position); and venous thromboembolism for ≤ 3 months. Bridging was carried out using low-molecular-weight heparin until the day of the procedure. Compression bandage was not routinely placed.