51
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Nagasaka T, Koren O, Patel V, Naami R, Naami E, Shechter A, Kohan S, Allison Z, Lerner A, Cheng DE, Chakravarty T, Cheng W, Jilaihawi H, Ishii H, Nakamura M, Makkar RR. Two-Year Outcomes of Valve-in-Valve Using New-Generation Transcatheter Devices Compared With Redo-SAVR. Am J Cardiol 2023; 207:380-389. [PMID: 37778227 DOI: 10.1016/j.amjcard.2023.08.147] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/21/2023] [Accepted: 08/21/2023] [Indexed: 10/03/2023]
Abstract
Few studies have compared the clinical outcomes between valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) with new-generation valves and re-operative surgical aortic valve replacement (Redo-SAVR). We compared the clinical outcomes of patients who underwent ViV-TAVR with those of patients who underwent Redo-SAVR at Cedars-Sinai Medical Center between 2015 and 2021. New-generation valves were used for ViV-TAVR. A propensity score-matched (PSM) analysis was performed to adjust for differences in baseline characteristics. The primary end point was all-cause mortality at 30 days and 2 years. In-hospital procedural and clinical outcomes were also compared between the groups. A total of 256 patients (140 who underwent ViV-TAVR and 116 who underwent Redo-SAVR) were eligible for PSM. In the unmatched cohort, patients in the ViV-TAVR group were older and had more co-morbidities than those in the Redo-SAVR group. After PSM, there were no significant differences in all-cause death between the ViV-TAVR and Redo-SAVR groups at 30 days (3.9% vs 2.6%, p = 0.65) or 2 years (6.5% vs 7.8%, p = 0.75). The incidences of stroke and heart failure rehospitalization were similar at 30 days and 2 years. The cumulative complication rates during hospitalization were significantly lower in the ViV-TAVR group than in the Redo-SAVR group (11.7% vs 28.6% p = 0.015). The long-term outcomes of ViV-TAVR using new-generation valves were similar to those of Redo-SAVR, although ViV-TAVR was associated with lower rates of in-hospital complications.
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Affiliation(s)
- Takashi Nagasaka
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California; Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Ofir Koren
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California; Technion Israel Institute of Technology, Bruce Rappaport Faculty of Medicine, Haifa, Israel
| | - Vivek Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Robert Naami
- Internal Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Edmund Naami
- School of Medicine, University of Illinois, Chicago, Illinois
| | - Alon Shechter
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Siamak Kohan
- Internal Medicine, Kaiser Permanente Medical Center, Los Angeles, California
| | - Zev Allison
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Addee Lerner
- David Geffen School of Medicine, University of California (UCLA), Los Angeles, California
| | | | - Tarun Chakravarty
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Wen Cheng
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Hasan Jilaihawi
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Mamoo Nakamura
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Raj R Makkar
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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Colombo A, Leone PP. Adoption of TAVR in Europe vs the United States: Is it Deja-Vù? J Am Coll Cardiol 2023; 82:1903-1905. [PMID: 37877905 DOI: 10.1016/j.jacc.2023.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 09/05/2023] [Accepted: 09/06/2023] [Indexed: 10/26/2023]
Affiliation(s)
- Antonio Colombo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy; Cardio Center, IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy.
| | - Pier Pasquale Leone
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy; Cardio Center, IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy; The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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53
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Sá MP, Jacquemyn X, Van den Eynde J, Serna‐Gallegos D, Chu D, Clavel M, Pibarot P, Sultan I. Midterm Survival of Low-Risk Patients Treated With Transcatheter Versus Surgical Aortic Valve Replacement: Meta-Analysis of Reconstructed Time-to-Event Data. J Am Heart Assoc 2023; 12:e030012. [PMID: 37929669 PMCID: PMC10727380 DOI: 10.1161/jaha.123.030012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/10/2023] [Indexed: 11/07/2023]
Abstract
Background We performed a meta-analysis of reconstructed time-to-event data from randomized controlled trials (RCTs) and propensity-score matched (PSM) studies comparing transcatheter versus surgical aortic valve replacement (TAVR versus SAVR) to evaluate midterm outcomes in patients considered low risk for SAVR. Methods and Results Study-level meta-analysis of reconstructed time-to-event data from Kaplan-Meier curves of RCTs and PSM studies published by December 31, 2022 was conducted. Eight studies (3 RCTs, 5 PSM studies) met our eligibility criteria and included 5444 patients; 2639 patients underwent TAVR, and 2805 patients underwent SAVR. TAVR showed a higher risk of all-cause mortality at 8 years of follow-up (hazard ratio [HR] 1.22, [95% CI, 1.03-1.43], P=0.018). Up to 2 years of follow-up, TAVR was not inferior to SAVR (HR, 1.08 [95% CI, 0.89-1.31], P=0.448); however, we observed a statistically significant difference after 2 years with higher mortality with TAVR (HR, 1.51 [95% CI, 1.14-2.00]; P=0.004). This difference was driven by PSM studies; our sensitivity analysis showed a statistically significant difference between TAVR and SAVR when we included only PSM studies (HR, 1.41 [95% CI, 1.16-1.72], P=0.001) but no statistically significant difference when we included only RCTs (HR, 0.89 [95% CI, 0.69-1.16], P=0.398). Conclusions In comparison with TAVR, SAVR appeared to be associated with improved survival beyond 2 years in low-risk patients. However, the survival benefit of SAVR was observed only in PSM studies and not in RCTs. The addition of data from ongoing RCTs as well as longer follow-up in previous RCTs will help to confirm if there is a difference in mid- and long-term survival between TAVR versus SAVR in the low-risk population.
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Affiliation(s)
- Michel Pompeu Sá
- Department of Cardiothoracic SurgeryUniversity of PittsburghPAUSA
- UPMC Heart and Vascular InstituteUniversity of Pittsburgh Medical CenterPittsburghPAUSA
| | | | | | - Derek Serna‐Gallegos
- Department of Cardiothoracic SurgeryUniversity of PittsburghPAUSA
- UPMC Heart and Vascular InstituteUniversity of Pittsburgh Medical CenterPittsburghPAUSA
| | - Danny Chu
- Department of Cardiothoracic SurgeryUniversity of PittsburghPAUSA
- UPMC Heart and Vascular InstituteUniversity of Pittsburgh Medical CenterPittsburghPAUSA
| | - Marie‐Annick Clavel
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de QuébecQuébec CityQuébecCanada
- Department of Medicine, Faculty of MedicineUniversité LavalQuébec CityQuébecCanada
| | - Philippe Pibarot
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de QuébecQuébec CityQuébecCanada
- Department of Medicine, Faculty of MedicineUniversité LavalQuébec CityQuébecCanada
| | - Ibrahim Sultan
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de QuébecQuébec CityQuébecCanada
- Department of Medicine, Faculty of MedicineUniversité LavalQuébec CityQuébecCanada
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Imran H, Saad M. Transcatheter Versus Surgical Aortic Valve Replacement in Low-Risk Patients: Puzzle Solved? J Am Heart Assoc 2023; 12:e030953. [PMID: 37929671 PMCID: PMC10727414 DOI: 10.1161/jaha.123.030953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Affiliation(s)
- Hafiz Imran
- Lifespan Cardiovascular InstituteProvidenceRIUSA
- Department of Medicine, Division of CardiologyWarren Alpert Medical School of Brown UniversityProvidenceRIUSA
| | - Marwan Saad
- Lifespan Cardiovascular InstituteProvidenceRIUSA
- Department of Medicine, Division of CardiologyWarren Alpert Medical School of Brown UniversityProvidenceRIUSA
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55
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Heuts S, Kawczynski MJ, Sardari Nia P, Maessen JG, Biondi-Zoccai G, Gabrio A. Bayesian interpretation of non-inferiority in transcatheter versus surgical aortic valve replacement trials: a systematic review and meta-analysis. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2023; 37:ivad185. [PMID: 37982737 PMCID: PMC10684360 DOI: 10.1093/icvts/ivad185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 11/01/2023] [Accepted: 11/17/2023] [Indexed: 11/21/2023]
Abstract
OBJECTIVES The concept of non-inferiority is widely adopted in randomized trials comparing transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR). However, uncertainty exists regarding the long-term outcomes of TAVR, and non-inferiority may be difficult to assess. We performed a systematic review and meta-analysis of randomized trials comparing TAVR and SAVR, with a specific emphasis on the non-inferiority margin for 5-year all-cause mortality. METHODS A systematic search was applied to 3 electronic databases. Randomized trials comparing TAVR and SAVR were included. Bayesian methods were implemented to evaluate the posterior probability of non-inferiority at different trial non-inferiority margins under either a vague, Cauchy, or a literature-based prior. Primary outcomes were 5-year actuarial all-cause mortality, and the probability of non-inferiority at various transformed trial non-inferiority margins. Secondary outcomes were long-term survival and 1- and 2-year actuarial survival. RESULTS Eight trials (n = 8698 patients) were included. Kaplan-Meier-derived 5-year survival was 61.6% (95% CI 59.8-63.5%) for TAVR, and 63.7% (95% CI 61.9-65.6%) for SAVR. Six trials (n = 6370 patients) reported all-cause mortality at 5-year follow-up. Under a vague prior, the posterior median relative risk for all-cause mortality of TAVR was 1.14, compared to SAVR (95% credible interval 1.06-1.22, probability of relative risk <1.00 = 0.01%, I2 = 0%). Similar results in terms of point estimate and uncertainty measures were obtained using frequentist methods. Based on the various trial non-inferiority margins, the results of the analysis suggest that non-inferiority at 5 years is no longer likely. CONCLUSIONS It is unlikely that TAVR is still non-inferior to SAVR at 5 years in terms of all-cause mortality.
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Affiliation(s)
- Samuel Heuts
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre+, Maastricht, Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Netherlands
| | - Michal J Kawczynski
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre+, Maastricht, Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Netherlands
| | - Peyman Sardari Nia
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre+, Maastricht, Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Netherlands
| | - Jos G Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre+, Maastricht, Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Netherlands
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy
- Mediterranea Cardiocentro, Napoli, Italy
| | - Andrea Gabrio
- Department of Methodology and Statistics, Maastricht University, Maastricht, Netherlands
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56
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Gonnah AR, Abdelwahab M, Taylor R, Labib A, Masoud O, Debski M, Abdelaziz HK, Roberts DH. Health-related quality of life following TAVI or cardiac surgery in patients at intermediate and low risk: a systematic review and meta-analysis. Clin Med (Lond) 2023; 23:594-605. [PMID: 38065591 PMCID: PMC11046617 DOI: 10.7861/clinmed.2023-0258] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Recent randomised trials have shown that clinical outcomes with transcatheter aortic valve implantation (TAVI) are non-inferior to surgical aortic valve replacement (SAVR) in patients with symptomatic aortic stenosis at intermediate to low risk. Health-related quality of life (HrQoL) outcomes in these patient groups remain uncertain. A systematic search of the literature was conducted that included nine trials and 11,295 patients. Kansas City Cardiomyopathy Questionnaire (KCCQ), a heart-failure-specific measure and EuroQol-5D (EQ-5D) (a generic health status tool) changes were the primary outcomes. New York Heart Association (NYHA) classification was the secondary outcome. Improvement in KCCQ scores was greater with TAVI (mean difference (MD)=13.56, 95% confidence interval (CI) 11.67-15.46, p<0.001) at 1 month, as was the improvement in EQ-5D (MD=0.07, 95% CI 0.05-0.08, p<0.001). There was no difference in KCCQ (MD=1.05, 95% CI -0.11 to 2.21, p=0.08) or EQ-5D (MD=-0.01, 95% CI -0.03 to 0.01), p=0.37) at 12 months. NYHA functional class 3/4 was lower in patients undergoing TAVI at 1 month (MD=0.51, 95% CI 0.34-0.78, p=0.002), but there was no difference at 12 months (MD=1.10; 95% CI 0.87-1.38, p=0.43). Overall, TAVI offers early benefit in HRQoL outcomes compared with SAVR, but they are equivalent at 12 months.
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Affiliation(s)
| | | | - Rebecca Taylor
- Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - Aser Labib
- Southport and Ormskirk NHS Foundation Trust, Southport, UK
| | - Omar Masoud
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Maciej Debski
- University of East Anglia, Norwich, UK and research fellow, Norfolk and Norwich University Hospital, Norwich, UK
| | | | - David Hesketh Roberts
- Lancashire Cardiac Centre, Blackpool, UK, and honorary senior lecturer, University of Liverpool, Merseyside Liverpool
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Seiffert M, Vonthein R, Baumgartner H, Borger MA, Choi YH, Falk V, Frey N, Hagendorff A, Hagl C, Hamm C, König IR, Landmesser U, Massberg S, Reichenspurner H, Thiele H, Twerenbold R, Vens M, Walther T, Ziegler A, Cremer J, Blankenberg S. Transcatheter aortic valve implantation versus surgical aortic valve replacement in patients at low to intermediate surgical risk: rationale and design of the randomised DEDICATE Trial. EUROINTERVENTION 2023; 19:652-658. [PMID: 37655862 PMCID: PMC10587839 DOI: 10.4244/eij-d-23-00232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 07/24/2023] [Indexed: 09/02/2023]
Abstract
Transcatheter aortic valve implantation (TAVI) has become the preferred treatment option for patients with severe aortic stenosis at increased risk for surgical aortic valve replacement (SAVR) and for older patients irrespective of risk. However, in younger, low-risk patients for whom both therapeutic options, TAVI and SAVR, are applicable, the optimal treatment strategy remains controversial, as data on long-term outcomes remain limited. The DEDICATE-DZHK6 Trial is an investigator-initiated, industry-independent, prospective, multicentre, randomised controlled trial investigating the efficacy and safety of TAVI compared to SAVR in low- to intermediate-risk patients aged 65 years or older. To evaluate both treatment strategies, approximately 1,404 patients determined eligible for both TAVI and SAVR by the interdisciplinary Heart Team were randomised to TAVI or SAVR. Broad inclusion and strict exclusion criteria targeted an all-comers patient population. Procedures were performed according to local best practice with contemporary routine medical devices. The primary endpoints are a composite of mortality or stroke at 1 year and 5 years in order to incorporate midterm efficacy results and complement early safety data. Primary outcomes will be tested sequentially for non-inferiority and superiority. The DEDICATE-DZHK6 Trial has been designed to mirror clinical reality for the treatment of severe aortic stenosis and provide unique information on overall outcomes after TAVI and SAVR that can be directly applied to clinical routines. Its results will help further define optimal treatment strategies for low- to intermediate-risk patients in whom both TAVI and SAVR are currently advisable.
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Affiliation(s)
- Moritz Seiffert
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Centre for Population Health Innovation (POINT), University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research) partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Reinhard Vonthein
- Institute of Medical Biometry and Statistics, University of Lübeck, Lübeck, Germany
| | - Helmut Baumgartner
- Department of Cardiology III - Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Muenster, Germany
| | - Michael A Borger
- Department of Cardiac Surgery, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Yeong-Hoon Choi
- Department of Cardiac Surgery, Kerckhoff-Klinik, Bad Nauheim, Germany
- DZHK (German Centre for Cardiovascular Research) partner site Rhine-Main, Rhine-Main, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- DZHK (German Centre for Cardiovascular Research) partner site Berlin, Berlin, Germany
- Department of Health Sciences & Technology, ETH Zurich, Translational Cardiovascular Technology, Zurich, Switzerland
| | - Norbert Frey
- Department of Cardiology, Angiology, and Pneumology, Heidelberg University Hospital, Heidelberg, Germany
- DZHK (German Centre for Cardiovascular Research) partner site Heidelberg/Mannheim, Heidelberg, Germany
| | | | - Christian Hagl
- Department of Cardiac Surgery, University Hospital Munich, Ludwig-Maximilians-University Munich, Munich, Germany
- DZHK (German Centre for Cardiovascular Research) partner site Munich Heart Alliance, Munich, Germany
| | - Christian Hamm
- DZHK (German Centre for Cardiovascular Research) partner site Rhine-Main, Rhine-Main, Germany
- Campus Kerckhoff and Medical Clinic I, University of Giessen, Giessen, Germany
| | - Inke R König
- DZHK (German Centre for Cardiovascular Research) partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Institute of Medical Biometry and Statistics, University of Lübeck, Lübeck, Germany
| | - Ulf Landmesser
- DZHK (German Centre for Cardiovascular Research) partner site Berlin, Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany and Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Steffen Massberg
- Department of Cardiac Surgery, University Hospital Munich, Ludwig-Maximilians-University Munich, Munich, Germany
- Department of Cardiology, University Hospital Munich, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Hermann Reichenspurner
- DZHK (German Centre for Cardiovascular Research) partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Holger Thiele
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany and Leipzig Heart Science, Leipzig, Germany
| | - Raphael Twerenbold
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Centre for Population Health Innovation (POINT), University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research) partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Maren Vens
- Institute of Medical Biometry and Statistics, University of Lübeck, Lübeck, Germany
| | - Thomas Walther
- DZHK (German Centre for Cardiovascular Research) partner site Rhine-Main, Rhine-Main, Germany
- Department of Thoracic and Cardiovascular Surgery, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Andreas Ziegler
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Centre for Population Health Innovation (POINT), University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Cardio-CARE, Medizincampus Davos, Davos, Switzerland
- School of Mathematics, Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Jochen Cremer
- DZHK (German Centre for Cardiovascular Research) partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Department of Cardiovascular Surgery, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Stefan Blankenberg
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Centre for Population Health Innovation (POINT), University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research) partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
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Yeats BB, Sivakumar SK, Samaee M, Polsani V, Yadav PK, Thourani VH, Sellers S, Sathananthan J, Dasi LP. Calcium Fracture and Device Over Expansion in Transcatheter Aortic Valve Replacement for Bicuspid Aortic Valves. Ann Biomed Eng 2023; 51:2172-2181. [PMID: 37219698 DOI: 10.1007/s10439-023-03246-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 05/16/2023] [Indexed: 05/24/2023]
Abstract
Transcatheter aortic valve replacement (TAVR) in patients with bicuspid aortic valve disease (BAV) has potential risks of under expansion and non-circularity which may compromise long-term durability. This study aims to investigate calcium fracture and balloon over expansion in balloon-expandable TAVs on the stent deformation with the aid of simulation. BAV patients treated with the SAPIEN 3 Ultra with pre- and post-TAVR CTs were analyzed (n = 8). Simulations of the stent deployment were performed (1) with baseline simulation allowing calcium fracture, (2) without allowable calcium fracture and (3) with balloon over expansion (1 mm larger diameter). When compared to post CT, baseline simulations had minimal error in expansion (2.5% waist difference) and circularity (3.0% waist aspect ratio difference). When compared to baseline, calcium fracture had insignificant impact on the expansion (- 0.5% average waist difference) and circularity (- 1.6% average waist aspect ratio difference). Over expansion had significantly larger expansion compared to baseline (15.4% average waist difference) but had insignificant impact on the circularity (- 0.5% waist aspect ratio difference). We conclude that stent deformation can be predicted with minimal error, calcium fracture has small differences on the final stent deformation except in extreme calcified cases, and balloon over expansion expands the waist closer to nominal values.
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Affiliation(s)
- Breandan B Yeats
- Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, 387 Technology Cir NW, Atlanta, GA, 30313, USA
| | - Sri Krishna Sivakumar
- Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, 387 Technology Cir NW, Atlanta, GA, 30313, USA
| | - Milad Samaee
- Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, 387 Technology Cir NW, Atlanta, GA, 30313, USA
| | - Venkateshwar Polsani
- Department of Cardiology, Marcus Valve Center, Piedmont Heart Institute, Atlanta, GA, USA
| | - Pradeep K Yadav
- Department of Cardiology, Marcus Valve Center, Piedmont Heart Institute, Atlanta, GA, USA
| | - Vinod H Thourani
- Department of Cardiovascular Surgery, Marcus Valve Center, Piedmont Heart Institute, Atlanta, GA, USA
| | - Stephanie Sellers
- Cardiovascular Translational Lab, Centre for Heart Lung Innovation & Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, Canada
| | - Janarthanan Sathananthan
- Cardiovascular Translational Lab, Centre for Heart Lung Innovation & Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, Canada
| | - Lakshmi P Dasi
- Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, 387 Technology Cir NW, Atlanta, GA, 30313, USA.
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59
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Szotek M, Drużbicki Ł, Sabatowski K, Amoroso GR, De Schouwer K, Matusik PT. Transcatheter Aortic Valve Implantation and Cardiac Conduction Abnormalities: Prevalence, Risk Factors and Management. J Clin Med 2023; 12:6056. [PMID: 37762995 PMCID: PMC10531796 DOI: 10.3390/jcm12186056] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/26/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
Over the last decades, transcatheter aortic valve implantation (TAVI) or replacement (TAVR) has become a potential, widely accepted, and effective method of treating aortic stenosis in patients at moderate and high surgical risk and those disqualified from surgery. The method evolved what translates into a noticeable decrease in the incidence of complications and more beneficial clinical outcomes. However, the incidence of conduction abnormalities related to TAVI, including left bundle branch block and complete or second-degree atrioventricular block (AVB), remains high. The occurrence of AVB requiring permanent pacemaker implantation is associated with a worse prognosis in this group of patients. The identification of risk factors for conduction disturbances requiring pacemaker placement and the assessment of their relation to pacing dependence may help to develop methods of optimal care, including preventive measures, for patients undergoing TAVI. This approach is crucial given the emerging evidence of no worse outcomes for intermediate and low-risk patients undergoing TAVI in comparison to surgical aortic valve replacement. This paper comprehensively discusses the mechanisms, risk factors, and consequences of conduction abnormalities and arrhythmias, including AVB, atrial fibrillation, and ventricular arrhythmias associated with aortic stenosis and TAVI, as well as provides insights into optimized patient care, along with the potential of conduction system pacing and cardiac resynchronization therapy, to minimize the risk of unfavorable clinical outcomes.
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Affiliation(s)
- Michał Szotek
- Department of Electrocardiology, The John Paul II Hospital, 80 Prądnicka St., 31-202 Kraków, Poland
| | - Łukasz Drużbicki
- Department of Cardiovascular Surgery and Transplantology, The John Paul II Hospital, 80 Prądnicka St., 31-202 Kraków, Poland
| | - Karol Sabatowski
- Department of Cardiology and Cardiovascular Interventions, University Hospital, 2 Jakubowskiego St., 30-688 Kraków, Poland
| | - Gisella R. Amoroso
- Department of Cardiovascular Medicine, “SS Annunziata” Hospital, ASL CN1-Savigliano, Via Ospedali 9, 12038 Savigliano, Italy
| | - Koen De Schouwer
- Department of Cardiology, Cardiovascular Center, Onze-Lieve-Vrouwziekenhuis Hospital, Moorselbaan 164, 9300 Aalst, Belgium
| | - Paweł T. Matusik
- Department of Electrocardiology, The John Paul II Hospital, 80 Prądnicka St., 31-202 Kraków, Poland
- Institute of Cardiology, Faculty of Medicine, Jagiellonian University Medical College, 80 Prądnicka St., 31-202 Kraków, Poland
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Lerman TT, Levi A, Jørgensen TH, Søndergaard L, Talmor-Barkan Y, Kornowski R. Comparison of middle-term valve durability between transcatheter aortic valve implantation and surgical aortic valve replacement: an updated systematic review and meta-analysis of RCTs. Front Cardiovasc Med 2023; 10:1242608. [PMID: 37771663 PMCID: PMC10525352 DOI: 10.3389/fcvm.2023.1242608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 08/21/2023] [Indexed: 09/30/2023] Open
Abstract
Background This study aims to compare valve durability between transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR). Methods We conducted a systematic review and meta-analysis using data from randomized controlled trials (RCTs). The primary outcome was structural valve deterioration (SVD). Secondary outcomes were bioprosthetic valve failure, reintervention, effective orifice area (EOA), mean pressure gradient, and moderate-severe aortic regurgitation (AR, transvalvular and/or paravalvular). Results Twenty-five publications from seven RCTs consisting of 7,970 patients were included in the analysis with follow-up ranges of 2-8 years. No significant difference was found between the two groups with regard to SVD [odds ratio (OR) 0.72; 95% CI: 0.25-2.12]. The TAVI group was reported to exhibit a statistically significant higher risk of reintervention (OR 2.03; 95% CI: 1.34-3.05) and a moderate-severe AR (OR 6.54; 95% CI: 3.92-10.91) compared with the SAVR group. A trend toward lower mean pressure gradient in the TAVI group [(mean difference (MD) -1.61; 95% CI: -3.5 to 0.28)] and significant higher EOA (MD 0.20; 95% CI: 0.08-0.31) was noted. Conclusion The present data indicate that TAVI provides a comparable risk of SVD with favorable hemodynamic profile compared with SAVR. However, the higher risk of significant AR and reintervention was demonstrated. Systematic Review Registration PROSPERO (CRD42022363060).
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Affiliation(s)
- Tsahi T. Lerman
- Department of Internal Medicine F-Recanati, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel
- The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amos Levi
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel
- The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Troels Højsgaard Jørgensen
- Department of Cardiology, The Heart Center, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lars Søndergaard
- Department of Cardiology, The Heart Center, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Yeela Talmor-Barkan
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel
- The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ran Kornowski
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel
- The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Lazar HL. Commentary: Developing accurate tools for predicting outcomes following coronary artery bypass graft surgery: More data are needed. J Thorac Cardiovasc Surg 2023; 166:801-804. [PMID: 34998591 DOI: 10.1016/j.jtcvs.2021.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 12/10/2021] [Accepted: 12/15/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Harold L Lazar
- Division of Cardiac Surgery, Boston University School of Medicine, Boston, Mass.
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Park DY, An S, Kassab K, Jolly N, Attanasio S, Sawaqed R, Malhotra S, Doukky R, Vij A. Chronological comparison of TAVI and SAVR stratified to surgical risk: a systematic review, meta-analysis, and meta-regression. Acta Cardiol 2023; 78:778-789. [PMID: 37294002 DOI: 10.1080/00015385.2023.2218025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 12/19/2022] [Accepted: 05/19/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND Transcatheter aortic valve implantation (TAVI) has been established as a reasonable alternative to surgical aortic valve replacement (SAVR) in patients with severe aortic stenosis. However, long-term outcomes including valve durability and the need for reintervention are unanswered, especially in younger patients who tend to be low surgical risk. We performed a meta-analysis comparing clinical outcomes after TAVI and SAVR over 5 years stratified to low, intermediate, and high surgical risks. METHODS We identified propensity score-matched observational studies and randomised controlled trials comparing TAVI and SAVR. Primary outcomes, including all-cause mortality, moderate or severe aortic regurgitation, moderate or severe paravalvular regurgitation, pacemaker placement, and stroke, were extracted. Meta-analyses of outcomes after TAVI compared to SAVR were conducted for different periods of follow-up. Meta-regression was also performed to analyse the correlation of outcomes over time. RESULTS A total of 36 studies consisting of 7 RCTs and 29 propensity score-matched studies were selected. TAVI was associated with higher all-cause mortality at 4-5 years in patients with low or intermediate surgical risk. Meta-regression time demonstrated an increasing trend in the risk of all-cause mortality after TAVI compared with SAVR. TAVI was generally associated with a higher risk of moderate or severe aortic regurgitation, moderate or severe paravalvular regurgitation, and pacemaker placement. CONCLUSIONS TAVI demonstrated an increasing trend of all-cause mortality compared with SAVR when evaluated over a long-term follow-up. More long-term data from recent studies using newer-generation valves and state-of-the-art techniques are needed to accurately assign risks.
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Affiliation(s)
- Dae Yong Park
- Department of Medicine, John H. Stroger Jr Hospital of Cook County, Chicago, IL, USA
| | - Seokyung An
- Department of Biomedical Science, Seoul National University Graduate School, Seoul, Korea
| | - Kameel Kassab
- Division of Cardiology, Ascension Borgess Hospital/Michigan State University, Kalamazoo, MI, USA
| | - Neeraj Jolly
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA
| | - Steve Attanasio
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA
| | - Ray Sawaqed
- Division of Cardiothoracic Surgery, Cook County Health, Chicago, IL, USA
- Division of Cardiothoracic Surgery, Rush Medical College, Chicago, IL, USA
| | - Saurabh Malhotra
- Division of Cardiology, Cook County Health, Chicago, IL, USA
- Division of Cardiology, Rush Medical College, Chicago, IL, USA
| | - Rami Doukky
- Division of Cardiology, Cook County Health, Chicago, IL, USA
- Division of Cardiology, Rush Medical College, Chicago, IL, USA
| | - Aviral Vij
- Division of Cardiology, Cook County Health, Chicago, IL, USA
- Division of Cardiology, Rush Medical College, Chicago, IL, USA
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63
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Ferstl P, Achenbach S, Marwan M, Bittner DO. Comparison of oral anticoagulation by vitamin-K antagonists and non-vitamin-K antagonists for treatment of leaflet thickening after transcatheter aortic valve implantation (TAVI). Int J Cardiol 2023; 386:104-108. [PMID: 37244382 DOI: 10.1016/j.ijcard.2023.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 05/12/2023] [Accepted: 05/17/2023] [Indexed: 05/29/2023]
Abstract
INTRODUCTION Hypoattenuated leaflet thickening (HALT), as identified by CT imaging, is not infrequent after transcatheter aortic valve implantation (TAVI). The best choice of oral anticoagulation is unknown. We compared the effectiveness of Direct Oral AntiCoagulants (DOAC) and Vitamin-K Antagonists (VKA) to resolve HALT in patients with serial CT aquisitions. METHODS A total of 46 consecutive TAVI patients in whom anticoagulation had been initiated because of HALT and who underwent follow-up CT were identified. Indication and type of anticoagulation was according to physician discretion. Patients on DOAC were compared to VKA therapy regarding resolution of HALT. RESULTS Mean age of the 46 patients was 80 ± 6 years (59% men), and the mean duration of anticoagulation was 156 days. Overall, 41 patients (89%) showed resolution of HALT with anticoagulation therapy, whereas HALT persisted in 5 patients (11%). Resolution of HALT was seen in 26 out of 30 (87%) patients receiving VKA and in 15 out of 16 (94%) patients receiving DOAC, respectively. Groups did not differ regarding age, cardiovascular risk factors, TAVI prosthesis type and size or duration of anticoagulation (all p > 0.05). CONCLUSION Anticoagulation therapy resolves leaflet thickening after TAVI in most patients. Non-Vitamin-K antagonists seem to be an effective alternative to Vitamin-K antagonists. This finding needs to be confirmed in larger prospective trials.
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Affiliation(s)
- P Ferstl
- Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Department of Cardiology, Erlangen, Germany.
| | - S Achenbach
- Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Department of Cardiology, Erlangen, Germany
| | - M Marwan
- Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Department of Cardiology, Erlangen, Germany
| | - D O Bittner
- Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Department of Cardiology, Erlangen, Germany
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Juarez-Casso FM, Crestanello JA. The Evolving Role of Surgical Aortic Valve Replacement in the Era of Transcatheter Valvular Procedures. J Clin Med 2023; 12:5299. [PMID: 37629341 PMCID: PMC10455383 DOI: 10.3390/jcm12165299] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 07/11/2023] [Accepted: 07/19/2023] [Indexed: 08/27/2023] Open
Abstract
Surgical aortic valve replacement (SAVR) has long been the standard treatment for severe symptomatic aortic stenosis (AS). However, transcatheter aortic valve replacement (TAVR) has emerged as a minimally invasive alternative; it was initially intended for high-risk patients and has now expanded its use to patients of all risk groups. While TAVR has demonstrated promising outcomes in diverse patient populations, uncertainties persist regarding its long-term durability and potential complications, raising the issue of the ideal lifetime management strategy for patients with AS. Therefore, SAVR continues to play an important role in clinical practice, particularly in younger patients with longer life expectancies, those with complex aortic anatomy who are unsuitable for TAVR, and those requiring concomitant surgical procedures. The choice between TAVR and SAVR warrants personalized decision-making, considering patient characteristics, comorbidities, anatomical considerations, and overall life expectancy. A multidisciplinary approach involving an experienced heart team is crucial in the preoperative evaluation process. In this review, we aimed to explore the current role of surgical management in addressing aortic valve stenosis amidst the expanding utilization of less invasive transcatheter procedures.
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Affiliation(s)
| | - Juan A. Crestanello
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN 55905, USA;
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65
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Thogata H, Garikipati S, Reddy S S, Abhinav Reddy P, Kumar Jella H. Long-Term Prognosis and Predictors of Mortality in Patients Undergoing Transcatheter Aortic Valve Replacement: A Retrospective Analysis. Cureus 2023; 15:e44432. [PMID: 37791197 PMCID: PMC10543993 DOI: 10.7759/cureus.44432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 08/30/2023] [Indexed: 10/05/2023] Open
Abstract
BACKGROUND Aortic valve disease is a common and impactful disorder that imposes significant health burdens and is associated with increased mortality rates. Particularly noteworthy is the emergence of transcatheter aortic valve replacement (TAVR), a minimally invasive procedure that has revolutionized the management of aortic valve disease. However, there remain certain unresolved questions and ongoing research regarding the long-term effectiveness and suitability of TAVR in various patient populations, underscoring the need for further investigation and clinical scrutiny. OBJECTIVE This retrospective analysis aimed to investigate the long-term outcomes and predictors of mortality in 500 patients who underwent transcatheter aortic valve replacement (TAVR). METHODS This retrospective analysis included individuals who received transcatheter aortic valve replacement (TAVR) at Sri Venkata Sai (SVS) Medical College, Mahabubnagar, Telangana, India, between January 2020 and July 2023. Demographic characteristics, including age, gender, and comorbidities, were recorded, and long-term outcomes after TAVR were assessed, including the incidence of survival rates and major adverse cardiac events (MACE). Predictors of mortality were also identified using Cox proportional hazards regression analysis. RESULTS The study group exhibited an average age of 75.6 years (standard deviation (SD): 6.8), with 58% male and 42% female patients. Hypertension (74%), coronary artery disease (CAD) (68%), diabetes mellitus (DM) (42%), and chronic kidney disease (CKD) stage ≥ 3 (36%) were prevalent comorbidities. The median follow-up duration was 5.2 years (interquartile range (IQR): 4.3-6.8 years). The overall long-term survival rate after TAVR was 73.5% (95% confidence interval (CI): 69.8%-77.1%). Additionally, MACE occurred in 21% of patients throughout the follow-up period. The cumulative incidence of MACE at one year, three years, and five years was 6.8% (95% CI: 4.2%-9.5%), 14.2% (95% CI: 10.6%-18.7%), and 21.8% (95% CI: 17.3%-26.7%), respectively. The study found that higher age (hazard ratio (HR): 1.08, 95% CI: 1.04-1.12, p < 0.001), male gender (HR: 1.48, 95% CI: 1.15-1.91, p = 0.002), and the presence of CAD (HR: 1.72, 95% CI: 1.29-2.30, p < 0.001) were linked to an elevated risk of mortality. Additionally, diabetes mellitus (HR: 1.39, 95% CI: 1.05-1.85, p = 0.022) and CKD stage ≥ 3 (HR: 1.96, 95% CI: 1.47-2.61, p < 0.001) emerged as notable predictors of mortality. Conversely, a history of prior coronary artery bypass grafting (CABG) (HR: 0.62, 95% CI: 0.46-0.84, p = 0.003) was associated with a reduced risk of mortality. No significant associations were found between mortality and hypertension (HR: 1.12, 95% CI: 0.88-1.43, p = 0.360) or prior percutaneous coronary intervention (PCI) (HR: 1.21, 95% CI: 0.88-1.67, p = 0.245). CONCLUSION Age, male gender, CAD, DM, and CKD stage ≥ 3 were significant indicators of mortality risk in TAVR patients. Risk stratification and individualized management are crucial in optimizing long-term outcomes following TAVR procedures.
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Affiliation(s)
- Harshitha Thogata
- Department of General Medicine, Narayana Medical College and Hospital, Nellore, IND
| | - Sushmitha Garikipati
- Department of General Medicine, Apollo Institute of Medical Sciences and Research, Hyderabad, IND
| | - Shanthi Reddy S
- Department of General Medicine, Osmania Medical College and Hospital, Hyderabad, IND
| | - Pathe Abhinav Reddy
- Department of General Medicine, Davao Medical School Foundation, Inc., Davao City, PHL
| | - Harish Kumar Jella
- Department of General Medicine, Sri Venkata Sai (SVS) Medical College and Hospital, Mahabubnagar, IND
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Medilek K, Bis J, Polansky P, Kvasnicka T, Borg A, Dusek J, Brtko M, Tuna M, Praus R, Ballon M, Stasek J, Littnerova S, Parizek P. Computed tomography is better than echocardiography in predicting balloon-expandable transcutaneous implantation valve size in a real-world clinical practice single-center study. Echocardiography 2023; 40:784-791. [PMID: 37417924 DOI: 10.1111/echo.15643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 06/06/2023] [Accepted: 06/20/2023] [Indexed: 07/08/2023] Open
Abstract
AIMS Transcatheter aortic valve replacement (TAVR) has become the standard of care for selected patients with severe aortic stenosis. Multidetector computed tomography (MDCT) and transoesophageal 2D/3D (two-dimensional/three-dimensional) echocardiography (ECHO) are used for aortic annulus (AA) sizing. The aim of this study was to compare the accuracy of AA sizing by ECHO versus MDCT for Edwards Sapien balloon expandable valve in a single center. METHODS AND RESULTS Data from 145 consecutive patients with TAVR (Sapien XT or Sapien S3) were analyzed retrospectively. A total of 139 (96%) patients had favorable outcomes after TAVR (at most mild aortic regurgitation and only one valve implanted). The 3D ECHO AA area and area-derived diameter were smaller than the corresponding MDCT parameters (464 ± 99 vs. 479 ± 88 mm2 , p < .001, and 24.2 ± 2.7 vs. 25.0 ± 5.5 mm, p = .002, respectively). The 2D ECHO annulus measurement was smaller than both the MDCT and 3D ECHO area-derived diameters (22.6 ± 2.9 vs. 25.0 ± 5.5 mm, p = .013, and 22.6 ± 2.9 vs. 24.2 ± 2.7 mm, p < .001, respectively) but larger than the minor axis diameter of the AA derived from MDCT and 3D ECHO by multiplanar reconstruction (p < .001). The 3D ECHO circumference-derived diameter was also smaller than the MDCT circumference-derived diameter (24.3 ± 2.5 vs. 25.0 ± 2.3, p = .007). The sphericity index by 3D ECHO was smaller than that by MDCT (1.2 ± .1 vs. 1.3 ± .1, p < .001). In up to 1/3 of the patients, 3D ECHO measurements would have predicted different (generally smaller) valve size than was the valve size implanted with favorable result. The concordance of the implanted valve size with the recommended size based on preprocedural MDCT and 3D ECHO AA area was 79.4% versus 61% (p = .001), and for the area-derived diameter, the concordance was 80.1% versus 61.7% (p = .001). 2D ECHO diameter concordance was similar to MDCT (78.7%). CONCLUSIONS 3D ECHO AA measurements are smaller than MDCT measurements. If 3D ECHO-based parameters alone are used to size the Edwards Sapien balloon expandable valve, then the selected valve size would have been smaller than the valve size implanted with favorable result in 1/3 of the patients. MDCT preprocedural TAVR assessment should be the preferred method over 3D ECHO in routine clinical practice to determine Edwards Sapien valve size.
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Affiliation(s)
- Karel Medilek
- Department of Cardioangiology, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
- Faculty of Medicine Hradec Kralove, Charles University Prague, Czech Republic
| | - Josef Bis
- Department of Cardioangiology, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Pavel Polansky
- Department of Cardiothoracic Surgery, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Tomas Kvasnicka
- Department of Radiology, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Alex Borg
- Department of Cardiology, Mater Dei Hospital, Triq Dun Karm, L-Imsida MSD 2090 and University of Malta, Msida MSD, Malta
| | - Jaroslav Dusek
- Department of Cardioangiology, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Miroslav Brtko
- Department of Cardiothoracic Surgery, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Martin Tuna
- Department of Cardiothoracic Surgery, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Rudolf Praus
- Department of Cardioangiology, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Marek Ballon
- Department of Cardioangiology, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Josef Stasek
- Department of Cardioangiology, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Simona Littnerova
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Petr Parizek
- Department of Cardioangiology, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
- Faculty of Medicine Hradec Kralove, Charles University Prague, Czech Republic
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Masraf H, Sef D, Chin SL, Hunduma G, Trkulja V, Miskolczi S, Velissaris T, Luthra S. Long-Term Survival among Octogenarians Undergoing Aortic Valve Replacement with or without Simultaneous Coronary Artery Bypass Grafting: A 22-Year Tertiary Single-Center Experience. J Clin Med 2023; 12:4841. [PMID: 37510956 PMCID: PMC10381828 DOI: 10.3390/jcm12144841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 07/12/2023] [Accepted: 07/21/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND The impact of concomitant coronary artery bypass grafting (CABG) on aortic valve replacement (AVR) in octogenarians is still debated. We analyzed the characteristics and long-term survival of octogenarians undergoing isolated AVR and AVR + CABG. METHODS All octogenarians who consecutively underwent AVR with or without concomitant CABG at our tertiary cardiac center between 2000 and 2022 were included. Patients with redo, emergent, or any other concomitant procedures were excluded. The primary endpoints were 30-day and long-term survival. The secondary endpoints were early postoperative outcomes and determinants of long-term survival. Univariable and multivariable logistic regression analyses were performed to identify independent predictors of 30-day mortality, and Cox regression analysis was performed for predictors of adverse long-term survival. RESULTS A total of 1011 patients who underwent AVR (83.0 [81.0-85.0] years, 42.0% males) and 1055 with AVR + CABG (83.0 [81.2-85.4] years, 66.1% males) were included in our study. Survival at 30 days and at 1, 3, and 5 years in the AVR group was 97.9%, 91.5%, 80.5%, and 66.2%, respectively, while in the AVR + CABG group it was 96.2%, 89.6%, 77.7%, and 64.7%, respectively. There was no significant difference in median postoperative survival between the AVR and AVR + CABG groups (7.1 years [IQR: 6.7-7.5] vs. 6.6 years [IQR: 6.3-7.2], respectively, p = 0.21). Significant predictors of adverse long-term survival in the AVR group included age (hazard ratio (HR): 1.09; 95% CI: 1.06-1.12, p < 0.001), previous MI (HR: 2.08; 95% CI: 1.32-3.28, p = 0.002), and chronic kidney disease (HR 2.07; 95% CI: 1.33-3.23, p = 0.001), while in the AVR + CABG group they included age (HR: 1.06; 95% CI: 1.04-1.10, p < 0.001) and diabetes mellitus (HR: 1.48; 95% CI: 1.15-1.89, p = 0.002). Concomitant CABG was not an independent risk factor for adverse long-term survival (HR: 0.89; 95% CI: 0.77-1.02, p = 0.09). CONCLUSIONS The long-term survival of octogenarians who underwent AVR or AVR + CABG was similar and was not affected by adding concomitant CABG. However, octogenarians who underwent concomitant CABG with AVR had significantly higher in-hospital mortality. Each decision should be discussed within the heart team.
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Affiliation(s)
- Hannah Masraf
- Wessex Cardiothoracic Centre, University Hospital Southampton, Southampton SO16 6YD, UK
| | - Davorin Sef
- Wessex Cardiothoracic Centre, University Hospital Southampton, Southampton SO16 6YD, UK
| | - Sirr Ling Chin
- Wessex Cardiothoracic Centre, University Hospital Southampton, Southampton SO16 6YD, UK
| | - Gabriel Hunduma
- Wessex Cardiothoracic Centre, University Hospital Southampton, Southampton SO16 6YD, UK
| | | | - Szabolcs Miskolczi
- Wessex Cardiothoracic Centre, University Hospital Southampton, Southampton SO16 6YD, UK
| | - Theodore Velissaris
- Wessex Cardiothoracic Centre, University Hospital Southampton, Southampton SO16 6YD, UK
| | - Suvitesh Luthra
- Wessex Cardiothoracic Centre, University Hospital Southampton, Southampton SO16 6YD, UK
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Madhavan MV, Kodali SK, Thourani VH, Makkar R, Mack MJ, Kapadia S, Webb JG, Cohen DJ, Herrmann HC, Williams M, Greason K, Pibarot P, Hahn RT, Jaber W, Xu K, Alu M, Smith CR, Leon MB. Outcomes of SAPIEN 3 Transcatheter Aortic Valve Replacement Compared With Surgical Valve Replacement in Intermediate-Risk Patients. J Am Coll Cardiol 2023; 82:109-123. [PMID: 37407110 DOI: 10.1016/j.jacc.2023.04.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 03/03/2023] [Accepted: 05/05/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Previous studies demonstrated transcatheter aortic valve replacement (TAVR) with an earlier generation balloon-expandable valve to be noninferior to surgical aortic valve replacement (SAVR) for death and disabling stroke in intermediate-risk patients with symptomatic, severe aortic stenosis at 5 years. However, limited long-term data are available with the more contemporary SAPIEN 3 (S3) bioprosthesis. OBJECTIVES The aim of this study was to compare 5-year risk-adjusted outcomes in intermediate-risk patients undergoing S3 TAVR vs SAVR. METHODS Propensity score matching was performed to account for baseline differences in intermediate-risk patients undergoing S3 TAVR in the PARTNER 2 (Placement of Aortic Transcatheter Valves) S3 single-arm study and SAVR in the PARTNER 2A randomized clinical trial. The primary composite endpoint consisted of 5-year all-cause death and disabling stroke. RESULTS A total of 783 matched pairs of intermediate-risk patients with severe aortic stenosis were studied. There were no differences in the primary endpoint between S3 TAVR and SAVR at 5 years (40.2% vs 42.7%; HR: 0.87; 95% CI: 0.74-1.03; P = 0.10). The incidence of mild or greater paravalvular regurgitation was more common after S3 TAVR. There were no differences in structural valve deterioration-related stage 2 and 3 hemodynamic valve deterioration or bioprosthetic valve failure. CONCLUSIONS In this propensity-matched analysis of intermediate-risk patients, 5-year rates of death and disabling stroke were similar between S3 TAVR and SAVR. Rates of structural valve deterioration-related hemodynamic valve deterioration were similar, but paravalvular regurgitation was more common after S3 TAVR. Longer-term follow-up is needed to further evaluate differences in late adverse clinical events and bioprosthetic valve durability. (PII S3i [PARTNER II Trial: Placement of Aortic Transcatheter Valves II - S3 Intermediate], NCT03222128; PII A (PARTNER II Trial: Placement of Aortic Transcatheter Valves II - XT Intermediate and High Risk], NCT01314313).
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Affiliation(s)
- Mahesh V Madhavan
- Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, New York, USA; Cardiovascular Research Foundation, New York, New York, USA
| | - Susheel K Kodali
- Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, New York, USA.
| | | | - Raj Makkar
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | | | | | - John G Webb
- St Paul's Hospital, Vancouver, British Columbia, Canada
| | - David J Cohen
- Cardiovascular Research Foundation, New York, New York, USA; St Francis Hospital, Roslyn, New York, USA
| | - Howard C Herrmann
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mathew Williams
- New York University Langone Medical Center, New York, New York, USA
| | | | - Philippe Pibarot
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Rebecca T Hahn
- Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, New York, USA; Cardiovascular Research Foundation, New York, New York, USA
| | | | - Ke Xu
- Edwards Lifesciences, Irvine, California, USA
| | - Maria Alu
- Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, New York, USA; Cardiovascular Research Foundation, New York, New York, USA
| | - Craig R Smith
- Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, New York, USA
| | - Martin B Leon
- Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, New York, USA; Cardiovascular Research Foundation, New York, New York, USA
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Tamm AR, Jobst ML, Geyer M, Hahad O, Buderus V, Schmidt A, Prochaska JH, Wild PS, Treede H, Münzel T, von Bardeleben RS. Quality of life in patients with transcatheter aortic valve implantation: an analysis from the INTERVENT project. Front Cardiovasc Med 2023; 10:1181771. [PMID: 37435055 PMCID: PMC10330696 DOI: 10.3389/fcvm.2023.1181771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 06/05/2023] [Indexed: 07/13/2023] Open
Abstract
Background Transcatheter aortic valve implantation (TAVI) is a standard treatment for patients with aortic valve stenosis due to its very low mortality and complication rates. However, survival and physical integrity are not the only important factors. Quality of life (QoL) improvement is a crucial part in the evaluation of therapy success. Methods Patients with TAVI were questioned about their QoL before, one month and one year after the intervention as part of the INTERVENT registry trial at Mainz University Medical Center. Three different questionnaires were included in the data collection (Katz ADL, EQ-5D-5l, PHQ-D). Results We included 285 TAVI patients in the analysis (mean age 79.8 years, 59.4% male, mean EuroSCORE II 3.8%). 30-day mortality was 3.6%, complications of any kind occurred in 18.9% of the patients. Main finding was a significant increase in the general state of health measured on the visual analog scale by an average of 4.53 (± 23.58) points (BL to 1-month follow-up, p = 0.009) and by 5.19 (± 23.64) points (BL to 12-month follow-up, p = 0.016). There was also an improvement of depression symptoms, which was reflected in a decrease in the total value of the PHQ-D by 1.67 (± 4.75) points (BL to 12-month follow-up, p = 0.001). The evaluation of the EQ-5D-5l showed a significant improvement in mobility after one month (M = -0.41 (± 1.31), p < 0.001. Regarding the independence of the patients, no significant difference could be found. Apart from that, patients with risk factors, comorbidities or complications also benefited from the intervention despite their poor starting position. Conclusion We could show an early benefit of QoL in TAVI patients with significant improvement in the subjective state of health and a decrease in symptoms of depression. These findings were consistent over 1 year of follow up.
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Affiliation(s)
- Alexander R. Tamm
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Mainz, Germany
| | - Marina L. Jobst
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Mainz, Germany
| | - Martin Geyer
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Mainz, Germany
| | - Omar Hahad
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Mainz, Germany
| | - Victoria Buderus
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Mainz, Germany
| | - Alexander Schmidt
- Department of Cardiology, Preventive Cardiology and Preventive Medicine, University Medical Center Mainz, Mainz, Germany
| | - Jürgen H. Prochaska
- Department of Cardiology, Preventive Cardiology and Preventive Medicine, University Medical Center Mainz, Mainz, Germany
| | - Philipp S. Wild
- Department of Cardiology, Preventive Cardiology and Preventive Medicine, University Medical Center Mainz, Mainz, Germany
| | - Hendrik Treede
- Department of Cardio-Thoracic and Vascular Surgery, University Medical Center Mainz, Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Mainz, Germany
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Muneretto C, Di Bacco L, Di Eusanio M, Folliguet T, Rosati F, D'Alonzo M, Cugola D, Curello S, Palacios CM, Baudo M, Pollari F, Fischlein T. Sutureless and Rapid Deployment vs. Transcatheter Valves for Aortic Stenosis in Low-Risk Patients: Mid-Term Results. J Clin Med 2023; 12:4045. [PMID: 37373738 DOI: 10.3390/jcm12124045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/07/2023] [Accepted: 06/12/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Recent trials showed that TAVI is neither inferior nor superior to surgical aortic valve replacement. The aim of this study was to evaluate the outcomes of Sutureless and Rapid Deployment Valves (SuRD-AVR) when compared to TAVI in low surgical risk patients with isolated aortic stenosis. METHODS Data from five European Centers were retrospectively collected. We included 1306 consecutive patients at low surgical risk (EUROSCORE II < 4) who underwent aortic valve replacement by means of SuRD-AVR (n = 636) or TAVI (n = 670) from 2014 to 2019. A 1:1 nearest-neighbor propensity-score was performed, and two balanced groups of 346 patients each were obtained. The primary endpoints of the study were: 30-day mortality and 5-year overall survival. The secondary endpoint was 5-year survival freedom from major adverse cardiovascular and cerebrovascular events (MACCEs). RESULTS Thirty-day mortality was similar between the two groups (SuRD-AVR:1.7%, TAVI:2.0%, p = 0.779), while the TAVI group showed a significantly lower 5-year overall survival and survival freedom from MACCEs (5-year matched overall survival: SuRD-AVR: 78.5%, TAVI: 62.9%, p = 0.039; 5-year matched freedom from MACCEs: SuRD-AVR: 64.6%, TAVI: 48.7%, p = 0.004). The incidence of postoperative permanent pacemaker implantation (PPI) and paravalvular leak grade ≥ 2 (PVL) were higher in the TAVI group. Multivariate Cox Regression analysis identified PPI as an independent predictor for mortality. CONCLUSIONS TAVI patients had a significantly lower five-year survival and survival freedom from MACCEs with a higher rate of PPI and PVL ≥ 2 when compared to SuRD-AVR.
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Affiliation(s)
- Claudio Muneretto
- Division of Cardiac Surgery, University of Brescia Medical School, 250123 Brescia, Italy
| | - Lorenzo Di Bacco
- Division of Cardiac Surgery, University of Brescia Medical School, 250123 Brescia, Italy
| | | | - Thierry Folliguet
- Service de Chirurgie Thoracique et Cardio-Vasculaire, Hôpital H. Mondor, 94010 Créteil, France
| | - Fabrizio Rosati
- Division of Cardiac Surgery, University of Brescia Medical School, 250123 Brescia, Italy
| | - Michele D'Alonzo
- Division of Cardiac Surgery, University of Brescia Medical School, 250123 Brescia, Italy
| | - Diego Cugola
- Cardiac Surgery Unit, ASST Papa Giovanni XXIII, 24127 Bergamo, Italy
| | - Salvatore Curello
- Cardiac Catheterization Laboratory, Spedali Civili, 250123 Brescia, Italy
| | | | - Massimo Baudo
- Division of Cardiac Surgery, University of Brescia Medical School, 250123 Brescia, Italy
| | - Francesco Pollari
- Cardiac Surgery Department, Klinikum Nürnberg-Paracelsus Medical University, 90419 Nürnberg, Germany
| | - Theodor Fischlein
- Cardiac Surgery Department, Klinikum Nürnberg-Paracelsus Medical University, 90419 Nürnberg, Germany
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71
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Aurigemma C, Romagnoli E, Burzotta F, Trani C. Transcatheter aortic valve implantation: does the age matter? Minerva Cardiol Angiol 2023; 71:321-323. [PMID: 36719672 DOI: 10.23736/s2724-5683.22.06133-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Cristina Aurigemma
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy
| | - Enrico Romagnoli
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy -
| | | | - Carlo Trani
- Università Cattolica del Sacro Cuore, Rome, Italy
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Sahebjam M, Zoroufian A, Hajizeinali A, Salarifar M, Jalali A, Ayati A, Farmanesh M. Comparison of 1-year Follow-up Echocardiographic Outcomes of Sapien 3 Versus Evolut R Bioprosthetic Transcatheter Aortic Valves: A Single-center Retrospective Iranian Cohort Study. Crit Pathw Cardiol 2023; 22:54-59. [PMID: 37053035 DOI: 10.1097/hpc.0000000000000321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
OBJECTIVE The current study aimed to compare 1-year echocardiographic outcomes of the new generations of self-expanding (Evolut R) versus balloon-expandable (Sapien 3) bioprosthetic transcatheter aortic valves. METHODS In this study, gradients and flow velocities obtained from transthoracic Doppler-echocardiography were retrospectively collected from patients who underwent 2 new generations of transcatheter aortic valve implantation interventions with Sapien 3 and Evolut R valves. Patients underwent echocardiography before the procedure and at discharge, 6 months, and 1-year follow-up. RESULTS Of the 66 patients, 28 received Sapien 3 and 38 received Evolut R valves. Evolut R valve presented a lower mean gradient at all follow-up time points compared with Sapien 3 valves (14.4 mm Hg, 14.9 mm Hg, 15.5 mm Hg compared with 10.1 mm Hg, 11.6 mm Hg, 11.8 mm Hg, respectively; all P -values <0.001). Small valve sizes of Evolut R, including 23 and 26, had higher echocardiographic mean gradient or peak gradient at the time of discharge compared with larger valves, including sizes 29 and 34 (11.1 mm Hg and 11.2 mm Hg vs. 10.2 mm Hg, 9.1 mm Hg) and 1-year follow-up (11.0 mm Hg, 11.0 mm Hg vs. 9.9 mm Hg, 8.4 mm Hg; all P -values = 0.001). Although Sapien 3 valves demonstrated a higher peak gradient in smaller sizes at discharge (18.44 mm Hg in size 23 vs. 17.9 mm Hg, 16.5 mm Hg in size 26 and 29, respectively; P = 0.001), the peak gradients did not show a statistically significant difference in the 1-year follow-up. CONCLUSIONS The current study detected significantly lower mean and peak gradients in Evolut R compared with Sapien 3 at all follow-up time points. Furthermore, smaller valve sizes were associated with significantly higher gradients at all follow-ups, regardless of the valve type.
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Affiliation(s)
- Mohammad Sahebjam
- From the Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Department of Echocardiography, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Arezou Zoroufian
- From the Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Department of Echocardiography, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Alimohammad Hajizeinali
- From the Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mojtaba Salarifar
- From the Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Arash Jalali
- From the Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Aryan Ayati
- From the Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahkameh Farmanesh
- From the Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Department of Echocardiography, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
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Aranda-Michel E, Toubat O, Brennan Z, Bhagat R, Siki M, Paluri S, Duda M, Han J, Komlo C, Blitzer D, Louis C, Pruitt E, Sultan I. A primer for students regarding advanced topics in cardiothoracic surgery, part 2: Primer 7 of 7. JTCVS OPEN 2023; 14:362-371. [PMID: 37425452 PMCID: PMC10329042 DOI: 10.1016/j.xjon.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 04/02/2023] [Accepted: 04/08/2023] [Indexed: 07/11/2023]
Affiliation(s)
- Edgar Aranda-Michel
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Omar Toubat
- Department of Cardiac Surgery, Keck Medicine of University of Southern California, Los Angeles, Calif
| | - Zach Brennan
- Michigan State University College of Osteopathic Medicine, Michigan State University, East Lansing, Mich
| | - Rohun Bhagat
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Mary Siki
- Department of Cardiothoracic Surgery, Tulane University, New Orleans, La
| | - Sarin Paluri
- Department of Cardiothoracic Surgery, Chicago College of Osteopathic Medicine, Midwestern University, Chicago, Ill
| | - Matthew Duda
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
| | - Jason Han
- Department of Cardiac Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Caroline Komlo
- Department of Cardiothoracic Surgery, Yale University, New Haven, Conn
| | - David Blitzer
- Department of Cardiothoracic Surgery, Columbia University, New York, NY
| | - Clauden Louis
- Department of Cardiothoracic Surgery, Brigham and Women's Hospital, Harvard University, Boston, Mass
| | - Eric Pruitt
- Department of Cardiothoracic Surgery, University of Florida, Gainesville, Fla
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
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Haramati A, Latib A, Lazarus MS. Post-procedural structural heart CT imaging: TAVR, TMVR, and other interventions. Clin Imaging 2023; 101:86-95. [PMID: 37311399 DOI: 10.1016/j.clinimag.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/16/2023] [Accepted: 05/25/2023] [Indexed: 06/15/2023]
Abstract
Transcatheter valve replacement has experienced substantial growth in the past decade and this technique can now be used for any of the four heart valves. Transcatheter aortic valve replacement (TAVR) has overtaken surgical aortic valve replacement. Transcatheter mitral valve replacement (TMVR) is often performed in pre-existing valves or after prior valve repair, although numerous devices are undergoing trials for replacement of native valves. Transcatheter tricuspid valve replacement (TTVR) is similarly under active development. Lastly, transcatheter pulmonic valve replacement (TPVR) is most often used for revision treatment of congenital heart disease. Given the growth of these techniques, radiologists are increasingly called upon to interpret post-procedural imaging for these patients, particularly with CT. These cases will often arise unexpectedly and require detailed knowledge of potential post-procedural appearances. We review both normal and abnormal post-procedural findings on CT. Certain complications-device migration or embolization, paravalvular leak, or leaflet thrombosis-can occur after replacement of any valve. Other complications are specific to each type of valve, including coronary artery occlusion after TAVR, coronary artery compression after TPVR, or left ventricular outflow tract obstruction after TMVR. Finally, we review access-related complications, which are of particular concern due to the requirement of large-bore catheters for these procedures.
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Affiliation(s)
- Adina Haramati
- Department of Radiology, New York-Presbyterian/Weill Cornell Medicine, 525 East 68(th) Street, New York, NY 10065, United States of America
| | - Azeem Latib
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210(th) Street, Bronx, NY 10467, United States of America
| | - Matthew S Lazarus
- Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210(th) Street, Bronx, NY 10467, United States of America.
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Lauten P, Costello-Boerrigter LC, Goebel B, Gonzalez-Lopez D, Schreiber M, Kuntze T, Al Jassem M, Lapp H. Transcatheter Aortic Valve Implantation: Addressing the Subsequent Risk of Permanent Pacemaker Implantation. J Cardiovasc Dev Dis 2023; 10:230. [PMID: 37367395 PMCID: PMC10299451 DOI: 10.3390/jcdd10060230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 05/17/2023] [Accepted: 05/22/2023] [Indexed: 06/28/2023] Open
Abstract
Transcatheter aortic valve implantation (TAVI) is now a commonly used therapy in patients with severe aortic stenosis, even in those patients at low surgical risk. The indications for TAVI have broadened as the therapy has proven to be safe and effective. Most challenges associated with TAVI after its initial introduction have been impressively reduced; however, the possible need for post-TAVI permanent pacemaker implantation (PPI) secondary to conduction disturbances continues to be on the radar. Conduction abnormalities post-TAVI are always of concern given that the aortic valve lies in close proximity to critical components of the cardiac conduction system. This review will present a summary of noteworthy pre-and post-procedural conduction blocks, the best use of telemetry and ambulatory device monitoring to avoid unnecessary PPI or to recognize the need for late PPI due to delayed high-grade conduction blocks, predictors to identify those patients at greatest risk of requiring PPI, important CT measurements and considerations to optimize TAVI planning, and the utility of the MInimizing Depth According to the membranous Septum (MIDAS) technique and the cusp-overlap technique. It is stressed that careful membranous septal (MS) length measurement by MDCT during pre-TAVI planning is necessary to establish the optimal implantation depth before the procedure to reduce the risk of compression of the MS and consequent damage to the cardiac conduction system.
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Affiliation(s)
- Philipp Lauten
- Department of Cardiology, Heart Center, Zentralklinik Bad Berka, Robert-Koch-Allee 9, 99437 Bad Berka, Germany (B.G.); (H.L.)
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Galper BZ, Chinnakondepalli KM, Wang K, Magnuson EA, Lu M, Thourani VH, Kodali S, Makkar R, Herrmann HC, Kapadia S, Williams M, Webb J, Smith CR, Mack MJ, Leon MB, Cohen DJ. Economic Outcomes of Transcatheter Versus Surgical Aortic Valve Replacement in Patients with Severe Aortic Stenosis and Low Surgical Risk: Results from the PARTNER 3 Trial. Circulation 2023; 147:1594-1605. [PMID: 37154049 DOI: 10.1161/circulationaha.122.062481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 03/08/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND In patients with severe symptomatic aortic stenosis at low surgical risk, transfemoral transcatheter aortic valve replacement (TAVR) with the SAPIEN 3 valve has been shown to reduce the composite of death, stroke, or rehospitalization at 2-year follow-up compared with surgical aortic valve replacement (SAVR). Whether TAVR is cost-effective compared with SAVR for low-risk patients remains uncertain. METHODS Between 2016 and 2017, 1000 low-risk patients with aortic stenosis were randomly assigned to TAVR with the SAPIEN 3 valve or SAVR in the PARTNER 3 trial (Placement of Aortic Transcatheter Valves). Of these patients, 929 underwent valve replacement, were enrolled in the United States, and were included in the economic substudy. Procedural costs were estimated using measured resource use. Other costs were determined by linkage with Medicare claims or by regression models when linkage was not feasible. Health utilities were estimated using the EuroQOL 5-item questionnaire. With the use of a Markov model informed by in-trial data, lifetime cost-effectiveness from the perspective of the US health care system was estimated in terms of cost per quality-adjusted life-year gained. RESULTS Although procedural costs were nearly $19 000 higher with TAVR, total index hospitalization costs were only $591 more with TAVR compared with SAVR. Follow-up costs were lower with TAVR such that TAVR led to 2-year cost savings of $2030/patient compared with SAVR (95% CI, -$6222 to $1816) and a gain of 0.05 quality-adjusted life-years (95% CI, -0.003 to 0.102). In our base-case analysis, TAVR was projected to be an economically dominant strategy with a 95% probability that the incremental cost-effectiveness ratio for TAVR would be <$50 000/quality-adjusted life-year gained (consistent with high economic value from a US health care perspective). These findings were sensitive to differences in long-term survival, however, such that a modest long-term survival advantage with SAVR would render SAVR cost-effective (although not cost saving) compared with TAVR. CONCLUSIONS For patients with severe aortic stenosis and low surgical risk similar to those enrolled in the PARTNER 3 trial, transfemoral TAVR with the SAPIEN 3 valve is cost saving compared with SAVR at 2 years and is projected to be economically attractive in the long run as long as there are no substantial differences in late death between the 2 strategies. Long-term follow-up will be critical to ultimately determine the preferred treatment strategy for low-risk patients from both a clinical and economic perspective.
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Affiliation(s)
| | | | - Kaijun Wang
- Saint-Luke's Mid America Heart Institute, Kansas City, MO (K.M.C., K.W., E.A.M.)
| | - Elizabeth A Magnuson
- Saint-Luke's Mid America Heart Institute, Kansas City, MO (K.M.C., K.W., E.A.M.)
| | | | | | - Susheel Kodali
- New York-Presbyterian/Columbia University Irving Medical Center, New York (S. Kodali, C.R.S., M.B.L.)
| | - Raj Makkar
- Cedars-Sinai Medical Center, Los Angeles, CA (R.M.)
| | | | | | | | - John Webb
- St. Paul's Hospital, Vancouver, BC, Canada (J.W.)
| | - Craig R Smith
- New York-Presbyterian/Columbia University Irving Medical Center, New York (S. Kodali, C.R.S., M.B.L.)
| | | | - Martin B Leon
- New York-Presbyterian/Columbia University Irving Medical Center, New York (S. Kodali, C.R.S., M.B.L.)
- Cardiovascular Research Foundation, New York, NY (M.B.L., D.J.C.)
| | - David J Cohen
- Cardiovascular Research Foundation, New York, NY (M.B.L., D.J.C.)
- St. Francis Hospital, Roslyn, NY (D.J.C.)
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Steyer A, Mas-Peiro S, Leistner DM, Puntmann VO, Nagel E, Dey D, Goeller M, Koch V, Booz C, Vogl TJ, Martin SS. Computed tomography-based pericoronary adipose tissue attenuation in patients undergoing TAVR: a novel method for risk assessment. Front Cardiovasc Med 2023; 10:1192093. [PMID: 37288259 PMCID: PMC10242002 DOI: 10.3389/fcvm.2023.1192093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 04/27/2023] [Indexed: 06/09/2023] Open
Abstract
Objectives This study aims to assess the attenuation of pericoronary adipose tissue (PCAT) surrounding the proximal right coronary artery (RCA) in patients with aortic stenosis (AS) and undergoing transcatheter aortic valve replacement (TAVR). RCA PCAT attenuation is a novel computed tomography (CT)-based marker for evaluating coronary inflammation. Coronary artery disease (CAD) in TAVR patients is common and usually evaluated prior to intervention. The most sensible screening method and consequential treatment approach are unclear and remain a matter of ceaseless discussion. Thus, interest remains for safe and low-demand predictive markers to identify patients at risk for adverse outcomes postaortic valve replacement. Methods This single-center retrospective study included patients receiving a standard planning CT scan prior to TAVR. Conventional CAD diagnostic tools, such as coronary artery calcium score and significant stenosis via invasive coronary angiography and coronary computed tomography angiography, were determined in addition to RCA PCAT attenuation using semiautomated software. These were assessed for their relationship with major adverse cardiovascular events (MACE) during a 24-month follow-up period. Results From a total of 62 patients (mean age: 82 ± 6.7 years), 15 (24.2%) patients experienced an event within the observation period, 10 of which were attributed to cardiovascular death. The mean RCA PCAT attenuation was higher in patients enduring MACE than that in those without an endpoint (-69.8 ± 7.5 vs. -74.6 ± 6.2, P = 0.02). Using a predefined cutoff of >-70.5 HU, 20 patients (32.3%) with high RCA PCAT attenuation were identified, nine (45%) of which met the endpoint within 2 years after TAVR. In a multivariate Cox regression model including conventional CAD diagnostic tools, RCA PCAT attenuation prevailed as the only marker with significant association with MACE (P = 0.02). After dichotomization of patients into high- and low-RCA PCAT attenuation groups, high attenuation was related to greater risk of MACE (hazard ration: 3.82, P = 0.011). Conclusion RCA PCAT attenuation appears to have predictive value also in a setting of concomitant AS in patients receiving TAVR. RCA PCAT attenuation was more reliable than conventional CAD diagnostic tools in identifying patients at risk for MACE .
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Affiliation(s)
- Alexandra Steyer
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt, Germany
- Institute for Experimental and Translational Cardiovascular Imaging, Goethe University, University Hospital Frankfurt, Frankfurt, Germany
| | - Silvia Mas-Peiro
- Department of Cardiology, University Hospital Frankfurt, Frankfurt, Germany
- German Centre for Cardiovascular Research (DZHK), Berlin, Germany
- Cardiopulmonary Institute (CPI), Frankfurt am Main, Germany
| | - David M. Leistner
- Department of Cardiology, University Hospital Frankfurt, Frankfurt, Germany
| | - Valentina O. Puntmann
- Institute for Experimental and Translational Cardiovascular Imaging, Goethe University, University Hospital Frankfurt, Frankfurt, Germany
| | - Eike Nagel
- Institute for Experimental and Translational Cardiovascular Imaging, Goethe University, University Hospital Frankfurt, Frankfurt, Germany
- German Centre for Cardiovascular Research (DZHK), Berlin, Germany
| | - Damini Dey
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Markus Goeller
- Department of Cardiology, Friedrich-Alexander-University Hospital Erlangen, Erlangen, Germany
| | - Vitali Koch
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt, Germany
- Institute for Experimental and Translational Cardiovascular Imaging, Goethe University, University Hospital Frankfurt, Frankfurt, Germany
| | - Christian Booz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt, Germany
| | - Thomas J. Vogl
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt, Germany
| | - Simon S. Martin
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt, Germany
- Institute for Experimental and Translational Cardiovascular Imaging, Goethe University, University Hospital Frankfurt, Frankfurt, Germany
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Trongtorsak A, Thangjui S, Adhikari P, Shrestha B, Kewcharoen J, Navaravong L, Kanjanauthai S, Attanasio S, Saudye HA. Gender Disparities after Transcatheter Aortic Valve Replacement with Newer Generation Transcatheter Heart Valves: A Systematic Review and Meta-Analysis. Med Sci (Basel) 2023; 11:medsci11020033. [PMID: 37218985 DOI: 10.3390/medsci11020033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 05/04/2023] [Accepted: 05/04/2023] [Indexed: 05/24/2023] Open
Abstract
Previous studies have demonstrated gender disparities in mortality and vascular complications after transcatheter aortic valve replacement (TAVR) with early generation transcatheter heart valves (THVs). It is unclear, however, whether gender-related differences persist with the newer generation THVs. We aim to assess gender disparities after TAVR with newer generation THVs. The MEDLINE and Embase databases were thoroughly searched from inception to April 2023 to identify studies that reported gender-specific outcomes after TAVR with newer generation THVs (Sapien 3, Corevalve Evolut R, and Evolut Pro). The outcomes of interest included 30-day mortality, 1-year mortality, and vascular complications. In total, 5 studies (4 databases) with a total of 47,933 patients (21,073 females and 26,860 males) were included. Ninety-six percent received TAVR via the transfemoral approach. The females had higher 30-day mortality rates (odds ratio (OR) = 1.53, 95% confidence interval (CI) 1.31-1.79, p-value (p) < 0.001) and vascular complications (OR = 1.43, 95% CI 1.23-1.65, p < 0.001). However, one-year mortality was similar between the two groups (OR = 0.78, 95% CI 0.61-1.00, p = 0.28). The female gender continues to be associated with higher 30-day mortality rates and vascular complications after TAVR with newer generation transcatheter heart valves, while there was no difference in 1-year mortality between the genders. More data is needed to explore the causes and whether we can improve TAVR outcomes in females.
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Affiliation(s)
- Angkawipa Trongtorsak
- Ascension Saint Francis Hospital, Internal Medicine Residency Program, Evanston, IL 60202, USA
| | - Sittinun Thangjui
- Bassett Healthcare Network, Internal Medicine Residency Program, New York, NY 13326, USA
| | - Pabitra Adhikari
- Ascension Saint Francis Hospital, Internal Medicine Residency Program, Evanston, IL 60202, USA
| | - Biraj Shrestha
- Reading Hospital-Tower Health, Internal Medicine Residency Program, West Reading, PA 19611, USA
| | - Jakrin Kewcharoen
- Division of Cardiovascular Medicine, Loma Linda University Health, Loma Linda, CA 92350, USA
| | - Leenhapong Navaravong
- Division of Cardiovascular Medicine, School of Medicine, University of Utah, Salt Lake City, UT 84112, USA
| | - Somsupha Kanjanauthai
- Division of Cardiovascular Medicine, University of Southern California, Los Angeles, CA 90007, USA
| | - Steve Attanasio
- Rush University Medical Center, Division of Cardiovascular Medicine, Chicago, IL 60612, USA
| | - Hammad A Saudye
- Ascension Saint Francis Hospital, Division of Cardiovascular Medicine, Evanston, IL 60202, USA
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79
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Forrest JK, Deeb GM, Yakubov SJ, Gada H, Mumtaz MA, Ramlawi B, Bajwa T, Teirstein PS, DeFrain M, Muppala M, Rutkin BJ, Chawla A, Jenson B, Chetcuti SJ, Stoler RC, Poulin MF, Khabbaz K, Levack M, Goel K, Tchétché D, Lam KY, Tonino PAL, Ito S, Oh JK, Huang J, Popma JJ, Kleiman N, Reardon MJ. 3-Year Outcomes After Transcatheter or Surgical Aortic Valve Replacement in Low-Risk Patients With Aortic Stenosis. J Am Coll Cardiol 2023; 81:1663-1674. [PMID: 36882136 DOI: 10.1016/j.jacc.2023.02.017] [Citation(s) in RCA: 41] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 02/14/2023] [Accepted: 02/15/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND Randomized data comparing outcomes of transcatheter aortic valve replacement (TAVR) with surgery in low-surgical risk patients at time points beyond 2 years is limited. This presents an unknown for physicians striving to educate patients as part of a shared decision-making process. OBJECTIVES The authors evaluated 3-year clinical and echocardiographic outcomes from the Evolut Low Risk trial. METHODS Low-risk patients were randomized to TAVR with a self-expanding, supra-annular valve or surgery. The primary endpoint of all-cause mortality or disabling stroke and several secondary endpoints were assessed at 3 years. RESULTS There were 1,414 attempted implantations (730 TAVR; 684 surgery). Patients had a mean age of 74 years and 35% were women. At 3 years, the primary endpoint occurred in 7.4% of TAVR patients and 10.4% of surgery patients (HR: 0.70; 95% CI: 0.49-1.00; P = 0.051). The difference between treatment arms for all-cause mortality or disabling stroke remained broadly consistent over time: -1.8% at year 1; -2.0% at year 2; and -2.9% at year 3. The incidence of mild paravalvular regurgitation (20.3% TAVR vs 2.5% surgery) and pacemaker placement (23.2% TAVR vs 9.1% surgery; P < 0.001) were lower in the surgery group. Rates of moderate or greater paravalvular regurgitation for both groups were <1% and not significantly different. Patients who underwent TAVR had significantly improved valve hemodynamics (mean gradient 9.1 mm Hg TAVR vs 12.1 mm Hg surgery; P < 0.001) at 3 years. CONCLUSIONS Within the Evolut Low Risk study, TAVR at 3 years showed durable benefits compared with surgery with respect to all-cause mortality or disabling stroke. (Medtronic Evolut Transcatheter Aortic Valve Replacement in Low Risk Patients; NCT02701283).
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Affiliation(s)
- John K Forrest
- Yale University School of Medicine, New Haven, Connecticut, USA.
| | - G Michael Deeb
- University of Michigan Health Systems University Hospital, Ann Arbor, Michigan, USA
| | | | - Hemal Gada
- University of Pittsburgh Medical Center, Harrisburg, Pennsylvania, USA
| | - Mubashir A Mumtaz
- University of Pittsburgh Medical Center, Harrisburg, Pennsylvania, USA
| | - Basel Ramlawi
- Lankenau Heart Institute, Philadelphia, Pennsylvania, USA
| | - Tanvir Bajwa
- Aurora St Luke's Medical Center, Milwaukee, Wisconsin, USA
| | | | | | | | - Bruce J Rutkin
- North Shore University Hospital, Manhasset, New York, USA
| | - Atul Chawla
- Mercy Medical Center, Iowa Heart, Des Moines, Iowa, USA
| | - Bart Jenson
- Mercy Medical Center, Iowa Heart, Des Moines, Iowa, USA
| | - Stanley J Chetcuti
- University of Michigan Health Systems University Hospital, Ann Arbor, Michigan, USA
| | | | | | - Kamal Khabbaz
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Melissa Levack
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kashish Goel
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Ka Yan Lam
- Catharina Ziekenhuis, Eindhoven, the Netherlands
| | | | - Saki Ito
- Echocardiography Core Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Jae K Oh
- Echocardiography Core Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Neal Kleiman
- Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
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80
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Waksman R, Bhogal S, Gordon P, Ehsan A, Wilson SR, Levitt R, Parikh P, Bilfinger T, Hanna N, Buchbinder M, Asch FM, Kim FY, Weissman G, Ben-Dor I, Shults CC, Ali S, Sutton JA, Shea C, Zhang C, Garcia-Garcia HM, Satler LF, Rogers T. Transcatheter Aortic Valve Replacement and Impact of Subclinical Leaflet Thrombosis in Low-Risk Patients: LRT Trial 4-Year Outcomes. Circ Cardiovasc Interv 2023; 16:e012655. [PMID: 37192308 DOI: 10.1161/circinterventions.122.012655] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 03/31/2023] [Indexed: 05/18/2023]
Abstract
BACKGROUND The LRT trial (Low-Risk Transcatheter Aortic Valve Replacement [TAVR]) demonstrated the safety and feasibility of TAVR in low-risk patients, with excellent 1- and 2-year outcomes. The objective of the current study is to provide the overall clinical outcomes and the impact of 30-day hypoattenuated leaflet thickening (HALT) on structural valve deterioration at 4 years. METHODS The prospective, multicenter LRT trial was the first Food and Drug Administration-approved investigational device exemption study to evaluate feasibility and safety of TAVR in low-risk patients with symptomatic severe tricuspid aortic stenosis. Clinical outcomes and valve hemodynamics were documented annually through 4 years. RESULTS A total of 200 patients were enrolled, and follow-up was available on 177 patients at 4 years. The rates of all-cause mortality and cardiovascular death were 11.9% and 3.3%, respectively. The stroke rate rose from 0.5% at 30 days to 7.5% at 4 years, and permanent pacemaker implantation rose from 6.5% at 30 days to 11.7% at 4 years. Endocarditis was detected in 2.5% of the cohort, with no new cases reported between 2 and 4 years. Transcatheter heart valve hemodynamics remained excellent post-procedure and were maintained (mean gradient 12.56±5.54 mm Hg and aortic valve area 1.69±0.52 cm2) at 4 years. At 30 days, HALT was observed in 14% of subjects who received a balloon-expandable transcatheter heart valve. There was no difference in valve hemodynamics between patients with and without HALT (mean gradient 14.94±5.01 mm Hg versus 12.3±5.57 mm Hg; P=0.23) at 4 years. The overall rate of structural valve deterioration was 5.8%, and there was no impact of HALT on valve hemodynamics, endocarditis, or stroke at 4 years. CONCLUSIONS TAVR in low-risk patients with symptomatic severe tricuspid aortic stenosis was found to be safe and durable at 4 years. Structural valve deterioration rates were low irrespective of the type of valve, and the presence of HALT at 30 days did not affect structural valve deterioration, transcatheter valve hemodynamics, and stroke rate at 4 years. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02628899.
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Affiliation(s)
- Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC (R.W., S.B., I.B.-D., S.A., J.A.S., C.S., C.Z., H.M.G.-G., L.F.S., T.R.)
| | - Sukhdeep Bhogal
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC (R.W., S.B., I.B.-D., S.A., J.A.S., C.S., C.Z., H.M.G.-G., L.F.S., T.R.)
| | - Paul Gordon
- Division of Cardiology, Miriam Hospital, Providence, RI (P.G.)
| | - Afshin Ehsan
- Division of Cardiothoracic Surgery, Lifespan Cardiovascular Institute, Providence, RI (A.E.)
| | - Sean R Wilson
- Department of Cardiology, North Shore University Hospital, Manhasset, NY (S.R.W.)
| | - Robert Levitt
- Department of Cardiology, HCA Virginia Health System, Richmond (R.L.)
| | - Puja Parikh
- Department of Medicine (P.P.), Stony Brook Hospital, NY. St
| | | | - Nicholas Hanna
- John Heart Institute Cardiovascular Consultants, St. John Health System, Tulsa, OK (N.H.)
| | | | - Federico M Asch
- MedStar Health Research Institute, MedStar Washington Hospital Center, DC (F.M.A.)
| | - Francis Y Kim
- Department of Interventional Cardiology, Valley Health, Ridgewood, NJ (F.Y.K.)
| | - Gaby Weissman
- Department of Cardiology, MedStar Washington Hospital Center, DC (G.W.)
| | - Itsik Ben-Dor
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC (R.W., S.B., I.B.-D., S.A., J.A.S., C.S., C.Z., H.M.G.-G., L.F.S., T.R.)
| | - Christian C Shults
- Department of Cardiac Surgery, MedStar Washington Hospital Center, DC (C.C.S.)
| | - Syed Ali
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC (R.W., S.B., I.B.-D., S.A., J.A.S., C.S., C.Z., H.M.G.-G., L.F.S., T.R.)
| | - Joseph A Sutton
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC (R.W., S.B., I.B.-D., S.A., J.A.S., C.S., C.Z., H.M.G.-G., L.F.S., T.R.)
| | - Corey Shea
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC (R.W., S.B., I.B.-D., S.A., J.A.S., C.S., C.Z., H.M.G.-G., L.F.S., T.R.)
| | - Cheng Zhang
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC (R.W., S.B., I.B.-D., S.A., J.A.S., C.S., C.Z., H.M.G.-G., L.F.S., T.R.)
| | - Hector M Garcia-Garcia
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC (R.W., S.B., I.B.-D., S.A., J.A.S., C.S., C.Z., H.M.G.-G., L.F.S., T.R.)
| | - Lowell F Satler
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC (R.W., S.B., I.B.-D., S.A., J.A.S., C.S., C.Z., H.M.G.-G., L.F.S., T.R.)
| | - Toby Rogers
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC (R.W., S.B., I.B.-D., S.A., J.A.S., C.S., C.Z., H.M.G.-G., L.F.S., T.R.)
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD (T.R.)
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81
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Al-Azizi K, Shih E, DiMaio JM, Squiers JJ, Moubarak G, Kluis A, Banwait JK, Ryan WH, Szerlip MI, Potluri SP, Hamandi M, Lanfear AT, Meidan TG, Stoler RC, Mixon TA, Krueger AR, Mack MJ. Assessment of TVT and STS Risk Score Performances in Patients Undergoing Transcatheter Aortic Valve Replacement. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:100600. [PMID: 39130722 PMCID: PMC11308024 DOI: 10.1016/j.jscai.2023.100600] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 01/03/2023] [Accepted: 02/01/2023] [Indexed: 08/13/2024]
Abstract
Background The Society of Thoracic Surgeons (STS) score has been used to risk stratify patients undergoing transcatheter aortic valve replacement (TAVR). The Transcatheter Valve Therapy (TVT) score was developed to predict in-hospital mortality in high/prohibitive-risk patients. Its performance in low and intermediate-risk patients is unknown. We sought to compare TVT and STS scores' ability to predict clinical outcomes in all-surgical-risk patients undergoing TAVR. Methods Consecutive patients undergoing TAVR from 2012-2020 within a large health care system were retrospectively reviewed and stratified by STS risk score. Predictive abilities of TVT and STS scores were compared using observed-to-expected mortality ratios (O:E) and area under the receiver operating characteristics curves (AUCs) for 30-day and 1-year mortality. Results We assessed a total of 3270 patients (mean age 79 ± 9 years, 45% female), including 191 (5.8%) low-risk, 1093 (33.4%) intermediate-risk, 1584 (48.4%) high-risk, and 402 (5.8%) inoperable. Mean TVT and STS scores were 3.5% ± 2.0% and 6.1% ± 4.3%, respectively. Observed 30-day and 1-year mortality were 2.8% (92/3270; O:E TVT 0.8 ± 0.16 vs STS 0.46 ± 0.09), and 13.2% (432/3270), respectively. In the all-comers population, both TVT and STS risk scores showed poor prediction of 30-day (AUC: TVT 0.68 [0.62-0.74] vs STS 0.64 [0.58-0.70]), and 1-year (AUC: TVT 0.65 [0.62-0.58] vs STS 0.65 [0.62-0.58]) mortality. After stratifying by surgical risk, discrimination of the TVT and STS scores remained poor in all categories at 30 days and 1 year. Conclusions An updated TAVR risk score with improved predictive ability across all-surgical-risk categories should be developed based on a larger national registry.
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Affiliation(s)
- Karim Al-Azizi
- Department of Cardiology, Baylor Scott & White The Heart Hospital, Plano, Texas
| | - Emily Shih
- Department of Cardiothoracic Surgery, Baylor Scott & White The Heart Hospital, Plano, Texas
- Baylor Scott & White Research Institute, Plano, Texas
| | - J. Michael DiMaio
- Department of Cardiothoracic Surgery, Baylor Scott & White The Heart Hospital, Plano, Texas
- Baylor Scott & White Research Institute, Plano, Texas
| | - John J. Squiers
- Department of Cardiothoracic Surgery, Baylor Scott & White The Heart Hospital, Plano, Texas
| | | | - Austin Kluis
- Baylor Scott & White Research Institute, Plano, Texas
| | | | - William H. Ryan
- Department of Cardiothoracic Surgery, Baylor Scott & White The Heart Hospital, Plano, Texas
| | - Molly I. Szerlip
- Department of Cardiology, Baylor Scott & White The Heart Hospital, Plano, Texas
| | | | | | | | | | - Robert C. Stoler
- Department of Cardiology, Baylor University Medical Center, Dallas, Texas
| | - Timothy A. Mixon
- Department of Cardiology, Baylor Scott & White Medical Center–Temple, Temple, Texas
| | - Anita R. Krueger
- Department of Cardiothoracic Surgery, Baylor Scott & White All Saints Medical Center, Fort Worth, Texas
| | - Michael J. Mack
- Department of Cardiothoracic Surgery, Baylor Scott & White The Heart Hospital, Plano, Texas
- Baylor Scott & White Research Institute, Plano, Texas
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82
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Hawkins RB, Deeb GM, Sukul D, Patel HJ, Gualano SK, Chetcuti SJ, Grossman PM, Ailawadi G, Fukuhara S. Redo Surgical Aortic Valve Replacement After Prior Transcatheter Versus Surgical Aortic Valve Replacement. JACC Cardiovasc Interv 2023; 16:942-953. [PMID: 37100557 DOI: 10.1016/j.jcin.2023.03.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 03/10/2023] [Accepted: 03/10/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Aortic stenosis treatment should consider risks and benefits for lifetime management. Although the feasibility of redo transcatheter aortic valve replacement (TAVR) remains unclear, concerns are emerging regarding reoperation after TAVR. OBJECTIVES The authors sought to define comparative risk of surgical aortic valve replacement (SAVR) after prior TAVR or SAVR. METHODS Data on patients undergoing bioprosthetic SAVR after TAVR and/or SAVR were extracted from the Society of Thoracic Surgeons Database (2011-2021). Overall and isolated SAVR cohorts were analyzed. The primary outcome was operative mortality. Risk adjustment using hierarchical logistic regression as well as propensity score matching for isolated SAVR cases were performed. RESULTS Of 31,106 SAVR patients, 1,126 had prior TAVR (TAVR-SAVR), 674 had prior SAVR and TAVR (SAVR-TAVR-SAVR), and 29,306 had prior SAVR (SAVR-SAVR). Yearly rates of TAVR-SAVR and SAVR-TAVR-SAVR increased over time, whereas SAVR-SAVR was stable. The TAVR-SAVR patients were older, with higher acuity, and with greater comorbidities than other cohorts. The unadjusted operative mortality was highest in the TAVR-SAVR group (17% vs 12% vs 9%, respectively; P < 0.001). Compared with SAVR-SAVR, risk-adjusted operative mortality was significantly higher for TAVR-SAVR (OR: 1.53; P = 0.004), but not SAVR-TAVR-SAVR (OR: 1.02; P = 0.927). After propensity score matching, operative mortality of isolated SAVR was 1.74 times higher for TAVR-SAVR than SAVR-SAVR patients (P = 0.020). CONCLUSIONS The number of post-TAVR reoperations is increasing and represent a high-risk population. Yet even in isolated SAVR cases, SAVR after TAVR is independently associated with increased risk of mortality. Patients with life expectancy beyond a TAVR valve and unsuitable anatomy for redo-TAVR should consider a SAVR-first approach.
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Affiliation(s)
- Robert B Hawkins
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA; Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - G Michael Deeb
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA; Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Devraj Sukul
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA; Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA; Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Sarah K Gualano
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA; Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Stanley J Chetcuti
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA; Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - P Michael Grossman
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA; Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA; Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Shinichi Fukuhara
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA; Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA.
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83
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Prandi FR, Niv Granot Y, Margonato D, Belli M, Illuminato F, Vinayak M, Barillà F, Romeo F, Tang GHL, Sharma S, Kini A, Lerakis S. Coronary Obstruction during Valve-in-Valve Transcatheter Aortic Valve Replacement: Pre-Procedural Risk Evaluation, Intra-Procedural Monitoring, and Follow-Up. J Cardiovasc Dev Dis 2023; 10:jcdd10050187. [PMID: 37233154 DOI: 10.3390/jcdd10050187] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 04/20/2023] [Accepted: 04/21/2023] [Indexed: 05/27/2023] Open
Abstract
Valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) is emerging as an effective treatment for patients with symptomatically failing bioprosthetic valves and a high prohibitive surgical risk; a longer life expectancy has led to a higher demand for these valve reinterventions due to the increased possibilities of outliving the bioprosthetic valve's durability. Coronary obstruction is the most feared complication of valve-in-valve (ViV) TAVR; it is a rare but life-threatening complication and occurs most frequently at the left coronary artery ostium. Accurate pre-procedural planning, mainly based on cardiac computed tomography, is crucial to determining the feasibility of a ViV TAVR and to assessing the anticipated risk of a coronary obstruction and the eventual need for coronary protection measures. Intraprocedurally, the aortic root and a selective coronary angiography are useful for evaluating the anatomic relationship between the aortic valve and coronary ostia; transesophageal echocardiographic real-time monitoring of the coronary flow with a color Doppler and pulsed-wave Doppler is a valuable tool that allows for a determination of real-time coronary patency and the detection of asymptomatic coronary obstructions. Because of the risk of developing a delayed coronary obstruction, the close postprocedural monitoring of patients at a high risk of developing coronary obstructions is advisable. CT simulations of ViV TAVR, 3D printing models, and fusion imaging represent the future directions that may help provide a personalized lifetime strategy and tailored approach for each patient, potentially minimizing complications and improving outcomes.
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Affiliation(s)
- Francesca Romana Prandi
- Division of Cardiology, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Division of Cardiology, Department of Systems Medicine, Tor Vergata University, 00133 Rome, Italy
| | - Yoav Niv Granot
- Division of Cardiology, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Davide Margonato
- Cardiovascular Imaging Unit, San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Martina Belli
- Division of Cardiology, Department of Systems Medicine, Tor Vergata University, 00133 Rome, Italy
- Cardiovascular Imaging Unit, San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Federica Illuminato
- Division of Cardiology, Department of Systems Medicine, Tor Vergata University, 00133 Rome, Italy
| | - Manish Vinayak
- Division of Cardiology, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Francesco Barillà
- Division of Cardiology, Department of Systems Medicine, Tor Vergata University, 00133 Rome, Italy
| | - Francesco Romeo
- Faculty of Medicine, Unicamillus-Saint Camillus International University of Health and Medical Sciences, 00131 Rome, Italy
| | - Gilbert H L Tang
- Department of Cardiovascular Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Samin Sharma
- Division of Cardiology, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Annapoorna Kini
- Division of Cardiology, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Stamatios Lerakis
- Division of Cardiology, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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84
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Lerman TT, Levi A, Talmor-Barkan Y, Kornowski R. Early and Mid-Term Outcomes of Transcatheter Aortic Valve Implantation versus Surgical Aortic Valve Replacement: Updated Systematic Review and Meta-Analysis. J Cardiovasc Dev Dis 2023; 10:jcdd10040157. [PMID: 37103036 PMCID: PMC10146134 DOI: 10.3390/jcdd10040157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 03/31/2023] [Accepted: 04/02/2023] [Indexed: 04/08/2023] Open
Abstract
(1) Background: The use of transcatheter aortic valve implantation (TAVI) for the treatment of severe symptomatic aortic stenosis is expanding significantly. We aimed to perform a meta-analysis comparing the safety and efficacy of TAVI versus surgical aortic valve replacement (SAVR) during the early and mid-term follow-up period. (2) Methods: We conducted a meta-analysis of randomized controlled trials (RCTs) comparing 1- to 2-year outcomes between TAVI and SAVR. The study protocol was preregistered in PROSPERO and the results were reported according to PRISMA guidelines. (3) Results: The pooled analysis included data from eight RCTs totaling 8780 patients. TAVI was associated with a lower risk of all-cause mortality or disabling stroke (OR 0.87, 95%CI 0.77–0.99), significant bleeding (OR 0.38, 95%CI 0.25–0.59), acute kidney injury (AKI; OR 0.53, 95%CI 0.40–0.69) and atrial fibrillation (OR 0.28, 95%CI 0.19–0.43). SAVR was associated with a lower risk of major vascular complication (MVC; OR 1.99, 95%CI 1.29–3.07) as well as permanent pacemaker implantation (PPI; OR 2.28, 95%CI 1.45–3.57). (3) Conclusions: TAVI compared with SAVR during early and mid-term follow-up was associated with a lower risk of all-cause mortality or disabling stroke, significant bleeding, AKI and atrial fibrillation; however, it was associated with a higher risk of MVC and PPI.
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Affiliation(s)
- Tsahi T. Lerman
- Department of Internal Medicine F-Recanati, Beilinson Hospital, Rabin Medical Center, Petah Tikva 4941492, Israel
- Department of Cardiology, Rabin Medical Center, Petah Tikva 4941492, Israel
- The Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Amos Levi
- Department of Cardiology, Rabin Medical Center, Petah Tikva 4941492, Israel
- The Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Yeela Talmor-Barkan
- Department of Cardiology, Rabin Medical Center, Petah Tikva 4941492, Israel
- The Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Ran Kornowski
- Department of Cardiology, Rabin Medical Center, Petah Tikva 4941492, Israel
- The Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
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85
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Li Z, Messika-Zeitoun D, Petrich W, Edwards J. Comparison of transcatheter and surgical aortic valve replacement long-term outcomes: a retrospective cohort study with overlap propensity score weighting. Open Heart 2023; 10:openhrt-2022-002205. [PMID: 37105684 PMCID: PMC10152047 DOI: 10.1136/openhrt-2022-002205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 02/15/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND AND AIMS Randomised controlled trials comparing transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) were performed in highly selected populations and data regarding long-term secondary complications beyond mortality are scarce. This study used data from Ontario, Canada to compare mid-term and long-term clinical outcomes in a representative real-world cohort of patients who underwent TAVR and SAVR from 2007 to 2016. METHODS A novel overlap weighting propensity score method was used to match patients undergoing TAVR or SAVR. Primary outcomes were all-cause, cardiovascular and non-cardiovascular mortality either in-hospital or at 1, 3 and 5 years postdischarge. Secondary outcomes included adverse outcomes and readmission. Long-term primary and secondary outcomes were compared using a weighted competing risks subdistribution proportional hazards model. RESULTS The study included 9355 SAVR and 2641 TAVR patients. All-cause mortality at 1 year (HR 1.21; 95% CI 1.02 to 1.43), 3 years (HR 1.45; 95% CI 1.28 to 1.64) and 5 years (HR 1.48; 95% CI 1.33 to 1.65) was significantly higher among patients underwent TAVR compared with SAVR, with both cardiovascular mortality at 3 and 5 years and non-cardiovascular mortality at 1, 3 and 5 years significantly higher for TAVR. Hazards of myocardial infarction and readmission for angina at 1, 3 and 5 years were significantly greater for TAVR. CONCLUSIONS In this overlap weighted cohort, both cardiac and non-cardiac mortality rates were increased in TAVR patients. Residual or unmeasured confounding may have contributed to these findings. More studies are needed to identify factors predictive of long-term outcomes in real-world cohorts.
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Affiliation(s)
- Zhe Li
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - David Messika-Zeitoun
- Division of Cardiology, Univeristy of Ottawa Heart Institue, Ottawa, Ontario, Canada
| | | | - Jodi Edwards
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- ICES, Ottawa, Ontario, Canada
- School of Epidemiology and Biostatistics, University of Ottawa, Ottawa, Ontario, Canada
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86
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Ahmad Y, Howard JP, Arnold AD, Madhavan MV, Cook CM, Alu M, Mack MJ, Reardon MJ, Thourani VH, Kapadia S, Thyregod HGH, Sondergaard L, Jørgensen TH, Toff WD, Van Mieghem NM, Makkar RR, Forrest JK, Leon MB. Transcatheter versus surgical aortic valve replacement in lower-risk and higher-risk patients: a meta-analysis of randomized trials. Eur Heart J 2023; 44:836-852. [PMID: 36660821 DOI: 10.1093/eurheartj/ehac642] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 10/09/2022] [Accepted: 10/26/2022] [Indexed: 01/21/2023] Open
Abstract
AIMS Additional randomized clinical trial (RCT) data comparing transcatheter aortic valve implantation (TAVI) with surgical aortic valve replacement (SAVR) is available, including longer term follow-up. A meta-analysis comparing TAVI to SAVR was performed. A pragmatic risk classification was applied, partitioning lower-risk and higher-risk patients. METHODS AND RESULTS The main endpoints were death, strokes, and the composite of death or disabling stroke, occurring at 1 year (early) or after 1 year (later). A random-effects meta-analysis was performed. Eight RCTs with 8698 patients were included. In lower-risk patients, at 1 year, the risk of death was lower after TAVI compared with SAVR [relative risk (RR) 0.67; 95% confidence interval (CI) 0.47 to 0.96, P = 0.031], as was death or disabling stroke (RR 0.68; 95% CI 0.50 to 0.92, P = 0.014). There were no differences in strokes. After 1 year, in lower-risk patients, there were no significant differences in all main outcomes. In higher-risk patients, there were no significant differences in main outcomes. New-onset atrial fibrillation, major bleeding, and acute kidney injury occurred less after TAVI; new pacemakers, vascular complications, and paravalvular leak occurred more after TAVI. CONCLUSION In lower-risk patients, there was an early mortality reduction with TAVI, but no differences after later follow-up. There was also an early reduction in the composite of death or disabling stroke, with no difference at later follow-up. There were no significant differences for higher-risk patients. Informed therapy decisions may be more dependent on the temporality of events or secondary endpoints than the long-term occurrence of main clinical outcomes.
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Affiliation(s)
- Yousif Ahmad
- Yale School of Medicine, Yale University, 135 College Street, Suite 101, New Haven, CT 06510, USA
| | - James P Howard
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London W120HS, UK
| | - Ahran D Arnold
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London W120HS, UK
| | - Mahesh V Madhavan
- Division of Cardiology, Department of Medicine, Columbia University Medical Center/New York-Presbyterian Hospital, W. 168th St. New York, NY 10032, USA.,Clinical Trials Center, The Cardiovascular Research Foundation, 1700 Broadway, New York, NY 10019, USA
| | | | - Maria Alu
- Clinical Trials Center, The Cardiovascular Research Foundation, 1700 Broadway, New York, NY 10019, USA
| | - Michael J Mack
- Department of Cardiovascular Disease, Baylor Scott and White Health, 4700 Alliance Blvd, Plano, TX 75093, USA
| | - Michael J Reardon
- Houston Methodist DeBakey Heart & Vascular Center, 6565 Fannin St Suite 1901, Houston, TX 77030, USA
| | - Vinod H Thourani
- Department of Cardiovascular Surgery, Marcus Valve Center, Piedmont Heart and Vascular Institute, 95 Collier Rd NW Suite 5015, Atlanta, GA 30309, USA
| | - Samir Kapadia
- Cleveland Clinic, 9500 Euclid Ave. Cleveland, OH 44195, USA
| | - Hans Gustav Hørsted Thyregod
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Section 2151, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - Lars Sondergaard
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Section 2151, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - Troels Højsgaard Jørgensen
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Section 2151, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - William D Toff
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Biomedical Research Centre, Glenfield Hospital, University Rd, Leicester LE1 7RH, UK
| | - Nicolas M Van Mieghem
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Raj R Makkar
- Cedars-Sinai Medical Center, Smidt Heart Institute, S San Vicente Blvd, Los Angeles, CA 90048, USA
| | - John K Forrest
- Yale School of Medicine, Yale University, 135 College Street, Suite 101, New Haven, CT 06510, USA
| | - Martin B Leon
- Division of Cardiology, Department of Medicine, Columbia University Medical Center/New York-Presbyterian Hospital, W. 168th St. New York, NY 10032, USA.,Clinical Trials Center, The Cardiovascular Research Foundation, 1700 Broadway, New York, NY 10019, USA
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87
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Kuck KH, Leidl R, Frankenstein L, Wahlers T, Sarmah A, Candolfi P, Shore J, Green M. Cost-Effectiveness of SAPIEN 3 Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement in German Severe Aortic Stenosis Patients at Low Surgical Mortality Risk. Adv Ther 2023; 40:1031-1046. [PMID: 36622552 PMCID: PMC9988804 DOI: 10.1007/s12325-022-02392-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 11/28/2022] [Indexed: 01/10/2023]
Abstract
INTRODUCTION In the randomized PARTNER 3 trial, transcatheter aortic valve implantation (TAVI) with the SAPIEN 3 device significantly reduced a composite of all-cause death, stroke, and rehospitalization, compared with surgical aortic valve replacement (SAVR), in patients with severe symptomatic aortic stenosis and low risk of surgical mortality. Furthermore, TAVI has been shown to be cost-effective in low-risk patients, compared with SAVR, in a number of countries. This study aimed to determine the cost-effectiveness of TAVI with SAPIEN 3 versus SAVR in Germany. METHODS A previously published two-stage Markov-based model that captured clinical outcomes from the PARTNER 3 trial was adapted for the German context using the German Statutory Health Insurance perspective. The model had a lifetime horizon. The cost-utility analysis estimated changes in direct healthcare costs as well as survival and health-related quality of life using TAVI with SAPIEN 3 compared with SAVR. RESULTS TAVI with SAPIEN 3 increased quality-adjusted life years (QALYs) by + 0.72 at an increased cost of €8664 per patient. The incremental cost-effectiveness/QALY ratio was €12,037, which fell below that of other cardiovascular interventions in use in Germany. The cost-effectiveness of TAVI over SAVR remained robust across multiple challenging scenarios and was driven by lower longer-term management costs compared with SAVR. CONCLUSIONS TAVI with SAPIEN 3 appears to be a clinically meaningful, cost-effective treatment option over SAVR for patients with severe symptomatic aortic stenosis and low risk for surgical mortality in Germany. CLINICAL TRIAL REGISTRATION NUMBER www. CLINICALTRIALS gov identifier: NCT02675114.
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Affiliation(s)
- Karl H Kuck
- Department of Cardiology, University Heart Center, Lübeck, Germany.,LANS Cardio, Hamburg, Germany
| | - Reiner Leidl
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München, Neuherberg, Germany.,Munich School of Management, Ludwig-Maximilians-Universität, Munich, Germany
| | - Lutz Frankenstein
- Department of Cardiology, Angiology, and Pulmonology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | | | | | - Judith Shore
- York Health Economics Consortium, University of York, York, UK
| | - Michelle Green
- York Health Economics Consortium, University of York, York, UK
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88
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Aziminia N, Nitsche C, Mravljak R, Bennett J, Thornton GD, Treibel TA. Heart failure and excess mortality after aortic valve replacement in aortic stenosis. Expert Rev Cardiovasc Ther 2023; 21:193-210. [PMID: 36877090 PMCID: PMC10069375 DOI: 10.1080/14779072.2023.2186853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 02/28/2023] [Indexed: 03/07/2023]
Abstract
INTRODUCTION In aortic stenosis (AS), the heart transitions from adaptive compensation to an AS cardiomyopathy and eventually leads to decompensation with heart failure. Better understanding of the underpinning pathophysiological mechanisms is required in order to inform strategies to prevent decompensation. AREAS COVERED In this review, we therefore aim to appraise the current pathophysiological understanding of adaptive and maladaptive processes in AS, appraise potential avenues of adjunctive therapy before or after AVR and highlight areas of further research in the management of heart failure post AVR. EXPERT OPINION Tailored strategies for the timing of intervention accounting for individual patient's response to the afterload insult are underway, and promise to guide better management in the future. Further clinical trials of adjunctive pharmacological and device therapy to either cardioprotect prior to intervention or promote reverse remodeling and recovery after intervention are needed to mitigate the risk of heart failure and excess mortality.
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Affiliation(s)
- Nikoo Aziminia
- Institute of Cardiovascular Science, University College London, London, England
- Barts Heart Centre, London, England
| | - Christian Nitsche
- Institute of Cardiovascular Science, University College London, London, England
- Barts Heart Centre, London, England
| | | | - Jonathan Bennett
- Institute of Cardiovascular Science, University College London, London, England
- Barts Heart Centre, London, England
| | - George D Thornton
- Institute of Cardiovascular Science, University College London, London, England
- Barts Heart Centre, London, England
| | - Thomas A Treibel
- Institute of Cardiovascular Science, University College London, London, England
- Barts Heart Centre, London, England
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89
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Martinez J, Alperi A, Silva I, Pascual I, Ledesma D, Alvarez R, Almendarez M, Avanzas P, del Valle R, Moris C. Leaving obstacles aside: Antegrade paravalvular leakage closure after transcatheter aortic valve replacement. Clin Case Rep 2023; 11:e6971. [PMID: 36860724 PMCID: PMC9969761 DOI: 10.1002/ccr3.6971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 02/05/2023] [Indexed: 03/03/2023] Open
Abstract
Paravalvular leakage (PVL) is yet a potential and serious complication after transcatheter aortic valve replacement. Percutaneous PVL closure may be the treatment of choice upon failure of balloon postdilation in patients with excessive surgical risk. If the retrograde approach fails, an antegrade strategy might provide the solution.
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Affiliation(s)
| | - Alberto Alperi
- Hospital Universitario Central de AsturiasOviedoSpain,Instituto de Investigación Sanitaria del Principado de Asturias, ISPAOviedoSpain
| | - Iria Silva
- Hospital Universitario Central de AsturiasOviedoSpain
| | - Isaac Pascual
- Hospital Universitario Central de AsturiasOviedoSpain,Instituto de Investigación Sanitaria del Principado de Asturias, ISPAOviedoSpain,University of OviedoOviedoSpain
| | - David Ledesma
- Hospital Universitario Central de AsturiasOviedoSpain
| | - Rut Alvarez
- Hospital Universitario Central de AsturiasOviedoSpain
| | | | - Pablo Avanzas
- Hospital Universitario Central de AsturiasOviedoSpain,Instituto de Investigación Sanitaria del Principado de Asturias, ISPAOviedoSpain,University of OviedoOviedoSpain
| | - Raquel del Valle
- Hospital Universitario Central de AsturiasOviedoSpain,Instituto de Investigación Sanitaria del Principado de Asturias, ISPAOviedoSpain
| | - Cesar Moris
- Hospital Universitario Central de AsturiasOviedoSpain,Instituto de Investigación Sanitaria del Principado de Asturias, ISPAOviedoSpain,University of OviedoOviedoSpain
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90
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Gozdek M, Kuźma Ł, Dąbrowski EJ, Janiak M, Pietrzak M, Skonieczna K, Woźnica M, Wydeheft L, Makhoul M, Matteucci M, Litwinowicz R, Kowalówka A, Wańha W, Pasierski M, Ronco D, Massimi G, Jiritano F, Fina D, Martucci G, Raffa GM, Suwalski P, Lorusso R, Meani P, Kowalewski M. Outcomes of Transcatheter Aortic Valve Implantation Comparing Medtronic's Evolut PRO and Evolut R: A Systematic Review and Meta-Analysis of Observational Studies. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3439. [PMID: 36834131 PMCID: PMC9967567 DOI: 10.3390/ijerph20043439] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 02/09/2023] [Accepted: 02/14/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Transcatheter aortic valve implantation (TAVI) has become a broadly acceptable alternative to AV surgery in patients with aortic stenosis (AS). New valve designs are becoming available to address the shortcomings of their predecessors and improve clinical outcomes. METHODS A systematic review and meta-analysis was carried out to compare Medtronic's Evolut PRO, a new valve, with the previous Evolut R design. Procedural, functional and clinical endpoints according to the VARC-2 criteria were assessed. RESULTS Eleven observational studies involving N = 12,363 patients were included. Evolut PRO patients differed regarding age (p < 0.001), sex (p < 0.001) and STS-PROM estimated risk. There was no difference between the two devices in terms of TAVI-related early complications and clinical endpoints. A 35% reduction of the risk of moderate-to-severe paravalvular leak (PVL) favoring the Evolut PRO was observed (RR 0.66, 95%CI, [0.52, 0.86] p = 0.002; I2 = 0%). Similarly, Evolut PRO-treated patients demonstrated a reduction of over 35% in the risk of serious bleeding as compared with the Evolut R (RR 0.63, 95%CI, [0.41, 0.96]; p = 0.03; I2 = 39%), without differences in major vascular complications. CONCLUSIONS The evidence shows good short-term outcomes of both the Evolut PRO and Evolut R prostheses, with no differences in clinical and procedural endpoints. The Evolut PRO was associated with a lower rate of moderate-to-severe PVL and major bleeding.
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Affiliation(s)
- Mirosław Gozdek
- Department of Cardiology, Hospital of the Ministry of Interior, 72-122 Bydgoszcz, Poland
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, 85-094 Bydgoszcz, Poland
| | - Łukasz Kuźma
- Department of Invasive Cardiology, Medical University of Bialystok, 15-540 Bialystok, Poland
| | - Emil Julian Dąbrowski
- Department of Invasive Cardiology, Medical University of Bialystok, 15-540 Bialystok, Poland
| | - Michał Janiak
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, 85-094 Bydgoszcz, Poland
| | - Martyna Pietrzak
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, 85-094 Bydgoszcz, Poland
| | - Karolina Skonieczna
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, 85-094 Bydgoszcz, Poland
| | - Mikołaj Woźnica
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, 85-094 Bydgoszcz, Poland
| | - Lidia Wydeheft
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, 85-094 Bydgoszcz, Poland
| | - Maged Makhoul
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, 85-094 Bydgoszcz, Poland
- Department of Cardiac Surgery, Harefield Hospital, London UB9 6JH, UK
| | - Matteo Matteucci
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, 85-094 Bydgoszcz, Poland
- Cardiac Surgery Unit, ASST dei Sette Laghi, Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy
- Cardiothoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), The Cardiovascular Research Institute Maastricht (CARIM), 6229 ER Maastricht, The Netherlands
| | - Radosław Litwinowicz
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, 85-094 Bydgoszcz, Poland
- Department of Cardiac Surgery, Regional Specialist Hospital, 86-300 Grudziądz, Poland
| | - Adam Kowalówka
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, 85-094 Bydgoszcz, Poland
- Department of Cardiac Surgery, Upper-Silesian Heart Center, 40-752 Katowice, Poland
- Department of Cardiac Surgery, Faculty of Medical Sciences, Medical University of Silesia, 40-752 Katowice, Poland
| | - Wojciech Wańha
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, 85-094 Bydgoszcz, Poland
- Department of Cardiac Surgery, School of Medicine in Katowice, Medical University of Silesia, 40-752 Katowice, Poland
| | - Michał Pasierski
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, 85-094 Bydgoszcz, Poland
- Department of Cardiac Surgery and Transplantology, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, 02-507 Warsaw, Poland
| | - Daniele Ronco
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, 85-094 Bydgoszcz, Poland
- Cardiothoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), The Cardiovascular Research Institute Maastricht (CARIM), 6229 ER Maastricht, The Netherlands
| | - Giulio Massimi
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, 85-094 Bydgoszcz, Poland
- Cardiothoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), The Cardiovascular Research Institute Maastricht (CARIM), 6229 ER Maastricht, The Netherlands
| | - Federica Jiritano
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, 85-094 Bydgoszcz, Poland
- Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy
| | - Dario Fina
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, 85-094 Bydgoszcz, Poland
- Department of Cardiothoracic, Vascular Anesthesia and Intensive Care Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico, San Donato Milanese, 20097 Milan, Italy
| | - Gennaro Martucci
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, 85-094 Bydgoszcz, Poland
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (IRCCS-ISMETT), 90100 Palermo, Italy
| | - Giuseppe Maria Raffa
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, 85-094 Bydgoszcz, Poland
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (IRCCS-ISMETT), 90100 Palermo, Italy
| | - Piotr Suwalski
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, 85-094 Bydgoszcz, Poland
- Department of Cardiac Surgery and Transplantology, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, 02-507 Warsaw, Poland
| | - Roberto Lorusso
- Cardiothoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), The Cardiovascular Research Institute Maastricht (CARIM), 6229 ER Maastricht, The Netherlands
| | - Paolo Meani
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, 85-094 Bydgoszcz, Poland
- Department of Cardiothoracic, Vascular Anesthesia and Intensive Care Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico, San Donato Milanese, 20097 Milan, Italy
| | - Mariusz Kowalewski
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, 85-094 Bydgoszcz, Poland
- Cardiothoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), The Cardiovascular Research Institute Maastricht (CARIM), 6229 ER Maastricht, The Netherlands
- Department of Cardiac Surgery and Transplantology, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, 02-507 Warsaw, Poland
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91
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Brescia AA, Ailawadi G. Commentary: The reality of The Society of Thoracic Surgeons risk calculators at high volume centers. J Thorac Cardiovasc Surg 2023; 165:607-608. [PMID: 33838913 DOI: 10.1016/j.jtcvs.2021.03.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 03/09/2021] [Accepted: 03/10/2021] [Indexed: 01/18/2023]
Affiliation(s)
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
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92
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Franke B, Schlief A, Walczak L, Sündermann S, Unbehaun A, Kempfert J, Solowjowa N, Kühne T, Goubergrits L. Comparison of hemodynamics in biological surgical aortic valve replacement and transcatheter aortic valve implantation: An in-silico study. Artif Organs 2023; 47:352-360. [PMID: 36114598 DOI: 10.1111/aor.14405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 08/03/2022] [Accepted: 08/30/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVES In aortic valve replacement (AVR), the treatment strategy as well as the model and size of the implanted prosthesis have a major impact on the postoperative hemodynamics and thus on the clinical outcome. Preinterventional prediction of the hemodynamics could support the treatment decision. Therefore, we performed paired virtual treatment with transcatheter AVR (TAVI) and biological surgical AVR (SAVR) and compared hemodynamic outcomes using numerical simulations. METHODS 10 patients with severe aortic stenosis (AS) undergoing TAVI were virtually treated with both biological SAVR and TAVI to compare post-interventional hemodynamics using numerical simulations of peak-systolic flow. Virtual treatment procedure was done using an in-house developed tool based on position-based dynamics methodology, which was applied to the patient's anatomy including LVOT, aortic root and aorta. Geometries were automatically segmented from dynamic CT-scans and patient-specific flow rates were calculated by volumetric analysis of the left ventricle. Hemodynamics were assessed using the STAR CCM+ software by solving the RANS equations. RESULTS Virtual treatment with TAVI resulted in realistic hemodynamics comparable to echocardiographic measurements (median difference in transvalvular pressure gradient [TPG]: -0.33 mm Hg). Virtual TAVI and SAVR showed similar hemodynamic functions with a mean TPG with standard deviation of 8.45 ± 4.60 mm Hg in TAVI and 6.66 ± 3.79 mm Hg in SAVR (p = 0.03) while max. Wall shear stress being 12.6 ± 4.59 vs. 10.2 ± 4.42 Pa (p = 0.001). CONCLUSIONS Using the presented method for virtual treatment of AS, we were able to reliably predict post-interventional hemodynamics. TAVI and SAVR show similar hemodynamics in a pairwise comparison.
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Affiliation(s)
- Benedikt Franke
- Institute of Computer-assisted Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Adriano Schlief
- Institute of Computer-assisted Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Lars Walczak
- Institute of Computer-assisted Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Fraunhofer MEVIS, Bremen, Germany
| | - Simon Sündermann
- Department of Cardiology and Angiology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Axel Unbehaun
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Jörg Kempfert
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Natalia Solowjowa
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Titus Kühne
- Institute of Computer-assisted Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Leonid Goubergrits
- Institute of Computer-assisted Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Einstein Center Digital Future, Berlin, Germany
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Shellenberger RA, Crass S, Jevicks J, Badhwar A, Albright J, Kumar A. Bedside physical examination for the diagnosis of aortic stenosis: A systematic review and meta-analysis. CJC Open 2023. [DOI: 10.1016/j.cjco.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023] Open
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94
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Prediction of conduction disturbances in patients undergoing transcatheter aortic valve replacement. Clin Res Cardiol 2023; 112:677-690. [PMID: 36680617 PMCID: PMC10160192 DOI: 10.1007/s00392-023-02160-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 01/12/2023] [Indexed: 01/22/2023]
Abstract
AIM Transcatheter aortic valve replacement (TAVR) can cause intraventricular conduction disturbances (ICA), particularly left bundle branch block (BBB) and high-degree atrioventricular block (HAVB). The aim of this study was to investigate clinical, anatomical, procedural, and electrophysiological parameters predicting ICA after TAVR. METHODS Patients with severe aortic stenosis (n = 203) without pacing devices undergoing TAVR with a self-expanding (n = 103) or balloon-expanding (n = 100) valve were enrolled. Clinical and anatomical parameters, such as length of the membranous septum (MS) and implantation depth, were assessed. His-ventricular interval (HVi) before and after implantation was determined. 12-lead-electrocardiograms (ECG) before, during and after 3 and 30 days after TAVR were analyzed for detection of any ICA. RESULTS Among 203 consecutive patients (aortic valve area 0.78 ± 0.18 cm2, age 80 ± 6 years, 54% male, left ventricular ejection fraction 52 ± 10%), TAVR led to a significant prolongation of infranodal conduction in all patients from 49 ± 10 ms to 59 ± 16 ms (p = 0.01). The HVi prolongation was independent of valve types, occurrence of HAVB or ICA. Fifteen patients (7%) developed HAVB requiring permanent pacemaker (PPM) implantation and 63 patients (31%) developed ICA within 30 days. Pre-existing BBB (OR 11.64; 95% CI 2.87-47.20; p = 0.001), new-onset left BBB (OR 15.72; 95% CI 3.05-81.03; p = 0.001), and diabetes mellitus (OR 3.88; 95% CI 1.30-15.99; p = 0.02) independently predicted HAVB requiring PPM. Neither pre-existing right BBB, a prolonged postHVi, increases in PR duration, any of the TAVR implantation procedural and anatomic nor echocardiographic characteristics were predictive for later HAVB. CONCLUSIONS New-onset left BBB and diabetes mellitus independently predicted HAVB requiring PPM after TAVR and helped to identify patients at risk. Electrophysiologic study (EPS) of atrioventricular conduction was neither specific nor predictive of HAVB and can be skipped. TRIAL REGISTRATION NUMBER NCT04128384 ( https://www. CLINICALTRIALS gov ).
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95
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Meta-analysis of short- and long-term clinical outcomes of the self-expanding Evolut R/pro valve versus the balloon-expandable Sapien 3 valve for transcatheter aortic valve implantation. Int J Cardiol 2023; 371:100-108. [PMID: 36130623 DOI: 10.1016/j.ijcard.2022.09.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 09/14/2022] [Accepted: 09/15/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND The Evolut R/Pro and the Sapien 3 are the most commonly valve systems used today for transcatheter aortic valve implantation (TAVI). However, there is a still uncertainty regarding the efficacy and safety comparison of these two valves. METHODS We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies comparing the Evolut R/Pro versus the Sapien 3. The primary outcome was all-cause mortality (short and long-term). The secondary outcomes were stroke, bleeding, permanent pacemaker implantation (PPI), acute kidney injury (AKI), major vascular complication, device success, moderate- severe aortic regurgitation (AR), and pressure gradients. RESULTS Twenty-one publications totaling 35,248 patients were included in the analysis. Evolut R/Pro was associated with higher risk of short-term all-cause mortality (OR = 1.31;95% CI 1.15-1.49, p < 0.001) and a trend of higher long-term mortality (OR = 1.07;95% CI 1.00-1.16, p = 0.06). The Evolut R/Pro was associated with higher risk of PPI and AR and lower risk for bleeding, major vascular complication, and pressure gradients. There was no significant difference between the groups regarding the risk of stroke, AKI and device success. CONCLUSIONS The Evolut R/Pro valve system compared to the Sapien 3 is associated with higher risk of short-term mortality, significant AR and PPI while providing the advantage of lower risk of bleeding, major vascular complication, and lower residual transvalvular gradients.
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96
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Formica F, Gallingani A, Tuttolomondo D, Hernandez-Vaquero D, D’Alessandro S, Pattuzzi C, Çelik M, Singh G, Ceccato E, Niccoli G, Lorusso R, Nicolini F. Redo Surgical Aortic Valve Replacement versus Valve-In-Valve Transcatheter Aortic Valve Implantation: A Systematic Review and Reconstructed Time-To-Event Meta-Analysis. J Clin Med 2023; 12:jcm12020541. [PMID: 36675469 PMCID: PMC9866823 DOI: 10.3390/jcm12020541] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/21/2022] [Accepted: 12/29/2022] [Indexed: 01/11/2023] Open
Abstract
Objective. Valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) has emerged as a useful alternative intervention to redo-surgical aortic valve replacement (Redo-SVAR) for the treatment of degenerated bioprosthesis valve. However, there is no robust evidence about the long-term outcome of both treatments. The aim of this meta-analysis was to analyze the long-term outcomes of Redo-SVAR versus ViV-TAVI by reconstructing the time-to-event data. Methods. The search strategy consisted of a comprehensive review of relevant studies published between 1 January 2000 and 30 September 2022 in three electronic databases, PubMed, Cochrane Central Register of Controlled Trials (CENTRAL) and EMBASE. Relevant studies were retrieved for the analysis. The primary endpoint was the long-term mortality for all death. The comparisons were made by the Cox regression model and by landmark analysis and a fully parametric model. A random-effect method was applied to perform the meta-analysis. Results. Twelve studies fulfilled the eligibility criteria and were included in the final analysis. A total of 3547 patients were included. Redo-SAVR group included 1783 patients, and ViV-TAVI included 1764 subjects. Redo-SAVR showed a higher incidence of all-cause mortality within 30-days [Hazard ratio (HR) 2.12; 95% CI = 1.49−3.03; p < 0.0001)], whereas no difference was observed between 30 days and 1 year (HR = 1.03; 95% CI = 0.78−1.33; p = 0.92). From one year, Redo-SAVR showed a longer benefit (HR = 0.52; 95% CI = 0.40−0.67; p < 0.0001). These results were confirmed for cardiovascular death (HR = 2.04; 95% CI = 1.29−3.22; p = 0.001 within one month from intervention; HR = 0.35; 95% CI = 0.18−0.71; p = 0.003 at 4-years follow-up). Conclusions. Although the long-term outcomes seem similar between Redo-SAVR and ViV-TAVI at a five-year follow-up, ViV-TAVI shows significative lower mortality within 30 days. This advantage disappeared between 30 days and 1 year and reversed in favor of redo-SAVR 1 year after the intervention.
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Affiliation(s)
- Francesco Formica
- Department of Medicine and Surgery, University of Parma, 43124 Parma, Italy
- Correspondence: or
| | - Alan Gallingani
- Cardiac Surgery Clinic, University Hospital of Parma, Via Gramsci 14, 43125 Parma, Italy
| | | | | | | | - Claudia Pattuzzi
- Department of Medicine and Surgery, University of Parma, 43124 Parma, Italy
- Cardiac Surgery Clinic, University Hospital of Parma, Via Gramsci 14, 43125 Parma, Italy
| | - Mevlüt Çelik
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, 3062 Rotterdam, The Netherlands
| | - Gurmeet Singh
- Division of Cardiac Surgery, Department of Critical Care Medicine, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB 11220, Canada
| | - Evelina Ceccato
- Department of Medicine and Surgery, University of Parma, 43124 Parma, Italy
- Medical Library, University of Parma, 43124 Parma, Italy
| | - Giampaolo Niccoli
- Department of Medicine and Surgery, University of Parma, 43124 Parma, Italy
- Cardiology Unit, University Hospital of Parma, Via Gramsci 14, 43125 Parma, Italy
| | - Roberto Lorusso
- Cardiovascular Research Institute Maastricht (CARIM), 6200 Maastricht, The Netherlands
| | - Francesco Nicolini
- Department of Medicine and Surgery, University of Parma, 43124 Parma, Italy
- Cardiac Surgery Clinic, University Hospital of Parma, Via Gramsci 14, 43125 Parma, Italy
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97
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Almedimigh AA, Albabtain MA, Alfayez LA, Alsubaie FF, Almoghairi A, Alotaiby M, Alkhushail A, Ismail H, Pragliola C, Adam AI, Arafat AA. Isolated surgical vs. transcatheter aortic valve replacement: a propensity score analysis. THE CARDIOTHORACIC SURGEON 2023. [DOI: 10.1186/s43057-022-00094-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Abstract
Background
The debate about the optimal approach for aortic valve replacement continues. We compared the hospital and long-term outcomes (survival, aortic valve reintervention, heart failure readmissions, and stroke) between transcatheter vs. surgical (TAVR vs. SAVR) aortic valve replacement. The study included 789 patients; 293 had isolated SAVR, and 496 had isolated TAVR. Patients with concomitant procedures were excluded. Propensity score matching identified 53 matched pairs.
Results
Patients who had TAVR were significantly older (P ˂ 0.001) and had significantly higher EuroSCORE II (P ˂ 0.001), NYHA class (P ˂ 0.001), and more prevalence of diabetes mellitus (P ˂ 0.001), hypertension (P ˂ 0.001), chronic lung disease (P = 0.001), recent myocardial infarction (P = 0.002), and heart failure (P ˂ 0.001), stroke (P = 0.02), atrial fibrillation (P = 0.004), and previous percutaneous coronary interventions (P ˂ 0.001) than SAVR patients. In the matched cohort, atrial fibrillation occurred more frequently after SAVR (P = 0.01), and hospital stay was significantly longer in SAVR patients (P ˂ 0.001). There were no differences in hospital mortality between groups (P ˃ 0.99). Survival at 1, 3, and 5 years was 97%, 95%, and 94% for SAVR and 91%, 79%, and 58% for TAVR patients. Survival was lower in TAVR patients before matching (P ˂ 0.001) and after matching (P = 0.045). Freedom from the composite endpoint of stroke, aortic valve reintervention, and heart failure readmission at 1, 3, and 5 years was 98.9%, 96%, and 94% for SAVR and 94%, 86%, and 75% for TAVR. The composite endpoint was significantly higher in the TAVR group than in SVR before matching (P ˂ 0.001), while there was no difference after matching (P = 0.07). There was no significant difference in the change in ejection fraction between groups (β: −0.88 (95% CI: −2.20–0.43), P = 0.19), and the reduction of the aortic valve peak gradient was significantly higher with TAVR (β: −7.80 (95% CI: −10.70 to −4.91); P ˂ 0.001).
Conclusions
TAVR could reduce postoperative atrial fibrillation and hospital stay. SAVR could have long-term survival benefits over TAVR with comparable long-term stroke, heart failure readmission, and aortic valve reinterventions between SAVR and TAVR.
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98
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Barili F, Brophy JM, Ronco D, Myers PO, Uva MS, Almeida RMS, Marin-Cuartas M, Anselmi A, Tomasi J, Verhoye JP, Musumeci F, Mandrola J, Kaul S, Papatheodorou S, Parolari A. Risk of Bias in Randomized Clinical Trials Comparing Transcatheter and Surgical Aortic Valve Replacement: A Systematic Review and Meta-analysis. JAMA Netw Open 2023; 6:e2249321. [PMID: 36595294 PMCID: PMC9857525 DOI: 10.1001/jamanetworkopen.2022.49321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
IMPORTANCE Recent European Society of Cardiology/European Association for Cardio-Thoracic Surgery (ESC/EACTS) guidelines highlighted some concerns about the randomized clinical trials (RCTs) comparing transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) for aortic stenosis. Quantification of these biases has not been previously performed. OBJECTIVE To assess whether randomization protects RCTs comparing TAVI and SAVR from biases other than nonrandom allocation. DATA SOURCES A systematic review of the literature between January 1, 2007, and June 6, 2022, on MEDLINE, Embase, and Cochrane Central Register of Controlled Trials was performed. Specialist websites were also checked for unpublished data. STUDY SELECTION The study included RCTs with random allocation to TAVI or SAVR with a maximum 5-year follow-up. DATA EXTRACTION AND SYNTHESIS Data extraction was performed by 2 independent investigators following the PRISMA guidelines. A random-effects meta-analysis was used for quantifying pooled rates and differential rates between treatments of deviation from random assigned treatment (DAT), loss to follow-up, and receipt of additional treatments. MAIN OUTCOMES AND MEASURES The primary outcomes were the proportion of DAT, loss to follow-up, and patients who were provided additional treatments and myocardial revascularization, together with their ratio between treatments. The measures were the pooled overall proportion of the primary outcomes and the risk ratio (RR) in the TAVI vs SAVR groups. RESULTS The search identified 8 eligible trials including 8849 participants randomly assigned to undergo TAVI (n = 4458) or SAVR (n = 4391). The pooled proportion of DAT among the sample was 4.2% (95% CI, 3.0%-5.6%), favoring TAVI (pooled RR vs SAVR, 0.16; 95% CI, 0.08-0.36; P < .001). The pooled proportion of loss to follow-up was 4.8% (95% CI, 2.7%-7.3%). Meta-regression showed a significant association between the proportion of participants lost to follow-up and follow-up time (slope, 0.042; 95% CI, 0.017-0.066; P < .001). There was an imbalance of loss to follow-up favoring TAVI (RR, 0.39; 95% CI, 0.28-0.55; P < .001). The pooled proportion of patients who had additional procedures was 10.4% (95% CI, 4.4%-18.5%): 4.6% (95% CI, 1.5%-9.3%) in the TAVI group and 16.5% (95% CI, 7.5%-28.1%) in the SAVR group (RR, 0.27; 95% CI, 0.15-0.50; P < .001). The imbalance between groups also favored TAVI for additional myocardial revascularization (RR, 0.40; 95% CI, 0.24-0.68; P < .001). CONCLUSIONS AND RELEVANCE This study suggests that, in RCTs comparing TAVI vs SAVR, there are substantial proportions of DAT, loss to follow-up, and additional procedures together with systematic selective imbalance in the same direction characterized by significantly lower proportions of patients undergoing TAVI that might affect internal validity.
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Affiliation(s)
- Fabio Barili
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Department of Cardiac Surgery, S. Croce Hospital, Cuneo, Italy
| | - James M. Brophy
- Department of Medicine, McGill Health University Center, Montreal, Quebec, Canada
| | - Daniele Ronco
- Department of University Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
| | - Patrick O. Myers
- Division of Cardiac Surgery, CHUV–Lausanne University Hospital, Lausanne, Switzerland
| | - Miguel Sousa Uva
- Department of Cardiac Surgery, Hospital Santa Cruz, Carnaxide, Portugal
- Department of Cardiac Surgery and Physiology, Porto University Medical School, Porto, Portugal
| | - Rui M. S. Almeida
- University Center Assis Gurgacz Foundation, Cascavel, Paraná, Brazil
| | - Mateo Marin-Cuartas
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Amedeo Anselmi
- Department of Thoracic and Cardiovascular Surgery, University Hospital of Rennes, Rennes, France
| | - Jacques Tomasi
- Department of Thoracic and Cardiovascular Surgery, University Hospital of Rennes, Rennes, France
| | - Jean-Philippe Verhoye
- Department of Thoracic and Cardiovascular Surgery, University Hospital of Rennes, Rennes, France
| | - Francesco Musumeci
- Department of Cardiac Surgery and Heart Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | | | - Sanjay Kaul
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Stefania Papatheodorou
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Alessandro Parolari
- Department of University Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
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Desai PV, Goel SS, Kleiman NS, Reardon MJ. Transcatheter Aortic Valve Implantation: Long-Term Outcomes and Durability. Methodist Debakey Cardiovasc J 2023; 19:15-25. [PMID: 37213878 PMCID: PMC10198228 DOI: 10.14797/mdcvj.1201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 04/27/2023] [Indexed: 05/23/2023] Open
Abstract
Transcatheter aortic valve implantation (TAVI) has become the standard of care in symptomatic older patients with severe aortic stenosis regardless of surgical risk. With the development of newer generation transcatheter bioprostheses, improved delivery systems, better preprocedure planning with imaging guidance, increased operator experience, shorter hospital length of stay, and low short- and mid-term complication rates, TAVI is gaining popularity among younger patients at low or intermediate surgical risk. Long-term outcomes and durability of transcatheter heart valves have become substantially important for this younger population due to their longer life expectancy. The lack of standardized definitions of bioprosthetic valve dysfunction and disagreement about how to account for the competing risks made comparison of transcatheter heart valves with surgical bioprostheses challenging until recently. In this review, the authors discuss the mid- to long-term (≥ 5 years) clinical outcomes observed in the landmark TAVI trials and analyze the available long-term durability data emphasizing the importance of using standardized definitions of bioprosthetic valve dysfunction.
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Affiliation(s)
| | - Sachin S. Goel
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, US
| | - Neal S. Kleiman
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, US
| | - Michael J. Reardon
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, US
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100
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Prosthesis Tailoring for Patients Undergoing Transcatheter Aortic Valve Implantation. J Clin Med 2023; 12:jcm12010338. [PMID: 36615141 PMCID: PMC9821207 DOI: 10.3390/jcm12010338] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/28/2022] [Accepted: 12/29/2022] [Indexed: 01/03/2023] Open
Abstract
Transcatheter aortic valve implantation (TAVI) has risen over the past 20 years as a safe and effective alternative to surgical aortic valve replacement for treatment of severe aortic stenosis, and is now a well-established and recommended treatment option in suitable patients irrespective of predicted risk of mortality after surgery. Studies of numerous devices, either newly developed or reiterations of previous prostheses, have been accruing. We hereby review TAVI devices, with a focus on commercially available options, and aim to present a guide for prosthesis tailoring according to patient-related anatomical and clinical factors that may favor particular designs.
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