One-year outcomes of cohort 1 in the Edwards SAPIEN Aortic Bioprosthesis European Outcome (SOURCE) registry: the European registry of transcatheter aortic valve implantation using the Edwards SAPIEN valve

The impact of the development of transcatheter aortic valve implantation on the management of severe aortic stenosis in high-risk patients: treatment strategies and outcome

OBJECTIVES

Transcatheter aortic valve implantation (TAVI) has reoriented the treatment of aortic stenosis (AS) for high-risk patients. Little is known about late outcome after TAVI, surgical aortic valve replacement (AVR) or medical treatment in a single centre. We report patients' characteristics, early and 6-year survival rates after the three therapeutic strategies, and the evolution over time. We also analysed predictive factors of mortality after TAVI or surgical AVR.

METHODS

Between October 2006 and December 2010, 478 high-risk consecutive patients were referred for severe symptomatic AS. After Heart Team evaluation, 253 underwent a TAVI, 102 a surgical AVR and 123 medical treatment including 33 compassionate percutaneous balloon aortic valvuloplasties (PBAVs). Follow-up was complete in 98% of patients.

RESULTS

Medically treated patients had higher risk scores than the other two groups. They presented a significantly worse survival (P < 0.001), with a 1-year rate of only 30%. The 33 patients who underwent compassionate PBAV presented the lowest survival rate, even lower than patients receiving drug therapy alone. In the TAVI group, patients had more comorbidities than those in the surgical group. There was no difference in 30-day survival rates [91 ± 2% for TAVI and 88 ± 3% for surgical AVR, hazard ratio (HR) for TAVI: 1.37; 95% CI: 0.73-2.58, P = 0.32]. Predictive factors of 30-day mortality were mainly postintervention complications illustrated by higher troponin levels and infection. The 6-year survival rates were 32 ± 4 and 40 ± 6% for TAVI and surgical AVR, respectively (HR for TAVI: 0.71; 95% CI: 0.53-0.97, P = 0.03), but the difference was no longer significant after adjustment on the Charlson comorbidity index (HR: 0.94; 95% CI: 0.68-1.29, P = 0.68). Predictive factors of late mortality were patients' comorbidities for both groups and paraprosthetic aortic regurgitation ≥2/4 for the TAVI group. The number of interventions (TAVI or surgery) increases over years, driven by the number of TAVI procedures without any decrease in surgical AVR.

CONCLUSIONS

In this single-centre study, medically treated patients with severe AS have a higher risk profile than those undergoing surgery or TAVI. Their survival is particularly poor and not improved by compassionate PBAV. When comparing TAVI and surgical AVR, there was no difference in 30-day and 6-year survival rates after adjusting for comorbidities.

Incidence and causes of silent and symptomatic stroke following surgical and transcatheter aortic valve replacement: a comprehensive review

Stroke associated with aortic valve replacement in calcific aortic stenosis, either via transcatheter implantation (TAVR) or via surgical replacement (SAVR), is one of the most devastating complications. However, data concerning the clinical impact and incidence of clinical and silent stroke complicating SAVR and TAVR are varying. This comprehensive review of the literature explores the genuine incidence of neurological events after these procedures. Additionally, potential factors responsible for the discrepancies in stroke rates in the current literature are analysed and a lack of uniform neurological definitions and standardized neurological assessments revealed. Current stroke rates after TAVR show a decline from 7 to 1.7-4.8% in recent studies. Randomized studies comparing TAVR with SAVR yielded initially a significantly higher stroke rate after TAVR procedures as opposed to SAVR. Recently published data showed opposite results with strokes being higher following SAVR. Current data concerning stroke after surgical valve replacement report significantly higher rates of clinical strokes (17%) than previously mentioned in the literature (≤4.9%). Silent cerebral lesions were detected in 68-93% after TAVR and 38-54% after SAVR. A broader application of cerebral protection devices may help to reduce embolic cerebral events.

Acute Kidney Injury After Transcatheter Aortic Valve Replacement

BACKGROUND

Acute kidney injury (AKI) during transcatheter aortic valve replacement (TAVR) increases morbidity and mortality. In this study, we investigated the incidence and risk factors for AKI in patients undergoing TAVR.

METHODS

Two hundred ninety consecutive patients underwent TAVR. Valve Academic Research Consortium (VARC)-I criteria for AKI diagnosis at 72 hours, and VARC-II criteria at seven days were employed.

RESULTS

Overall AKI incidence was 24.62% (65/264): 50 patients at 72 hours and 15 patients at seven days. Multivariate logistic regression determined transapical (TA) approach (OR: 4.46 [1.37-7.63]), preprocedural glomerular filtration rate less than 45 mL/min (OR: 3.47 [1.35-14.70]), and blood transfusion (OR: 3.34 [1.58-11.09]) as independent predictors for AKI at 72 hours; and prior coronary artery bypass grafting (OR: 3.02 [1.007-9.09]) and peripheral artery disease (PAD) (OR: 3.53 [1.06-11.62]) for AKI at seven days. In-hospital and 30-day mortality was higher in AKI patients. Non-AKI patients' survival was 93% at six months, 89% at 12 months, and 86% at 24 months, whereas survival in AKI at 72 hours was 66% at 6, 12, and 24 months (HR AKI vs. non-AKI: 3.9 [CI: 2.0-7.6]), and survival in AKI at seven days was 64% at 6, 12, and 24 months, HR: 3.13 (CI: 1.42-6.92). For the 12 dialysis patients survival was 82% at 6, 12, and 24 months.

CONCLUSIONS

AKI after TAVR is associated with worse outcomes. Blood transfusion should be administered restrictively in TAVR. Patients with CKD, PAD, prior CABG, and TA approach require close surveillance as they are at risk for AKI through seven days after TAVR. doi: 10.1111/jocs.12768 (J Card Surg 2016;31:416-422).

Transcatheter aortic valve replacement-state of the art and a glimpse to the future: 'the Tailored Approach'

Transcatheter aortic valve replacement determined a paradigm shift in the treatment of high-risk patients with severe symptomatic aortic valve stenosis. Notwithstanding the impressive results of the first-generation prostheses, a fast-paced technological evolution is taking place to overcome their limitations, in particular the vascular access damage and the paravalvular leak. Nowadays, with the availability of several different devices, the expert operator can select the right prosthesis for the specific anatomical and clinical situation. As 'One does not fit all', the 'Tailored TAVR Approach' we describe will conceivably become the future of this therapy.

Transaortic Aortic Valve Implantation in 100 Patients: Follow-up to 3 Years

OBJECTIVE

Transaortic aortic valve implantation (TAo-AVI) through the ascending aorta is a novel technique and is used as an alternative in patients with poor femoral access. Although early results have been promising, no midterm data have been published yet. To determine whether this approach is an acceptable treatment option, we analyzed the first 100 cases performed at our institution with a follow-up to 3 years.

METHODS

Between July 2011 and January 2015, a total of 100 patients with high-risk or inoperable aortic valve stenosis were treated with TAo-AVI. Preoperative patient data were collected and analyzed retrospectively. All surviving patients were seen for clinical and echocardiographic examination for follow-up.

RESULTS

Median follow-up was 15 months. Device success was accomplished in 94 patients (94%). There were no access site complications. The 30-day mortality rate was 9%. Stroke occurred in a total of six patients (6%). Survival at 1-, 2-, and 3 years was 75%, 62%, and 58%, respectively.

CONCLUSIONS

Our results show that TAo-AVI is a promising alternative to transapical implantation for treating severe inoperable aortic valve stenosis.

Coronary artery disease and transcatheter aortic valve replacement: current treatment paradigms

Aortic stenosis is the most common form of valvular heart disease in the elderly population and is often diagnosed in individuals who also have coronary artery disease. Surgical aortic valve replacement has been the standard of care for the treatment of aortic stenosis during the past decades, but the availability of transcatheter aortic valve replacement has now allowed different options for high or extreme surgical risk patients. The management of coronary artery disease in patients undergoing transcatheter aortic valve replacement remains a controversial issue, as available studies in the literature have generated conflicting results. This review offers a comprehensive portrait of coronary artery disease management in the presence of concomitant aortic stenosis and proposes treatment approaches for patients presenting both diseases.

Three-Year Outcomes of Transcatheter Aortic Valve Implantation in Patients With Varying Levels of Surgical Risk (from the CoreValve ADVANCE Study)

This study compared 3-year clinical outcomes of patients who underwent transcatheter aortic valve implantation with the Society of Thoracic Surgeons (STS) score ≤7% to those of patients with a score >7%. Data were drawn from the ADVANCE study, a multinational post-market clinical trial that enrolled real-world patients with severe aortic stenosis treated with the CoreValve bioprosthesis. Events were independently adjudicated using Valve Academic Research Consortium-1 definitions. A total of 996 patients were implanted: STS ≤7% (n = 697, median STS 4.3%, interquartile range 3.1% to 5.4%) and STS >7% (n = 298, median STS 9.7%, interquartile range 8.0% to 12.4%). At 3 years, the STS ≤7% group had lower rates of all-cause mortality (28.6 vs 45.9, p <0.01) and cardiovascular mortality (19.0 vs 30.2, p <0.01) than the STS >7% group. No differences were observed in cerebrovascular accidents, vascular complications, bleeding, or myocardial infarction. In patients with STS ≤7%, mortality at 3 years was higher in those with moderate or severe aortic regurgitation (AR) at discharge than in those with mild or less AR (39.9% vs 22.9%; hazard ratio 1.98; 95% confidence interval 1.37 to 2.86; p <0.01). Conversely, the severity of AR at discharge did not affect 3-year mortality in patients with STS >7% (42.9% vs 44.6%, moderate/severe vs mild/less; hazard ratio 1.04; 95% confidence interval, 0.62 to 1.75; p = 0.861; p for interaction = 0.047). In conclusion, patients with STS ≤7% had lower rates of all-cause and cardiovascular mortality at 3 years after transcatheter aortic valve implantation. Complication rates were low and stable in both groups, demonstrating the safety of this procedure for patients at various levels of surgical risk.

Antithrombotic therapy following transcatheter aortic valve implantation: what challenge do we face?

The issue of stroke and bleeding events following transcatheter aortic valve implantation (TAVI) and its relation with antithrombotic regimens before, during and after the procedure is increasingly recognized as an important issue. While dedicated trials are ongoing, there is no clear evidence at present on the best antithrombotic regimen in the context of TAVI. In this article, we will go through the mechanisms involved in embolic and bleeding complications of TAVI, and we will discuss the key aspects of antithrombotic treatment in patients undergoing TAVI.

Transcatheter Aortic Valve Replacement: a Kidney's Perspective

Transcatheter aortic valve replacement (TAVR) has now emerged as a viable treatment option for high-risk patients with severe aortic stenosis (AS) who are not suitable candidates for surgical aortic valve replacement (SAVR). Despite encouraging published outcomes, acute kidney injury (AKI) is common and lowers the survival of patients after TAVR. The pathogenesis of AKI after TAVR is multifactorial including TAVR specific factors such as the use of contrast agents, hypotension during rapid pacing, and embolization; preventive measures may include pre-procedural hydration, limitation of contrast dye exposure, and avoidance of intraprocedural hypotension. In recent years, the number of TAVR performed worldwide has been increasing, as well as published data on renal perspectives of TAVR including AKI, chronic kidney disease, end-stage kidney disease, and kidney transplantation. This review aims to present the current literature on the nephrology aspects of TAVR, ultimately to improve the patients' quality of care and outcomes.

Access and closure of the left ventricular apex: state of play

Calcific aortic stenosis is the most frequent manifestation of valvular heart disease. The preferred treatment for patients of all age groups is surgical aortic valve replacement. Recently, transcatheter aortic valve implantation (TAVI) has become the standard of care for patients that are deemed to be at high risk for open heart surgery. The most common access route for TAVI is the retrograde transfemoral (TF) approach, followed by the antegrade transapical (TA) approach. Both access routes have distinct indications. While the TF route is least invasive and the access of choice at most centers, the apical route is used complementary in patients with poor femoral access. In addition, the TA approach holds various benefits such as a short distance from the operator to the annulus facilitating exact positioning of the valve and the possibility to accommodate larger sheaths. Furthermore, the TA approach not only provides direct access to the aortic valve but also the mitral valve allowing for a wide range of interventions. Various apical closure devices are currently being developed under the premise of increasing overall safety of the TA-TAVI approach by further standardizing the procedure, alleviating left ventricular access and minimizing the risk of complications, such as apical bleeding. The aim of this article is to give an overview of current devices for apical closure. The ideal apical closure device should be easy to put in place, leave a minimum of foreign material, provide complete hemostasis and have a minimal risk of displacement. So far the range of commercially available devices in Europe is very limited with only one CE-certified device on the market and one device that is expected to receive CE-certification soon. Off-the-shelf closure devices could help flatten the initial operator learning curve and facilitate a safe apical access, ultimately leading to an entirely percutaneous TA-TAVI approach.

Acute kidney injury after transcatheter aortic valve implantation

Even though experience and techniques have constantly improved over the last years, peri- and postprocedural complications in high risk TAVI-collectives remain a major issue affecting outcome and survival. Acute kidney injury (AKI) is a frequent complication after transcatheter aortic valve implantation (TAVI) and effects outcome and survival. However, the definition of AKI in published studies dealing with the phenomenon of AKI after TAVI varies widely and lacks standardization. This Review aims to present an overview over the current literature concerning AKI after TAVI with regard to the definition of AKI, the impact of AKI on mortality and potential risk factors for renal impairment after TAVI.

1-Year Outcomes After Transfemoral Transcatheter or Surgical Aortic Valve Replacement: Results From the Italian OBSERVANT Study

BACKGROUND

There is a paucity of prospective and controlled data on the comparative effectiveness of transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) in a real-world setting.

OBJECTIVES

This analysis aims to describe 1-year clinical outcomes of a large series of propensity-matched patients who underwent SAVR and transfemoral TAVR.

METHODS

The OBSERVANT (Observational Study of Effectiveness of SAVR-TAVI Procedures for Severe Aortic Stenosis Treatment) trial is an observational prospective multicenter cohort study that enrolled patients with aortic stenosis (AS) who underwent SAVR or TAVR. The propensity score method was applied to select 2 groups with similar baseline characteristics. All outcomes were adjudicated through a linkage with administrative databases. The primary endpoints of this analysis were death from any cause and major adverse cardiac and cerebrovascular events (MACCE) at 1 year.

RESULTS

The unadjusted enrolled population (N = 7,618) included 5,707 SAVR patients and 1,911 TAVR patients. The matched population had a total of 1,300 patients (650 per group). The propensity score method generated a low-intermediate risk population (mean logistic EuroSCORE 1: 10.2 ± 9.2% vs. 9.5 ± 7.1%, SAVR vs. transfemoral TAVR; p = 0.104). At 1 year, the rate of death from any cause was 13.6% in the surgical group and 13.8% in the transcatheter group (hazard ratio [HR]: 0.99; 95% confidence interval [CI]: 0.72 to 1.35; p = 0.936). Similarly, there were no significant differences in the rates of MACCE, which were 17.6% in the surgical group and 18.2% in the transcatheter group (HR: 1.03; 95% CI: 0.78 to 1.36; p = 0.831). The cumulative incidence of cerebrovascular events, and rehospitalization due to cardiac reasons and acute heart failure was similar in both groups at 1 year.

CONCLUSIONS

The results suggest that SAVR and transfemoral TAVR have comparable mortality, MACCE, and rates of rehospitalization due to cardiac reasons at 1 year. These data need to be confirmed in longer term and dedicated ongoing randomized trials.

Reducing periprocedural complications in transcatheter aortic valve replacement: review of paravalvular leaks, stroke and vascular complications

Transcatheter aortic valve replacement has been established as the standard of care for inoperable patients and a valid alternative for high-risk individuals with severe symptomatic native aortic stenosis. Over the last decade, substantial improvement has been made in the transcatheter technology. Nevertheless, this less-invasive procedure is still associated with complications like paravalvular leaks, strokes and vascular complications. This review article discusses these worrisome complications associated with transcatheter aortic valve replacement and proposes methods to prevent these hurdles.

Defective recovery of QT dispersion following transcatheter aortic valve implantation: frequency, predictors and prognosis

Background

Corrected QT dispersion (cQTD) has been correlated with non-uniform ventricular repolarisation and increased mortality. In patients with aortic stenosis, cQTD has been shown improved after surgical valve replacement, but the effects of transcatheter aortic valve implantation (TAVI) are unknown. Therefore, we sought to explore the frequency, predictors and prognostic effects of defective cQTD recovery at 6 months after TAVI.

Methods

A total of 222 patients underwent TAVI with the Medtronic-CoreValve System between November 2005 and January 2012. Patients who were on class I or III antiarrhythmics or on chronic haemodialysis or who developed atrial fibrillation, a new bundle branch block or became pacemaker dependent after TAVI were excluded. As a result, pre-, post- and follow-up ECG (median: 6 months) analysis was available in 45 eligible patients. Defective cQTD recovery was defined as any progression beyond the baseline cQTD at 6 months.

Results

In the 45 patients, the mean cQTD was 47 ± 23 ms at baseline, 45 ± 17 ms immediately after TAVI and 40 ± 16 ms at 6 months (15% reduction, P = 0.049). Compared to baseline, cQTD at 6 months was improved in 60% of the patients whereas defective cQTD recovery was present in 40%. cQTD increase immediately after TAVI was an independent predictor of defective cQTD recovery at 6 months (per 10 ms increase; OR: 1.89, 95% CI: 1.15–3.12). By univariable analysis, defective cQTD recovery was associated with late mortality (HR: 1.52, 95% CI: 1.05–2.17).

Conclusions

Despite a gradual reduction of cQTD after TAVI, 40% of the patients had defective recovery at 6 months which was associated with late mortality. More detailed ECG analysis after TAVI may help to avoid late death.

Moderate and severe preoperative chronic kidney disease worsen clinical outcomes after transcatheter aortic valve implantation: meta-analysis of 4992 patients

BACKGROUND

There is a conflicting evidence on safety and efficacy of transcatheter aortic valve implantation in patients with preoperative chronic kidney disease (CKD). Therefore, we conducted a meta-analysis on the impact of CKD on outcomes after transcatheter aortic valve implantation.

METHODS AND RESULTS

Nine studies including 4992 patients were analyzed. Overall preoperative CKD (stages 3-5) significantly increased early (odds ratio [OR], 1.44; 95% confidence interval [CI], 1.08-1.94 and OR, 1.66; 95% CI, 1.04-2.67) and 1-year (OR, 1.66; 95% CI, 1.23-2.25 and OR, 1.32; 95% CI, 1.06-1.63) all-cause and cardiovascular mortality, respectively. Moderate CKD (stage 3) alone also increased early and 1-year all-cause mortality (OR, 1.43; 95% CI, 1.10-1.85 and OR, 1.41; 95% CI, 1.13-1.74). CKD stages 4 to 5 and 3 compared with stages 1 to 2 increased early stroke (OR, 2.67; 95% CI, 1.53-4.65 and OR, 1.66; 95% CI, 1.09-2.52), acute kidney injury (OR, 2.09; 95% CI, 1.17-3.72 and OR, 1.32; 95% CI, 1.09-1.60) and need for dialysis (OR, 5.92; 95% CI, 2.46-14.27 and OR, 1.55; 95% CI, 0.65-3.70), in the absence of significant differences in contrast medium administration (mean difference, -26.07; 95% CI, -53.00 to 0.85 and mean difference, -0.42; 95% CI, -16.10 to 15.26). Bleeding (life-threatening or major) was nonsignificantly increased in CKD 3 to 5 compared with CKD 1 to 2, but significantly increased in most severe patients (CKD 4-5 versus CKD 1-2: OR, 1.66; 95% CI, 1.13-2.44; CKD 4-5 versus CKD 3: OR, 1.68; 95% CI, 1.27-2.24).

CONCLUSIONS

Both moderate and severe preoperative CKD significantly worsen transcatheter aortic valve implantation prognosis. Future studies on risk evaluation, prevention, and postoperative management are needed.

Emergent cardiac surgery during transcatheter aortic valve implantation (TAVI): insights from the Edwards SAPIEN Aortic Bioprosthesis European Outcome (SOURCE) registry

AIMS

Transcatheter aortic valve implantation (TAVI) carries the risk of intraprocedural complications that may ultimately require emergent cardiac surgery (ECS). However, few data exist on the incidence, reasons and outcomes of patients needing ECS during TAVI. We analysed data from 2,307 TAVI patients, prospectively enrolled in the multicentre Edwards SAPIEN Aortic Bioprosthesis European Outcome (SOURCE) registry.

METHODS AND RESULTS

Twenty-seven (1.2%) of 2,307 patients required ECS. The rates of ECS were similar for patients undergoing transapical TAVI compared with transfemoral TAVI (1.1% vs. 1.2%). The leading causes for ECS were embolisation/migration of the TAVI valve prosthesis (9/27, 33%) and procedure-related aortic injury (n=7, 26%). Thirty-day mortality of ECS was high (51.9%) and showed cause-specific differences, with 100% mortality in patients with aortic rupture or cardiac tamponade, 0% death in those with acute aortic regurgitation and intermediate risk of death or intermediate mortality in those with aortic injury or valve embolisation/migration.

CONCLUSIONS

Rates of ECS during TAVI were low (1.2%). Although ECS was performed without time delay, emergent surgery was associated with a 30-day mortality of 52%. Complications with dramatic acute consequences (annular rupture, aortic injury) had higher mortality than those with less acute deterioration (aortic regurgitation). Prevention of complications requiring ECS during TAVI appears to be of critical importance, focusing on less traumatic, more flexible delivery catheter systems and retrievable valves to reduce the risk of aortic injury and valve embolisation, the two most common causes of ECS.

Activity and outcomes for aortic valve implantations performed in England and Wales since the introduction of transcatheter aortic valve implantation

OBJECTIVES

The first transcatheter aortic valve implantation (TAVI) in England and Wales was performed in 2007. This study presents the subsequent national activity and outcomes for both TAVI and aortic valve replacement (AVR).

METHODS

Data for all AVR and TAVI procedures between January 2006 and December 2012 in England and Wales were included. The number of procedures, patient characteristics, in-hospital and 30-day mortality, postoperative length of stay (PLOS) and survival were analysed separately for: isolated AVR; AVR + coronary artery bypass graft (CABG) surgery; AVR + other surgery and TAVI.

RESULTS

The number of TAVIs increased from 66 in 2007 (0.8% of all implants) to 1186 in 2012 (10.9% of all implants). AVR activity also increased over the study period. TAVI patients were older and had a higher mean logistic EuroSCORE than all AVR groups. The 30-day mortality rates were 2.1% for isolated AVR, 3.9% for AVR + CABG, 7.7% for AVR + other surgery and 6.2% for TAVI. In-hospital mortality has significantly improved for all groups. The 5-year survival rates were 82.6% for isolated AVR, 81.7% for AVR + CABG, 74.5% for AVR + other surgery and 46.1% for TAVI. The median PLOS after TAVI was similar to that of isolated AVR but shorter than that of the other AVR groups.

CONCLUSIONS

Since the introduction of TAVI, there has been an increase in both TAVI and AVR activity. TAVIs now represent over 10% of all aortic valve implants. There are distinct differences between procedural groups with respect to patient risk factors. Outcomes for all procedural groups have improved, but long-term TAVI results are required before its role in the treatment of aortic stenosis can be fully defined.

Management of concomitant coronary artery disease in patients undergoing transcatheter aortic valve implantation: the United Kingdom TAVI Registry

BACKGROUND

The management and impact of concomitant coronary artery disease in patients referred for TAVI remains contentious. We describe the prevalence, clinical impact and management of coronary artery disease (CAD) in patients in the United Kingdom TAVI Registry.

METHODS

All-inclusive study of patients undergoing TAVI in the United Kingdom (excluding Northern Ireland) from January 2007 to December 2011. Coronary artery disease at the time of TAVI was demonstrated on invasive angiography.

RESULTS

2588 consecutive patients were entered in the U.K. TAVI Registry. CAD was reported in 1171 pts with left main stem involvement in 12.4% of this cohort (n=145). Most patients were free of chest pain, but limited by dyspnoea (NYHA Class III & IV 81.9%). Angina was however more prevalent in those patients with CAD (p<0.0001). Hybrid PCI was uncommon, performed in only 14.7% of the CAD cohort (n=172). Survival at 30days, 1year, and 4years was 93.7%, 81.4% and 72.0% respectively. Adjusting for confounders in a multivariate model the presence and extent of CAD was not associated with early (30-days, p=0.36) or late (4years, p=0.10) survival.

CONCLUSIONS

This contemporary study of coronary artery disease management in an "all-comers" patient population undergoing TAVI demonstrates that whilst often an indicator of significant underlying comorbidity coronary artery disease is not associated with decreased short or long-term survival. The majority of patients with aortic stenosis and concomitant CAD can be managed effectively by TAVI alone. However, the importance of the Heart Team in making decisions on individual patients must not be underestimated.

Current status of transcatheter aortic valve replacement

The advent of transcatheter aortic valve replacement (TAVR) has modified the treatment of severe aortic stenosis (AS). Large randomized trials and multicenter registries have endorsed the efficacy of TAVR in improving outcomes in patients with severe AS who are inoperable or high surgical risk. There has been a noticeable shift in using TAVR in patients with AS who are not at a high surgical risk. Appropriate diagnosis, patient selection, and referral remain cornerstones to achieving optimal outcomes after TAVR or SAVR (surgical aortic valve replacement).

5-Year Outcomes After Transcatheter Aortic Valve Implantation With CoreValve Prosthesis

OBJECTIVES

The purpose of this analysis was to assess 5-year outcomes of transcatheter aortic valve implantation (TAVI) using the current technology of the self-expanding CoreValve prosthesis (Medtronic Inc., Minneapolis, Minnesota).

BACKGROUND

There is a paucity of evidence on long-term durability of currently available transcatheter heart valves.

METHODS

Starting in June 2007, all consecutive patients with severe aortic stenosis undergoing TAVI with the third-generation 18-F CoreValve device in 8 Italian centers were prospectively included in the ClinicalService Project. For the purposes of this study, we included only consecutive patients with 5-year follow-up data available (n = 353) treated from June 2007 to August 2009. All outcomes were reported according to VARC (Valve Academic Research Consortium)-1 criteria.

RESULTS

All-cause mortality rates at 1, 2, 3, 4, and 5 years were 21%, 29%, 38%, 48%, and 55.0%, respectively. Cardiovascular mortality rates at 1, 2, 3, 4, and 5 years were 10%, 14%, 19%, 23%, and 28.0%, respectively. The overall neurological event rate at 5 years was 7.5%, of which more than two-thirds occurred early after the procedure. During follow-up, there were 241 rehospitalizations for cardiovascular reasons in 164 (46%) patients. Among all rehospitalizations, acute heart failure was the most frequently reported (42.7%), followed by requirement of permanent pacemaker implantation (17.4%). On echocardiography, mean transaortic gradients decreased from 55.6 ± 16.8 mm Hg (pre-TAVI) to 12.8 ± 10.9 mm Hg (5-year post-TAVI) (p < 0.001). Late prosthesis failure occurred in 5 cases (1.4%); among these, redo TAVI was successfully carried out in 2 patients (0.6%) presenting with symptomatic prosthesis restenosis. The remaining 3 cases of prosthesis failure did not undergo further invasive interventions. Ten patients (2.8%) showed late mild stenosis with a mean transaortic gradient ranging from 20 to 40 mm Hg. No other cases of structural or nonstructural valvular deterioration were observed. Valve thrombosis or late valve embolization were not reported.

CONCLUSIONS

TAVI with the currently adopted CoreValve generation was associated with sustained clinical outcomes up to 5-year follow-up, with a low rate (1.4%) of significant prosthetic valve degeneration. The procedure appears to be an adequate and lasting resolution of aortic stenosis in selected high-risk patients.

5-year outcomes of transcatheter aortic valve replacement compared with standard treatment for patients with inoperable aortic stenosis (PARTNER 1): a randomised controlled trial

BACKGROUND

Based on the early results of the Placement of Aortic Transcatheter Valves (PARTNER) trial, transcatheter aortic valve replacement (TAVR) is an accepted treatment for patients with severe aortic stenosis who are not suitable for surgery. However, little information is available about the late clinical outcomes in such patients.

METHODS

We did this randomised controlled trial at 21 experienced valve centres in Canada, Germany, and the USA. We enrolled patients with severe symptomatic inoperable aortic stenosis and randomly assigned (1:1) them to transfemoral TAVR or to standard treatment, which often included balloon aortic valvuloplasty. Patients and their treating physicians were not masked to treatment allocation. The randomisation was done centrally, and sites learned of the assignment only after a patient had been screened, consented, and entered into the database. The primary outcome of the trial was all-cause mortality at 1 year in the intention-to-treat population, here we present the prespecified findings after 5 years. This study is registered with ClinicalTrials.gov, number NCT00530894.

FINDINGS

We screened 3015 patients, of whom 358 were enrolled (mean age 83 years, Society of Thoracic Surgeons Predicted Risk of Mortality 11·7%, 54% female). 179 were assigned to TAVR treatment and 179 were assigned to standard treatment. 20 patients crossed over from the standard treatment group and ten withdrew from study, leaving only six patients at 5 years, of whom five had aortic valve replacement treatment outside of the study. The risk of all-cause mortality at 5 years was 71·8% in the TAVR group versus 93·6% in the standard treatment group (hazard ratio 0·50, 95% CI 0·39-0·65; p<0·0001). At 5 years, 42 (86%) of 49 survivors in the TAVR group had New York Heart Association class 1 or 2 symptoms compared with three (60%) of five in the standard treatment group. Echocardiography after TAVR showed durable haemodynamic benefit (aortic valve area 1·52 cm(2) at 5 years, mean gradient 10·6 mm Hg at 5 years), with no evidence of structural valve deterioration.

INTERPRETATION

TAVR is more beneficial than standard treatment for treatment of inoperable aortic stenosis. TAVR should be strongly considered for patients who are not surgical candidates for aortic valve replacement to improve their survival and functional status. Appropriate selection of patients will help to maximise the benefit of TAVR and reduce mortality from severe comorbidities.

FUNDING

Edwards Lifesciences.

Comparative meta-analysis of balloon-expandable and self-expandable valves for transcatheter aortic valve replacement

BACKGROUND

Balloon-expandable valves (BEVs) and self-expandable valves (SEVs) are two major types of valves utilized for transcatheter aortic valve replacement (TAVR). We conducted a meta-analysis of available studies to compare the safety and efficacy of these two valve types.

METHODS

Medline search was conducted using standard search terms to determine eligible studies. Primary outcomes of the meta-analysis included death and stroke at 30days and 1year. Pooled estimates of procedural outcomes were also compared between the valve types. Analysis was performed for entire cohort and separately for patients undergoing transfemoral TAVR (TF-TAVR).

RESULTS

Analysis of entire cohort revealed similar 30-day mortality in the SEV and BEV cohorts. There was no significant difference in the incidence of stroke at 30days between the two study groups. Both pooled comparisons demonstrated a significant heterogeneity with I(2)>50%, necessitating the use of random effect modeling. We observed a significantly higher incidence of new pacemaker implantation, aortic regurgitation≥2+ at 30days, valve embolization, and need for >1 valve following SEV implantation compared with BEV implantation. Analysis of TF-TAVR cohort showed higher 30day [IRR (95% CI): 1.34 (1.19-1.52)] but a similar 1-year mortality [IRR (95% CI): 1.07 (0.96-1.19)] for SEV compared to BEV implantation.

CONCLUSION

Compared to BEV implantation, SEV implantation was associated with a similar risk of mortality and stroke at 30-day and 1-year follow-up duration. Analysis of the TF-TAVR cohort revealed a significantly higher mortality at 30days among patients undergoing SEV implantation, compared with BEV implantation. In addition, there was a significantly higher incidence of other adverse events noted above, following SEV implantation, compared with BEV implantation.

Clinical impact and evolution of mitral regurgitation following transcatheter aortic valve replacement: a meta-analysis

OBJECTIVES

Mitral regurgitation (MR) is a common entity in patients with aortic stenosis undergoing transcatheter aortic valve replacement (TAVR), but its influence on outcomes remains controversial. The purpose of this meta-analysis was to assess the clinical impact of and changes in significant (moderate-severe) MR in patients undergoing TAVR, overall and according to valve design (self-expandable (SEV) vs balloon-expandable (BEV)).

METHODS

All national registries and randomised trials were pooled using meta-analytical guidelines to establish the impact of moderate-severe MR on mortality after TAVR. Studies reporting changes in MR after TAVR on an individual level were electronically searched and used for the analysis.

RESULTS

Eight studies including 8015 patients (SEV: 3474 patients; BEV: 4492 patients) were included in the analysis. The overall 30-day and 1-year mortality was increased in patients with significant MR (OR 1.49, 95% CI 1.16 to 1.92; HR 1.32, 95% CI 1.12 to 1.55, respectively), but a significant heterogeneity across studies was observed (p<0.05). The impact of MR on mortality was not different between SEV and BEV in meta-regression analysis for 30-day (p=0.360) and 1-year (p=0.388) mortality. Changes in MR over time were evaluated in nine studies including 1278 patients. Moderate-severe MR (SEV: 326 patients; BEV: 192 patients) improved in 50.5% of the patients at a median follow-up of 180 (30-360) days after TAVR, and the degree of improvement was greater in patients who had received a BEV (66.7% vs 40.8% in the SEV group, p=0.001).

CONCLUSIONS

Concomitant moderate-severe MR was associated with increased early and late mortality following TAVR. A significant improvement in MR severity was detected in half of the patients following TAVR, and the degree of improvement was greater in those patients who had received a BEV.

Transcatheter aortic valve implantation--update and evidence

Transcatheter aortic valve implantation (T-AVI) has become the standard of care for high-risk patients suffering from severe aortic valve stenosis. More than 60,000 implants have been performed to date. While the first-generation T-AVI devices had some specific issues, the advancements in these first-generation devices and the development of second-generation devices significantly reduced the incidence of peri-procedural complications. The two major access routes are the transfemoral (TF) and the transapical (TA) approach. Both approaches have their advantages and should be considered equal alternatives for finding the best treatment option for the individual patient. Currently there are discussions about extending the indication to patients with lower risk profiles. However, there is no real evidence to justify an expansion, as results of surgical aortic valve replacement in low and intermediate risk patients are excellent.

Comparison of outcomes after one-versus-two transcatheter aortic valve implantation during a same procedure (from the FRANCE2 Registry)

Analysis of the causes, outcomes, and mortality of patients with severe symptomatic aortic stenosis requiring the implantation of 2 valves during transcatheter aortic valve implantation was conducted from the French Aortic National CoreValve and Edwards 2 (FRANCE2) registry. Pre- and postprocedural data from 3,919 patients from January 2010 to December 2011 (CoreValve or Edwards) were collated and analyzed. Characteristics of patients requiring immediate second valve procedures were compared with those of the other patients. The 72 patients (1.8%) who underwent implantation of a second valve were studied. Indications were device malpositioning (72%) and embolization (28%). Clinical and echocardiographic characteristics of patients receiving 2 valves were comparable with those of the other patients. The 2-year survival rate was 51.7% for patients with 2 valves as opposed to 62.3% for those with 1 valve (p<0.001). The need for a second valve was an independent predictor of all-cause (hazard ratio 2.32, 95% confidence interval 1.50 to 3.60, p<0.001) and cardiovascular (hazard ratio 2.64, 95% confidence interval 1.35 to 5.15, p<0.001) mortality at 2 years. During follow-up, clinical and echocardiographic data remained similar between the 2 groups. In conclusion, in the FRANCE2 study, the main causes for second valve implantation during the same procedure were malpositioning and embolization. Although the procedure was feasible, it was accompanied by excess mortality. Valve hemodynamic status was preserved during the course of follow-up.

Effectiveness of anticoagulant therapy in the treatment of post-TAVI bioprosthetic thrombosis

Bioprosthetic thromboses are rarely reported in post-transcatheter aortic valve implantation (TAVI). We describe herein the case of bioprosthetic valve thrombosis in an 82-year-old patient which resolved completely after anticoagulant therapy.