5-Year Outcomes of Self-Expanding Transcatheter Versus Surgical Aortic Valve Replacement in High-Risk Patients

Transcatheter aortic valve replacement in patients with severe comorbidities: A retrospective cohort study

OBJECTIVE

To investigate the long-term outcomes of patients with severe comorbidities (sCM) undergoing transcatheter aortic valve replacement (TAVR).

BACKGROUND

The benefit of TAVR may be limited among patients with sCM due to a lack of mortality- or quality-of-life-benefit.

METHODS

All TAVR patients in the Allina Health System between January 1, 2011 and August 7, 2018 were included (n = 890, 82 ± 8 years, 55% men). sCM included: severe lung disease, severe liver disease, end-stage renal disease, severe, severe dementia, severe dilated cardiomyopathy, and frailty. Outcomes between patients with (n = 215, 24%) and without (n = 675, 76%) sCM were compared.

RESULTS

At baseline, patients with sCM had worse symptoms, higher STS-PROM and a lower Kansas City Cardiomyopathy Questionnaire (KCCQ) score compared to those without. During a median follow-up of 15 months (IQR, 7-29 months), there were 208 (23%) deaths. Patients with sCM had a lower 3-year survival free from all-cause mortality (40% vs. 79%, p < .001), and lower 3-year survival free from the composite endpoint of all-cause mortality, re-hospitalization for heart failure, myocardial infarction or stroke (31% vs. 64%, p < .001) compared to those without sCM. The estimated monthly increase in KCCQ scores following TAVR was 1.5, 95%CI (1.3, 1.7), p < .001 irrespective of sCM grouping. From Cox regression analysis, severe comorbidities, with the exception of liver disease, were associated with an increased risk of all-cause mortality and any additional comorbidity was associated with a multiplicative increase in risk of mortality of 2.8 (95%CI 2.3, 3.6), p < .001.

CONCLUSIONS

TAVR patients with sCM have poor 3-year outcomes but may experience improvements in their quality of life.

Structural durability of early-generation Transcatheter aortic valve replacement valves compared with surgical aortic valve replacement valves in heart valve surgery: a systematic review and meta-analysis

Background

The current treatment for aortic stenosis includes open surgical aortic valve replacement (SAVR) as well as endovascular transcatheter aortic valve replacement (TAVR). This study aims to compare the 1-year, 2–3 year and 5-year structural durability of TAVR valves with that of SAVR valves.

Method

A systematic literature search was conducted in July 2019 on Medline (via PubMed), Embase and Cochrane electronic databases according to the PRISMA guidelines.

Results

Thirteen randomized controlled trials were included. From the meta-analysis, we observed higher rates of 1-year (OR: 7.65, CI: 4.57 to 12.79, p < 0.00001), 2–3-year (OR: 13.49, CI: 5.66 to 32.16, p < 0.00001) and 5-year paravalvular regurgitation (OR: 14.51, CI: 4.47 to 47.09, p < 0.00001) associated with the TAVR valves than the SAVR valves. There were also higher rates of 1-year (OR: 5.00, CI: 3.27 to 7.67, p < 0.00001), 2–3-year (OR: 8.14, CI: 3.58 to 18.50, p < 0.00001) and 5-year moderate or severe aortic regurgitation (MD: 14.65, CI: 4.55 to 47.19, p < 0.00001), and higher rates of 1-year (OR: 3.55, CI: 1.86 to 6.77, p = 0.0001), 2–3-year (OR: 3.55, CI: 1.86 to 6.77, p = 0.0001) and 5-year reintervention (OR: 3.55, CI: 1.22 to 10.38, p = 0.02) in the TAVR valves as compared to SAVR valves.

Conclusion

TAVR valves appear to be more susceptible to structural valve deterioration and thus potentially less structurally durable than SAVR valves, given that they may be associated with higher rates of moderate or severe aortic regurgitation, paravalvular regurgitation and reintervention in the 1-year-, 2–3 year, and 5-year period.

Transcatheter aortic valve implantation versus surgical aortic valve replacement for treatment of severe aortic stenosis: comparison of results from randomized controlled trials and real-world data

Objective

Results from randomized controlled trials (RCTs) and real-world study (RWS) appear to be discordant. We aimed to investigate whether data derived from RCTs and RWS evaluating long-term all-cause mortality of transcatheter aortic valve implantation (TAVI) versus surgical aortic valve replacement (SAVR) in patients with severe aortic stenosis (AS) were in agreement.

Methods

RCTs or RWS comparing TAVI and SAVR, reporting longterm (≥2-year follow-up) all-cause mortality, were identified. We also carried out subgroup analyses to access the effect in different subgroups. A pre-designated data extraction form including 5 domains and 26 items was used to explore the relationship between RCTs and RWS. Mortality and effect in different subgroups were evaluated using random-effects meta-analyses.

Results

Five RCTs (5421 participants, TAVI: 2759, SAVR: 2662) and 33 RWS (20839 participants; TAVI: 6585, SAVR: 14254) were identified. Pooled RCT analysis showed no difference in all-cause mortality between TAVI and SAVR (HR=0.97, 95% CI: 0.88-1.07; P=0.55). In RWS, TAVI was associated with an increased risk of allcause mortality (HR=1.46, 95% CI: 1.26-1.69; P<0.001) compared to SAVR.

Conclusion

These results highlight the inconsistencies between RCTs and RWS in assessing long-term all-cause mortality in the treatment of AS using TAVI or SAVR, which may be caused by interactions of clinical characteristics or study design. RCTs as well as RWS are both developing and improving; the advantages of one kind of design, measurement and evaluation can and should be thoughtfully referred to the other.

Outcomes of isolated surgical aortic valve replacement in the era of transcatheter aortic valve implantation

BACKGROUND AND AIMS

Until early into the 21st century, the only therapeutic option for aortic valve (AV) stenosis was surgical aortic valve replacement (AVR), but this changed with the introduction of transcatheter aortic valve implantation (TAVI). Our objective was to present the results of surgical AVR performed in low-risk patients in the era of TAVI, in a large tertiary medical center.

METHODS

Data from low surgical risk patients (defined as Euroscore < 5) greater than 60 years of age, who underwent isolated AVR surgery between 2004 and 2018, were obtained from our departmental database. Of the 313 study patients, 110 (35%) underwent isolated AVR before 2010 (early period) and 203 patients (65%) underwent the same procedure from 2010 onward (late period).

RESULTS

Mean age was 67 ± 5 years and 182 (58%) were male. Fifty-six patients (18%) had a unicuspid or bicuspid AV. Patient characteristics were similar between the early and late periods. There was no in-hospital or 30-day mortality throughout the entire cohort, with one case (0.3%) of postoperative stroke. Permanent pacemaker implantation was required in 2.2% (N = 7). Patients in the early period required significantly more re-exploration due to bleeding/tamponade (8.2% vs 1.5%; P = .008). Long-term mortality (1, 3, and 5 years) was higher in the early compared with the late period (2.7% vs 1%, 7.3% vs 3%, and 15.5% vs 3.4%, respectively; log-rank P = .005).

CONCLUSIONS

Surgical AVR provides excellent short- and long-term results with low morbidity and mortality in low surgical risk patients. While patient characteristics did not change dramatically over the years, the long-term results were encouraging.

Comparing Transcatheter Aortic Valve Replacement (AVR) With Surgical AVR in Lower Risk Patients: A Comprehensive Meta-Analysis and Systematic Review

Background

Transcutaneous aortic valve replacement (TAVR) is a novel percutaneous procedure for severe aortic stenosis and has been recently approved by Food and Drug Administration in lower risk patients. We performed the first ever meta-analysis and literature review of clinical trials comparing both 30-day and 1-year outcomes in lower risk patients undergoing TAVR vs. surgical aortic valve replacement (SAVR, having Society of Thoracic Surgeons score < 4% or equivalent).

Methods

Using predefined selection criteria as above, 68 articles were identified. Seven eligible articles were selected after extensive review. Primary effect outcomes were 30-day and 1-year all-cause mortality using risk ratio (RR) with significant P value of < 0.05.

Results

A total of 4,859 subjects were included. Risk of 30-day all-cause mortality was 40.1% less in TAVR group, RR 0.59 (95% confidence interval (CI): 0.38 - 0.92, P = 0.02) with no significant heterogeneity. Six studies except Schymik et al also reported 1-year risk. This was, however, not statistically significant with a 21% decrease in the TAVR group, RR 0.79 (95% CI: 0.57 - 1.09, P = 0.15). Six studies reported 30-day risk of secondary outcomes. The risk of 30-day stroke was 36% less in TAVR group, although this was not statistically significant, RR 0.64 (95% CI: 0.38 - 1.9, P = 0.10). The risk of acute kidney injury (AKI) stage 2 and above was 56% less in post-TAVR patients, RR 0.43 (95% CI: 0.35 - 0.54, P < 0.001) with no heterogeneity. For vascular complications, RR was high in TAVR group 4.62 (95% CI: 1.42-15.18, P = 0.01). Significant heterogeneity was demonstrated though (I² = 81). The risks for permanent pacemaker (PPM) were also higher in the TAVR group, RR 3.30 (95% CI: 2.04 - 5.33, P < 0.001) and significant heterogeneity was observed. After removing Thyregod et al and Partner 3 trial from the analysis, heterogeneity was removed, but the RR was still high 3.21 (95% CI: 2.54 - 4.068, P < 0.001). Post-operative incidence of endocarditis among TAVR patients was low but not statistically significant. The 30-day risk for infective endocarditis was RR 0.67 (95% CI: 0.13 - 3.48, P = 0.63). The 1-year risk was similarly low but not significant, RR 0.73 (95% CI: 0.28 - 1.92, P = 0.53).

Conclusions

Among low risk patients, TAVR was found to be superior in short-term all-cause mortality and 1-year stroke, a result that was statistically significant for TAVR and close to significance for stroke. TAVR patients were also less likely to have post-operative bleeding and AKI stage 2 and beyond. Post-operative incidence of endocarditis among TAVR patients was low but not statistically significant. However, the rates of PPM and vascular complications are higher in TAVR patients. The results of TAVR in low risk population are thus extremely encouraging. However, the issue of long-term valve durability in this group needs further studies. Also, caution needs to be exercised while extending the indications to extremely young patients due to lack of enough studies.

Noteworthy Literature in Cardiac Anesthesia for 2019

This article represents a selective review of literature published in 2019. Initial results from PubMed searching for a combination of terms, including cardiac anesthesiology and anesthesiology outcomes, yielded more than 1400 publications. From there, we manually screened the results and identified 5 major themes for the year of 2019, including transcatheter techniques, delirium and anesthesiology, coagulation management following cardiopulmonary bypass, perfusion management with del Nido cardioplegia, and applied clinical research. The following research accomplishments have expanded what is possible and set ambitious goals for the future.

Transcatheter Aortic Valve Replacement Programs: Clinical Outcomes and Developments

Transcatheter aortic valve replacement is a relatively recent revolutionary treatment that has now become a standard procedure for treating severe aortic stenosis. In this article, the authors review the clinical history of transcatheter aortic valve replacement, summarize the major clinical trials, and describe the evolution of the technique over time. In doing so, the authors hope to provide a clear and concise review of the history and clinical evidence behind transcatheter aortic valve replacement.

Comparison of Valve Durability and Outcomes of Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement in Patients With Severe Symptomatic Aortic Stenosis and Less-Than-High-Risk for Surgery

This study aimed to investigate the rate of severe structural valve deterioration (SVD) and long-term outcomes of patients with severe symptomatic aortic stenosis undergoing transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR). Propensity score matched analysis of patients who underwent TAVI (n = 216) and SAVR (n = 216) between 2008 and 2012. Long-term echocardiographic parameters and clinical outcomes were assessed after more than 6 years after TAVI/SAVR. Rate of severe SVD was 10.5% versus 4.5% in the TAVI and SAVR groups, respectively, but the difference was not statistically significant (hazard ratio [HR] 2.5; 95% confidence interval [CI] 0.7 to 8.3; p = 0.159). This was largely driven by higher rates of mean transprosthetic gradient ≥40 mm Hg (7.0 vs 3.4%; p = 0.327) and aortic regurgitation (4.7% vs 0%; p = 0.058). TAVI patients had lower survival rates at 6 years than SAVR patients (40.7% vs 59.6%, respectively, p <0.001, HR 2.15; 95% CI 1.45 to 3.20). Rate of cardiovascular events (14.4% TAVI vs 18.2% SAVR, HR 0.8; 95% CI 0.4 to 1.3; p = 0.347) and permanent pacemaker implantation (PPI; 16.0% TAVI vs 9.2% SAVR, p = 0.234) was similar between the 2 groups. In conclusion, incidence of moderate and severe SVD was not statistically different between TAVI and SAVR. Rate of moderate or severe aortic regurgitation was significantly higher in the TAVI group with predominant use of first-generation valves. Reintervention rate was low in both groups. Survival rate was lower after TAVI, probably because of higher frailty index, but incidence of cardiovascular events, PPI, and SVD was similar in both groups.

Incidence, Mechanisms, and Predictors of Mean Systolic Gradients ≥20 mm Hg after Transcatheter Aortic Valve Implantation

There is a significant increase in transvalvular gradients after transcatheter aortic valve implantation (TAVI) in some patients; however, mechanisms underlying the greater than expected gradients are unknown. We sought to determine the incidence and mechanisms of greater than expected gradients post-TAVI. A total of 424 patients who underwent TAVI at our institution between November 2008 and August 2015 and had at least 1 follow-up echocardiogram were included in the study. Greater than expected gradients were defined as mean systolic Doppler gradients ≥20 mm Hg. The primary end-point was incidence and mechanisms of mean systolic Doppler gradients ≥20 mm Hg. A total of 36 (8%) patients had mean systolic Doppler gradients ≥20 mm Hg. The mechanisms of mean systolic Doppler gradients ≥20 mm Hg were: patient prosthesis mismatch in 15 (42%) patients, high cardiac output in 13 (36%), prosthetic and periprosthetic regurgitation in 11 (31%), stenosis in 5 (14%), and multiple mechanisms in 8 (22%). Patients with mean systolic Doppler gradients ≥20 mm Hg had higher cardiac re-hospitalization rate, but no difference in mortality or major cardiovascular events when compared with the normal gradient group. Smaller prosthetic valve size (p <0.0001) and larger body mass index (p = 0.02) were associated with mean systolic Doppler gradients ≥20 mm Hg; warfarin therapy at discharge had no effect on gradients. In conclusion, about 8% patients had mean systolic Doppler gradients ≥20 mm Hg following TAVI, and patient-prosthesis mismatch was the most common mechanism. The mean systolic Doppler gradients ≥20 mm Hg after TAVI are not benign and warrant careful surveillance.

Mortality after transcatheter versus surgical aortic valve replacement: an updated meta-analysis of randomised trials

Background

To determine whether transcatheter aortic valve implantation (TAVI) improves early (30-day) and midterm (1-year) mortality compared with surgical aortic valve replacement (SAVR), we performed an updated meta-analysis of all the currently available randomised controlled trials (RCTs).

Methods

To identify all RCTs providing both 30-day and 1‑year mortality after TAVI versus SAVR, PubMed and ClinicalTrials.gov were searched up to and including July 2019. A risk difference (RD) and its 95% confidence interval were generated using data of prespecified outcomes in both the TAVI and SAVR groups. Study-specific estimates were pooled using inverse variance-weighted averages of RDs in the random-effects model.

Results

We identified seven eligible high-quality RCTs including a total of 7631 as-treated patients. Pooled analyses demonstrated significantly lower 30-day (RD −0.60%; p = 0.046) and 1‑year all-cause mortality (RD −1.12%; p = 0.03) after TAVI than after SAVR. No funnel plot asymmetry was detected for 30-day and 1‑year mortality. Meta-regression analyses indicated that RDs of 30-day and 1‑year mortality between TAVI and SAVR were not modulated by mean Society of Thoracic Surgeons Predicted Risk of Mortality score. Bleeding complications at 30 days and 1 year and stage 2/3 acute kidney injury at 30 days were significantly less frequent after TAVI than after SAVR, whereas major vascular complications and new permanent pacemaker implantation at 30 days and 1 year were significantly more frequent after TAVI than after SAVR.

Conclusion

The best evidence from the present meta-analysis of all the currently available RCTs suggests that TAVI may reduce 30-day and 1‑year all-cause mortality compared with SAVR.

Electronic supplementary material

The online version of this article (10.1007/s12471-020-01378-1) contains supplementary material, which is available to authorized users.

Network Meta-analysis of Surgical Aortic Valve Replacement and Different Transcatheter Heart Valve Systems for Symptomatic Severe Aortic Stenosis

BACKGROUND

Although different transcatheter heart valve (THV) systems have been introduced to overcome transcatheter aortic valve replacement (TAVR)-specific complications, head-to-head comparisons of these THV systems are scarce. The aim of this study was to compare different THV systems and surgical aortic valve replacement (SAVR) by conducting a network meta-analysis.

METHODS

PubMed and EMBASE were searched through November 2019 for studies comparing safety and efficacy of balloon-expandable valve (BEV), self-expanding valve (SEV), mechanically expandable valve (MEV), and SAVR for symptomatic severe aortic stenosis. End points in the short term at 30 days or discharge and the long term up to 2 years were assessed.

RESULTS

We identified 11 randomized controlled trials with a total of 10,300 patients eligible for inclusion in our study. There were no significant differences in all-cause death among different THV systems and SAVR in both short and long terms. Disabling stroke was significantly lower with MEV vs BEV and SAVR (hazard ratios [HRs] 0.31 [95% confidence interval [CI] 0.12-0.77] and 0.33 [95% CI 0.14-0.76], respectively) in the long term. MEV was associated with an increased risk of new permanent pacemaker implantation compared with BEV, SEV, and SAVR (HRs 3.82 [95% CI 1.83-7.97], 1.85 [95% CI 1.02-3.36], and 5.23 [95% CI 2.61-10.47], respectively) in the long term.

CONCLUSIONS

In patients with symptomatic severe aortic stenosis undergoing intervention, there were no significant differences in all-cause death among different THV systems and SAVR. MEV had low frequency of disabling stroke compared with BEV and SAVR, but an increased frequency of permanent pacemaker implantation compared with other interventions.

Five-Year Outcomes of Transcatheter or Surgical Aortic-Valve Replacement

BACKGROUND

There are scant data on long-term clinical outcomes and bioprosthetic-valve function after transcatheter aortic-valve replacement (TAVR) as compared with surgical aortic-valve replacement in patients with severe aortic stenosis and intermediate surgical risk.

METHODS

We enrolled 2032 intermediate-risk patients with severe, symptomatic aortic stenosis at 57 centers. Patients were stratified according to intended transfemoral or transthoracic access (76.3% and 23.7%, respectively) and were randomly assigned to undergo either TAVR or surgical replacement. Clinical, echocardiographic, and health-status outcomes were followed for 5 years. The primary end point was death from any cause or disabling stroke.

RESULTS

At 5 years, there was no significant difference in the incidence of death from any cause or disabling stroke between the TAVR group and the surgery group (47.9% and 43.4%, respectively; hazard ratio, 1.09; 95% confidence interval [CI], 0.95 to 1.25; P = 0.21). Results were similar for the transfemoral-access cohort (44.5% and 42.0%, respectively; hazard ratio, 1.02; 95% CI, 0.87 to 1.20), but the incidence of death or disabling stroke was higher after TAVR than after surgery in the transthoracic-access cohort (59.3% vs. 48.3%; hazard ratio, 1.32; 95% CI, 1.02 to 1.71). At 5 years, more patients in the TAVR group than in the surgery group had at least mild paravalvular aortic regurgitation (33.3% vs. 6.3%). Repeat hospitalizations were more frequent after TAVR than after surgery (33.3% vs. 25.2%), as were aortic-valve reinterventions (3.2% vs. 0.8%). Improvement in health status at 5 years was similar for TAVR and surgery.

CONCLUSIONS

Among patients with aortic stenosis who were at intermediate surgical risk, there was no significant difference in the incidence of death or disabling stroke at 5 years after TAVR as compared with surgical aortic-valve replacement. (Funded by Edwards Lifesciences; PARTNER 2 ClinicalTrials.gov number, NCT01314313.).

A meta-analysis of 1-year outcomes of transcatheter versus surgical aortic valve replacement in low-risk patients with severe aortic stenosis

Background

Transcatheter aortic valve replacement (TAVR) for the treatment symptomatic severe aortic stenosis (AS) is indicated in patients with intermediate or higher surgical risk. Latest trials showed TAVR, and surgical aortic valve replacement (SAVR) perform similarly at 1-year for the composite outcomes of mortality, stroke and rehospitalization. We performed a comprehensive meta-analysis to compare individual outcomes at 1-year for TAVR compared to SAVR in low-risk patients.

Methods

PubMed, Embase, and Cochrane central were searched for all the randomized controlled trials (RCTs) that reported 1-year comparative outcomes of TAVR and surgical aortic valve replacement (SAVR). Our conclusions are based upon the random-effects model using DerSimonian-Laird estimator.

Results

Data from 4 trials and 2887 randomized patients showed that TAVR had lower rates of all-cause mortality, cardiovascular mortality, and atrial fibrillation compared to SAVR at 1-year follow-up (P < 0.05 for all). Also, TAVR was also associated with a significantly higher risk of permanent pacemaker implantation and moderate-severe paravalvular leak (P < 0.05).

Conclusions

The latest randomised trial data demonstrates that in short-term, TAVR is safe and effective in reducing all-cause mortality or stroke. Longer follow-up of RCTs is needed to determine the durability of clinical benefits in TAVR over SAVR in low-risk patients.

Comparison of Survival of Transfemoral Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement for Aortic Stenosis in Low-Risk Patients Without Coronary Artery Disease

Increasing data support transcatheter aortic valve implantation (TAVI) as a valid option over surgical aortic valve replacement (SAVR) in the treatment for severe aortic stenosis (AS) also in patients with low operative risk. However, limited data exist on the outcome of TAVI and SAVR in low-risk patients without coronary artery disease (CAD). The FinnValve registry included data on 6463 patients who underwent TAVI or SAVR with bioprosthesis between 2008 and 2017. Herein, we evaluated the outcome of low operative risk as defined by STS-PROM score <3% and absence of CAD, previous stroke and other relevant co-morbidities. Only patients who underwent TAVI with third-generation prostheses and SAVR with Perimount Magna Ease or Trifecta prostheses were included in this analysis. The primary endpoints were 30-day and 3-year all-cause mortality. Overall, 1,006 patients (175 TAVI patients and 831 SAVR patients) met the inclusion criteria of this analysis. Propensity score matching resulted in 140 pairs with similar baseline characteristics. Among these matched pairs, 30-day mortality was 2.1% in both TAVI and SAVR cohorts (p = 1.00) and 3-year mortality was 17.0% after TAVI and 14.6% after SAVR (p = 0.805). Lower rates of bleeding and atrial fibrillation, and shorter hospital stay were observed after TAVI. The need of new permanent pacemaker implantation and the incidence of early stroke did not differ between groups. In conclusion, TAVI using third-generation prostheses achieved similar early and mid-term survival compared with SAVR in low-risk patients without CAD.

Relationship Between Hospital Surgical Aortic Valve Replacement Volume and Transcatheter Aortic Valve Replacement Outcomes

OBJECTIVES

The aim of this study was to examine whether hospital surgical aortic valve replacement (SAVR) volume was associated with corresponding transcatheter aortic valve replacement (TAVR) outcomes.

BACKGROUND

Recent studies have demonstrated a volume-outcome relationship for TAVR.

METHODS

In total, 208,400 fee-for-service Medicare beneficiaries were analyzed for all aortic valve replacement procedures from 2012 to 2015. Claims for patients <65 years of age, concomitant coronary artery bypass grafting surgery, other heart valve procedures, or other major open heart procedures were excluded, as were secondary admissions for aortic valve replacement. Hospital SAVR volumes were stratified on the basis of mean annual SAVR procedures during the study period. The primary outcomes were 30-day and 1-year post-operative TAVR survival. Adjusted survival following TAVR was assessed using multivariate Cox regression.

RESULTS

A total of 65,757 SAVR and 42,967 TAVR admissions were evaluated. Among TAVR procedures, 21.7% (n = 9,324) were performed at hospitals with <100 (group 1), 35.6% (n = 15,298) at centers with 100 to 199 (group 2), 22.9% (n = 9,828) at centers with 200 to 299 (group 3), and 19.8% (n = 8,517) at hospitals with ≥300 SAVR cases/year (group 4). Compared with group 4, 30-day TAVR mortality risk-adjusted odds ratios were 1.32 (95% confidence interval: 1.18 to 1.47) for group 1, 1.25 (95% confidence interval: 1.12 to 1.39) for group 2, and 1.08 (95% confidence interval: 0.82 to 1.25) for group 3. These adjusted survival differences in TAVR outcomes persisted at 1 year post-procedure.

CONCLUSIONS

Total hospital SAVR volume appears to be correlated with TAVR outcomes, with higher 30-day and 1-year mortality observed at low-volume centers. These data support the importance of a viable surgical program within the heart team, and the use of minimum SAVR hospital thresholds may be considered as an additional metric for TAVR performance.

Transcatheter aortic valve replacement in low risk patients: a review of PARTNER 3 and Evolut low risk trials

Transcatheter aortic valve replacement (TAVR) has become a mainstay in treatment for patients with severe aortic stenosis who are considered high-risk surgical candidates. The use of TAVR in low-risk patients with severe aortic stenosis is being explored as an alternative to surgical aortic valve replacement (SAVR). Recent results from the Medtronic Evolut Low Risk trial and the Placement of Aortic Transcatheter Valves (PARTNER) 3 trial shed light on the use of TAVR in low-risk surgical candidates. The Evolut Low Risk trial compared TAVR with a self-expanding supra-annular bioprosthesis to SAVR in 1468 patients with severe aortic stenosis who were low surgical risk. Patients with a mean age of 74 and a mean Society of Thoracic Surgeons (STS) risk score of 1.9% were randomized to either TAVR or SAVR groups. Using the composite end point of death or disabling stroke at 24 months, the study found an incidence of 5.3% in the TAVR arm and 6.7% in the surgical arm. The Evolut Low Risk trial thus concluded that TAVR was statistically noninferior but not superior to SAVR (difference, -1.4 percentage points; 95% Bayesian credible interval for the difference, -4.9 to 2.1; posterior probability of noninferiority, >0.999). The PARTNER 3 trial assigned 1,000 patients with severe aortic stenosis and low surgical risk to either TAVR with transfemoral placement of balloon expandable valve or SAVR. Patients with a mean age of 73 and a mean STS score of 1.9% were randomized to either TAVR or SAVR groups. With respect to the primary endpoint of composite death from any cause, stroke, or rehospitalization, the study found an occurrence of 8.5% in TAVR and 15.1% in SAVR, confirming both noninferiority and superiority in the TAVR group [absolute difference, -6.6 percentage points; 95% confidence interval (CI), -10.8 to -2.5; P<0.001 for noninferiority; hazard ratio, 0.54; 95% CI, 0.37 to 0.79; P=0.001 for superiority]. Both the Evolut low risk trial and the PARTNER 3 trial provide evidence that the use of TAVR extends beyond the scope of high and intermediate risk surgical patients and is at the very least equivalent to SAVR in the treatment low-risk surgical candidates when using a transfemoral approach in patients without bicuspid aortic valves. In this article we provide an extensive review on the Evolute low risk and PARTNER 3 trials, including a discussion on clinically relevant outcomes.

Meta-Analysis Comparing Results of Transcatheter Versus Surgical Aortic-Valve Replacement in Patients With Severe Aortic Stenosis

Transcatheter aortic-valve replacement (TAVR) has emerged as a promising strategy for treating patients with severe aortic stenosis. We aimed to compare TAVR with surgical aortic-valve replacement (SAVR) and determine the performance of TAVR over time and within several subgroups. We included 8 randomized trials comparing TAVR versus SAVR. Compared with SAVR, TAVR was associated with a lower rate of all-cause mortality or disabling stroke at 30-day (odds ratio [OR], 0.72; p = 0.004), 1-year (OR, 0.83; p = 0.01), and 2-year (OR, 0.86; p = 0.02), but not at long-term follow-up (rate ratio [RR], 1.02 [confidence interval 0.92 to 1.13]; p = 0.67). Notably, 5-year data showed numerically higher incidence in TAVR (RR, 1.11 [confidence interval 0.97 to 1.27]; p = 0.12). The risks associated with TAVR versus SAVR increased over time, showing a significant interaction (p for interaction = 0.01), as were for new-onset atrial fibrillation and rehospitalization. Incidences of major bleeding, new-onset fibrillation, and acute kidney injury were lower in TAVR, whereas transient ischemic attack, major vascular complications, permanent pacemaker implantation, reintervention, and paravalvular leak were lower in SAVR. Incidences for all-cause and cardiovascular mortality, myocardial infarction, and stroke were not statistically different. TAVR with transfemoral approach and new-generation valve was associated with reduction in all-cause mortality or disabling stroke compared with corresponding comparators. In conclusion, TAVR was associated with a lower risk for all-cause mortality or disabling stroke within 2 years, but not at long-term follow-up compared with SAVR; the risks seems to increase over time. More data are needed to determine longer-term performance of TAVR.

Two-Year Outcomes After Transcatheter Aortic Valve Replacement With Mechanical vs Self-expanding Valves: The REPRISE III Randomized Clinical Trial

Importance

To our knowledge, REPRISE III is the first large randomized comparison of 2 different transcatheter aortic valve replacement platforms: the mechanically expanded Lotus valve (Boston Scientific) and self-expanding CoreValve (Medtronic).

Objective

To evaluate outcomes of Lotus vs CoreValve after 2 years.

Design, Setting, and Participants

A total of 912 patients with high/extreme risk and severe, symptomatic aortic stenosis enrolled between September 22, 2014, and December 24, 2015, were randomized 2:1 to receive Lotus (607 [66.6%]) or CoreValve (305 [33.4%] at 55 centers in North America, Europe, and Australia. The first 2-year visit occurred on October 17, 2016, and the last was conducted on April 12, 2018. Clinical and echocardiographic assessments are complete through 2 years and will continue annually through 5 years.

Main Outcomes and Measures

All-cause mortality and all-cause mortality or disabling stroke at 2 years. Other clinical factors included overall stroke, disabling stroke, repeated procedures, rehospitalization, valve thrombosis, and pacemaker implantation. Echocardiographic analyses included effective orifice area, mean gradient, and paravalvular leaks (PVLs).

Results

Of 912 participants, the mean (SD) age was 82.8 (7.3) years, 465 (51%) were women, and the mean (SD) Society of Thoracic Surgeons predicted risk of mortality was 6.8% (4.0%). At 2 years, all-cause death was 21.3% with Lotus vs 22.5% with CoreValve (hazard ratio [HR], 0.94; 95% CI, 0.69-1.26; P = .67) and all-cause mortality or disabling stroke was 22.8% with Lotus and 27.0% with CoreValve (HR, 0.81; 95% CI, 0.61-1.07; P = .14). Overall stroke was 8.4% vs 11.4% (HR, 0.75; 95% CI, 0.48-1.17; P = .21); disabling stroke was more frequent with CoreValve vs Lotus (4.7% Lotus vs 8.6% CoreValve; HR, 0.53; 95% CI, 0.31-0.93; P = .02). More Lotus patients received a new permanent pacemaker (41.7% vs 26.1%; HR, 1.87; 95% CI, 1.41-2.49; P < .01) or had a valve thrombosis (3.0% vs 0.0%; P < .01) compared with CoreValve. More patients who received CoreValve experienced a repeated procedure (0.6% Lotus vs 2.9% CoreValve; HR, 0.19; 95% CI, 0.05-0.70; P < .01), valve migration (0.0% vs 0.7%; P = .05), or embolization (0.0% vs 2.0%; P < .01) than Lotus. Valve areas remained significantly larger and the mean gradient was lower with CoreValve than Lotus (valve area, mean [SD]: Lotus, 1.53 [0.49] cm2 vs CoreValve, 1.76 [0.51] cm2; P < .01; valve gradient, mean [SD]: Lotus, 13.0 [6.7] mm Hg vs 8.1 [3.7] mm Hg; P < .01). Moderate or greater PVL was more frequent with CoreValve (0.3% Lotus vs 3.8% CoreValve; P < .01) at 2 years. Larger improvements in New York Heart Association (NYHA) functional class were observed with Lotus compared with CoreValve (improved by ≥1 NYHA class: Lotus, 338 of 402 [84.1%] vs CoreValve, 143 of 189 [75.7%]; P = .01; improved by ≥2 NYHA classes: 122 of 402 [37.3%] vs 65 of 305 [21.3%]).

Conclusions and Relevance

After 2 years, all-cause mortality rates, mortality or disabling stroke were similar between Lotus and CoreValve. Disabling stroke, functional class, valve migration, and PVL favored the Lotus arm whereas valve hemodynamics, thrombosis, and new pacemaker implantation favored the CoreValve arm.

Trial Registration

clinicaltrials.gov Identifier: NCT02202434.

Impact of Sapien 3 Balloon-Expandable Versus Evolut R Self-Expandable Transcatheter Aortic Valve Implantation in Patients With Aortic Stenosis

Background:

Two competing transcatheter aortic valve replacement (TAVR) technologies are currently available. Head-to-head comparisons of the relative performances of these 2 devices have been published. However, long-term clinical outcome evaluation remains limited by the number of patients analyzed, in particular, for recent-generation devices.

Methods:

Based on the French administrative hospital-discharge database, the study collected information for all consecutive patients treated with a TAVR device commercialized in France between 2014 and 2018. Propensity score matching was used for the analysis of outcomes during follow-up. The objective of this study was to analyze the outcomes of TAVR according to Sapien 3 balloon-expandable (BE) versus Evolut R self-expanding TAVR technology at a nationwide level in France.

Results:

A total of 31 113 patients treated with either Sapien 3 BE or Evolut R self-expanding TAVR were found in the database. After matching on baseline characteristics, 20 918 patients were analyzed (10 459 in each group with BE or self-expanding valves). During follow-up (mean [SD], 358 [384]; median [interquartile range], 232 [10–599] days), BE TAVR was associated with a lower yearly incidence of all-cause death (relative risk, 0.88; corrected P =0.005), cardiovascular death (relative risk, 0.82; corrected P =0.002), and rehospitalization for heart failure (relative risk, 0.84; corrected P <0.0001). BE TAVR was also associated with lower rates of pacemaker implantation after the procedure (relative risk, 0.72; corrected P <0.0001).

Conclusions:

On the basis of the largest cohort available, we observed that Sapien 3 BE valves were associated with lower rates of all-cause death, cardiovascular death, rehospitalization for heart failure, and pacemaker implantation after a TAVR procedure.

Impact of leaflet thrombosis on hemodynamics and clinical outcomes after bioprosthetic aortic valve replacement: A meta-analysis

BACKGROUND

Leaflet thrombosis (LT, also called cusp thrombosis) detected by multidetector computed tomography (MDCT) is common in bioprosthetic aortic valve replacement (bAVR). However, it remains contradictory whether MDCT-defined LT following bAVR is associated with hemodynamic deterioration and stroke. Thus, we performed the first meta-analysis to assess hemodynamic outcomes and updated the latest researches on the clinical outcomes of MDCT-defined LT after bAVR.

HYPOTHESIS

MDCT-defined LT might be associated with worse hemodynamic and clinical outcomes after bAVR.

METHOD

MEDLINE, EMBASE, Cochrane Library, and ClinicalTrial.gov were searched from inception to 15th April 2019. The fix-effect model was utilized to calculate odds ratio (OR) and 95% confidence interval (CI). The primary outcomes were hemodynamic stability indexes, including mean pressure gradient (MPG), left ventricular ejection fraction (LVEF), paravalvular leak (PVL), and clinical heart failure. The secondary endpoints were major adverse cardiovascular and cerebrovascular events (MACCEs), which consisted of myocardial infarction, all-cause death, stroke, and transient ischemic attack (TIA).

RESULTS

Twelve studies with 4820 patients were included. The total prevalence of MDCT-defined LT was 9.7%. MDCT-defined LT was associated with a significantly increased risk of MPG (inverse variance 0.43, 95% CI: [0.30, 0.57]), MACCEs (OR 2.43, 95% CI: [1.45, 4.06]), stroke (OR 1.79, 95% CI: [1.03, 3.11]), and TIA (OR 4.09, 95% CI: [1.59, 10.54]). There were no differences for other outcomes.

CONCLUSIONS

MDCT-defined LT after bAVR is associated with increased MPG and increased risk of adverse cerebrovascular events, including TIA and stroke. While LVEF, PVL, and clinical heart failure were similar between patient with and without LT.

Infective endocarditis complicating transcatheter aortic valve implantation

Infective endocarditis complicating transcatheter aortic valve implantation (TAVI-IE) is a relatively rare condition with an incidence of 0.2%–3.1% at 1 year post implant. It is frequently caused by Enterococci, Staphylococcus aureus and coagulase negative staphylococci. While the incidence currently appears to be falling, the absolute number of cases is likely to rise substantially as TAVI expands into low risk populations following the publication of the PARTNER 3 and Evolut Low Risk trials. Important risk factors for the development of TAVI-IE include a younger age at implant and significant residual aortic regurgitation. The echocardiographic diagnosis of TAVI-IE can be challenging, and the role of supplementary imaging techniques including multislice computed tomography (MSCT) and positron emission tomography (18FDG PET) is still emerging. Treatment largely parallels that of conventional prosthetic valve endocarditis (PVE), with prolonged intravenous antibiotic therapy and consideration of surgical intervention forming the cornerstones of management. The precise role and timing of cardiac surgery in TAVI-IE is yet to be defined, with a lack of clear evidence to help identify which patients should be offered surgical intervention. Minimising unnecessary healthcare interventions (both during and after TAVI) and utilising appropriate antibiotic prophylaxis may have a role in preventing TAVI-IE, but robust evidence for specific preventative strategies is lacking. Further research is required to better select patients for advanced hybrid imaging, to guide surgical management and to inform prevention in this challenging patient cohort.

Long-term clinical outcome and performance of transcatheter aortic valve replacement with a self-expandable bioprosthesis

Aims 

In the last decade, transcatheter aortic valve (TAV) replacement determined a paradigm shift in the treatment of patients with severe symptomatic aortic stenosis. Data on long-term TAV performance are still limited. We sought to evaluate the clinical and haemodynamic outcomes of the CoreValve self-expandable valve up to 8-year follow-up (FU).

Methods and results 

Nine hundred and ninety inoperable or high-risk patients were treated with the CoreValve TAV in eight Italian Centres from June 2007 to December 2011. The median FU was 4.4 years (interquartile range 1.4–6.7 years). Longest FU reached 11 years. A total of 728 died within 8-year FU (78.3% mortality from Kaplan–Meier curve analysis). A significant functional improvement was observed in the majority of patients and maintained over time, with 79.3% of surviving patients still classified New York Heart Association class ≤ II at 8 years. Echocardiographic data showed that the mean transprosthetic aortic gradient remained substantially unchanged (9 ± 4 mmHg at discharge, 9 ± 5 mmHg at 8 years, P = 0.495). The rate of Grade 0/1 paravalvular leak was consistent during FU with no significant change from post-procedure to FU ≥5 years in paired analysis (P = 0.164). Structural valve deterioration (SVD) and late bioprosthetic valve failure (BVF) were defined according to a modification of the 2017 EAPCI/ESC/EACTS criteria. In cumulative incidence functions at 8 years, moderate and severe SVD were 3.0% [95% confidence interval (CI) 2.1–4.3%] and 1.6% (95% CI 0.6–3.9%), respectively, while late BVF was 2.5% (95% CI 1.2–5%).

Conclusion 

While TAVs are questioned about long-term performance and durability, the results of the present research provide reassuring 8-year evidence on the CoreValve first-generation self-expandable bioprosthesis.

Transcatheter versus surgical aortic valve replacement in low-risk patients: a meta-analysis of randomized trials

BACKGROUND

Transcatheter aortic valve replacement (TAVR) has emerged as a treatment option for severe aortic stenosis in patients at intermediate or high surgical risk. However, until recently there was insufficient evidence regarding the outcomes of TAVR compared to surgical aortic valve replacement (SAVR) for patients at low risk.

METHODS

We conducted a meta-analysis and systematic review of all randomized trials comparing the efficacy and safety of TAVR versus SAVR in patients at low surgical risk. Risk ratios (RR) and 95% confidence intervals (CIs) were calculated, using fixed- or random-effects model.

RESULTS

Four trials were eligible for analysis and comprised a total of 2887 patients (1497 allocated to TAVR and 1390 allocated to SAVR group). TAVR was associated with a 39% relative risk reduction (RRR) of major adverse cardiac events (MACE) (absolute risk reduction ARR of 3.7%; RR 0.61; 95% CI 0.47-0.79); 39% RRR of overall mortality (ARR of 1.4%; RR 0.61; 95% CI 0.39-0.96) and 45% RRR of cardiovascular mortality (ARR of 1.3%; RR 0.55; 95% CI 0.33-0.90), 69% RRR of life threatening or disabling bleeding (ARR of 7.0%; RR 0.31; 95% CI 0.22-0.44), 73% RRR of new-onset atrial fibrillation (ARR of 29%; RR 0.27; 95% CI 0.20-0.35) and 73% RRR of acute kidney injury (ARR of 2.1%; RR 0.27; 95% CI 0.14-0.56) as compared with SAVR. In contrast, TAVR was associated with a 4.7-fold increased risk of new pacemaker (PM) implantation (RR 4.72; 95% CI 1.83-12.15), which was driven by use of self-expanding valves.

CONCLUSION

TAVR in low-risk patients is superior to SAVR for the majority of outcomes.

Postimplant biological aortic prosthesis degeneration: challenges in transcatheter valve implants

Surgical aortic valve replacement (SAVR) is highly effective and can be achieved with relatively low risk in patients with severe aortic stenosis. Bioprostheses have been used most frequently during the past 60 years. However, the function of biological valves usually declines after 10-15 years from implant when structural valve degeneration occurs often mandating a reoperation once valve dysfunction becomes haemodynamically significant. Known for many years by surgeons and cardiologists taking care of patients with SAVR, the issue of postimplant structural valve degeneration has been recently highlighted also in patients with transcatheter aortic valve implant (TAVI). There is growing concern that TAVI valves exhibit structural valve degeneration due to inherent challenges of the deployment mode. The impact on postimplant degeneration of TAVI valves compared to SAVR has still to be understood and defined. Based on the ongoing process of expanding TAVI indications, several potential shortcomings and caveats, learned during the last 60 years of SAVR experience, should be taken into consideration to refine this technique.

Long-Term Functional and Structural Durability of Bioprosthetic Valves Placed in the Aortic Valve Position via Percutaneous Rout in Israel

There is limited organized "real life" data regarding the long-term structural and functional durability of transcatheter aortic valve implants, a topic of major importance. We assessed the 5-year structural and functional integrity outcomes following trans-catheter aortic valve implantation (TAVI) with both self-expandable and balloon-expandable prosthetic valve devices. This study included 450 consecutive patients who underwent TAVI for severe symptomatic aortic stenosis (AS) between September 2008 and December 2011. Data were acquired from a multicenter Israeli registry and the median follow up time was 5.6 years. In 184 patients (40.9%) who survived 5 years, prostheses displayed sustained hemodynamic performance, with average peak and mean aortic valve gradients of 16.2 ± 8.9 and 9.2 ± 6.6 mm Hg, respectively. Late structural valve deterioration was found in 22 (12.3%) patients. Of these, 16 (8.9%) experienced valve deterioration and 6 (3.3%) experienced valve failure. Among the 6 patients with bioprosthetic valve failure, only 3 underwent re-interventions. Bioprosthetic valve dysfunction occurred more frequently in patients with small valves (23 mm) and high peak and mean transvalvular gradients at baseline. In conclusion, a relatively low rate of valve deterioration or failure was noted in our long-term follow-up study after TAVI procedures with both the catheter-based self-expandable and balloon-expandable prosthetic valves.

Transcatheter Aortic Valve Replacement: Procedure and Outcomes

Initially, transcatheter aortic valve replacement (TAVR) was only used in patients with severe symptomatic aortic stenosis and prohibitive risk for surgical aortic valve replacement. Subsequently, TAVR was extended to patients with high and intermediate surgical risk. Recently, the results of randomized trials in low-surgical-risk patients showed superiority or noninferiority of TAVR versus surgical aortic valve replacement in this population. Procedural outcomes have been improved. Long-term durability of transcatheter heart valves remains to be confirmed. This article presents the evolution and current status of TAVR, with respect to the different types of devices and procedures as well as its outcomes.

Meta-analysis of Temporal and Surgical Risk Dependent Associations With Outcomes After Transcatheter Versus Surgical Aortic Valve Implantation

Temporal and surgical risk dependent associations with clinical outcomes in patients receiving transcatheter versus surgical aortic valve implantation (TAVI vs SAVI) are uncertain. In this meta-analysis, 7 randomized controlled trials (7,771 patients) were included to investigate trends in outcomes in TAVI versus SAVI up to 5 years, and variation in outcomes with respect to low-, intermediate-, and high-surgical risk of the patients up to 1 year. Estimates were calculated as random effects hazard ratios (HRs) with 95% confidence intervals (CI). All-cause mortality was similar in TAVI and SAVI at 30 days (HR 0.81, 95% CI 0.55 to 1.21, p = 0.31), 1 year (HR 0.97, 95% CI 0.89 to 1.06, p = 0.49), 2 years (HR 0.96, 95 CI 0.85 to 1.09, p = 0.54), and 5 years (HR 1.04, 95% CI 0.89 to 1.21, p = 0.62). Cardiac mortality, myocardial infarction and stroke were similar in both interventions up to 5 years. TAVI was associated with lower risk of atrial fibrillation, but higher risk of vascular complications, pacemaker implantation, and paravalvular leak up to 5 years. The lower risks of major bleeding and acute kidney injury with TAVI versus SAVI were limited to 1 and 2 years, respectively. Compared with SAVI, TAVI was superior in reducing all-cause mortality in low surgical risk patients at 30 days only, whereas TAVI was noninferior to SAVI in intermediate- and high-risk patients at 30 days and across all risks at 1 year. In conclusion, TAVI was noninferior to SAVI in terms of mortality, myocardial infarction, and stroke up to 5 years. TAVI improved survival versus SAVI in low-risk patients at 30 days.

Infective Endocarditis Following Transcatheter Aortic Valve Replacement: Comparison of Balloon- Versus Self-Expandable Valves

BACKGROUND

No data exist about the characteristics of infective endocarditis (IE) post-transcatheter aortic valve replacement (TAVR) according to transcatheter valve type. We aimed to determine the incidence, clinical characteristics, and outcomes of patients with IE post-TAVR treated with balloon-expandable valve (BEV) versus self-expanding valve (SEV) systems.

METHODS

Data from the multicenter Infectious Endocarditis After TAVR International Registry was used to compare IE patients with BEV versus SEV.

RESULTS

A total of 245 patients with IE post-TAVR were included (SEV, 47%; BEV, 53%). The timing between TAVR and IE was similar between groups (SEV, 5.5 [1.2-15] months versus BEV, 5.3 [1.7-11.4] months; P=0.89). Enterococcal IE was more frequent in the SEV group (36.5% versus 15.4%; P<0.01), and vegetation location differed according to valve type (stent frame, SEV, 18.6%; BEV, 6.9%; P=0.01; valve leaflet, SEV, 23.9%; BEV, 38.5%; P=0.01). BEV recipients had a higher rate of stroke/systemic embolism (20.0% versus 8.7%, adjusted OR: 2.46, 95% CI: 1.04-5.82, P=0.04). Surgical explant of the transcatheter valve (SEV, 8.7%; BEV, 13.8%; P=0.21), and in-hospital death at the time of IE episode (SEV, 35.6%; BEV, 37.7%; P=0.74) were similar between groups. After a mean follow-up of 13±12 months, 59.1% and 54.6% of the SEV and BEV recipients, respectively, had died (P=0.66).

CONCLUSIONS

The characteristics of IE post-TAVR, including microorganism type, vegetation location, and embolic complications but not early or late mortality, differed according to valve type. These results may help to guide the diagnosis and management of IE and inform future research studies in the field.

Antithrombotic therapy and bleeding events after aortic valve replacement with a novel bioprosthesis

OBJECTIVE

Several recent-generation surgical tissue valves have been found to have bleeding rates exceeding rates recommended by regulatory bodies. We explored bleeding events using data from the Pericardial Surgical Aortic Valve Replacement (PERIGON) Pivotal Trial for the Avalus valve (Medtronic, Minneapolis, Minn) to examine whether this end point remains relevant for the evaluation of bioprostheses.

METHODS

Patients (n = 1115) underwent aortic valve replacement. Bleeding and thromboembolic event episodes in patients within 3 years postimplant were analyzed for frequency, timing, and severity, focusing on patients taking antiplatelet/anticoagulant medications at the time of the event. Clinical and hemodynamic outcomes are also reported.

RESULTS

At 3 years, the Kaplan-Meier cumulative probability estimate of all-cause death was 7.2% (cardiac, 3.6%; valve-related, 1.1%). The Kaplan-Meier cumulative probability estimates of all and major hemorrhage were 8.7% and 5.2%, respectively. Ninety-nine bleeding events occurred in 86 patients: most occurred >30 days postsurgery. Among the 51 late major bleeds, in 5 cases the patients were taking anticoagulant/antiplatelet medication for prophylaxis after surgical aortic valve replacement at the time of the event, whereas the remaining patients were taking medications for other reasons. Age (hazard ratio, 1.035; 95% confidence interval, 1.004-1.068), peripheral vascular disease (hazard ratio, 2.135; 95% confidence interval, 1.106-4.122), renal dysfunction (hazard ratio, 1.920; 95% confidence interval, 1.055-3.494), and antithrombotic medication use at the time of the event (hazard ratio, 1.417; 95% confidence interval, 1.048-1.915) were associated with late bleeds (major and minor).

CONCLUSIONS

Overall clinical outcomes demonstrated low mortality and few complications except for major bleeding. Most bleeding events occurred >30 days after surgery and in patients taking antiplatelet and/or anticoagulation for indications other than postimplant prophylaxis.

Advances in transcatheter aortic valve replacement

Evidence in transcatheter aortic valve replacement (TAVR) has accumulated rapidly over the last few years and its application to clinical decision making are becoming more important. In this review, we discuss the advances in TAVR for patient selection, expanding indications, complications, and emerging technologies.

A meta-analysis of ≥5-year mortality after transcatheter versus surgical aortic valve replacement

INTRODUCTION

It remains unclear whether long-term survival is superior following transcatheter aortic valve implantation (TAVI) than following surgical aortic valve replacement (SAVR). We performed a meta-analysis of mortality with ≥5-year follow-up in randomized controlled trials (RCTs) and propensity-score matched (PSM) studies of TAVI versus SAVR.

EVIDENCE ACQUISITION

MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched through March 2019. Eligible studies were RCTs or PSM studies of TAVI versus SAVR enrolling patients with severe aortic stenosis and reporting all-cause mortality with ≥5-year follow-up as an outcome. A hazard ratio of mortality for TAVI versus SAVR was extracted from each individual study.

EVIDENCE SYNTHESIS

Our search identified 3 RCTs and 7 PSM studies enrolling 5498 patients. A pooled analysis of all 10 studies demonstrated a statistically significant 38% increase in mortality with TAVI relative to SAVR. A subgroup meta-analysis showed no statistically significant difference between TAVI and AVR in RCTs and a statistically significant 68% increase with TAVI relative to SAVR in PSM studies.

CONCLUSIONS

On the basis of a meta-analysis of 7 PSM studies, TAVI is associated with greater all-cause mortality with ≥5-year follow-up than SAVR. However, another meta-analysis of 3 RCTs suggests no difference in mortality between TAVI and SAVR.

Meta-Analysis Comparing Transcatheter Aortic Valve Implantation With Balloon Versus Self-Expandable Valves

Two transcatheter aortic valve systems are currently in use in the United States; balloon-expandable valves (BEV) and the self-expanding valve (SEV). However, comparative data outcomes between the 2 systems are limited, as only one randomized trial (RCT) performed a head-to-head comparison between BEVs and SEVs. However, there are several RCTs comparing BEV or SEV to surgical valve replacement. In this analysis, we used Bayesian network meta-analysis techniques to compare BEVs and SEVs. The primary outcome was all-cause mortality at maximum follow-up. Secondary outcomes were cardiovascular mortality, stroke, pacemaker implantation, reintervention, heart failure hospitalization, and moderate-severe paravalvular leak (PVL.). Eight RCTs with 8,095 patients were included. With the exception of less pacemaker implantation in BEV versus SEV (odds ratio [OR] 0.29, 95% confidence interval [CI] 0.11 to 0.77, I² = 51%), there was no difference between BEV and SEV in 30-day outcomes. During long-term follow-up (mean 3 ± 2 years); there was no difference between BEV and SEV in all-cause mortality (hazard ratio [HR] 1.1, 95% CI 0.87 to 1.5, I² = 19.6%), cardiovascular mortality (HR 1.1, 95% CI 0.73 to 1.6, I² = 18.5%), stroke (HR 1.3, 95% CI 0.73 to 2.1, I² = 16.9%), hospitalization (HR 0.87, 95% CI 0.41 to 1.6, I² = 62%), and reintervention (HR 0.68, 95% CI 0.2 to 2.3, I² = 62%). New pacemaker implantation and PVL were significantly less in BEV group (HR 0.45, 95% CI 0.24 to 0.80, I² = 38.2%), and (HR 0.03, 95% CI 0.0004 to 0.28, I² = 79%), respectively. In conclusion, similar outcomes were seen following transcatheter aortic valve implantation with BEV and SEV with the exception of higher rates of pacemaker implantation and PVL in SEV group.

TAVI and the future of aortic valve replacement

Aortic valve stenosis (AS) is the most common valvular pathology and has traditionally been managed using surgical aortic valve replacement (SAVR). A large proportion of affected patient demographics, however, are unfit to undergo major surgery given underlying comorbidities. Since its introduction in 2002, transcatheter aortic valve implantation (TAVI) has gained popularity and transformed the care available to different-risk group patients with severe symptomatic AS. Specific qualifying criteria and refinement of TAVI techniques are fundamental in determining successful outcomes for intervention. Given the successful applicability in high-risk patients, TAVI has been further developed and trialed in intermediate and low-risk patients. Within intermediate-risk patient groups, TAVI was shown to be noninferior to SAVR evaluating 30-d mortality and secondary endpoints such as the risk of bleeding, development of acute kidney injury, and length of admission. The feasibility of expanding TAVI procedures into low-risk patients is still a controversial topic in the literature. A number of trials have recently been published which demonstrate TAVI as noninferior and even superior over SAVR for primary study endpoints.

Transcatheter Bioprosthetic Aortic Valve Dysfunction: What We Know So Far

Transcatheter aortic valve replacement (TAVR) is an established alternative to surgical valve replacement for patients with severe aortic stenosis (AS) and increased surgical risk. On the basis of the favorable outcomes of recent randomized clinical trials conducted in intermediate and low risk populations, TAVR is expected in the near future to be offered to patients not only at lower surgical risk, but also with longer life expectancy. In this particular subset, the long-term durability of the bioprosthetic valve is of critical importance. The European Association of Percutaneous Cardiovascular Interventions (EAPCI), the European Society of Cardiology (ESC), and the European Association for Cardio-Thoracic Surgery (EACTS) recently introduced standardized criteria to define structural valve deterioration (SVD) and valve failure of transcatheter and surgical aortic bioprosthesis-this with the aim to generate uniformity in data reporting in future studies assessing long-term durability of aortic bioprosthesis. On this background, the aim of this article is to review the definition, incidence and predictors of transcatheter bioprosthetic valve dysfunction, including structural and non-structural valve deterioration (SVD/NSVD), valve thrombosis, and endocarditis.

Comparison of Clinical and Echocardiographic Outcomes After Transcatheter Aortic Valve Implantation With 31-mm CoreValve Versus 34-mm Evolut R Bioprostheses from the STS/ACC TVT Registry

Transcatheter aortic valve implantation with a bioprosthetic valve of insufficient size is associated with a higher risk of aortic regurgitation (AR). The 31-mm CoreValve and the next generation 34-mm Evolut R bioprostheses were designed to address the need for larger diameter aortic annuli. This analysis examined the clinical and hemodynamic outcomes following commercial transcatheter aortic valve implantation with the 31-mm CoreValve and 34-mm Evolut R in the Society of Thoracic Surgeons/the American College of Cardiology Transcatheter Valve Therapy Registry. Patients receiving a 31-mm CoreValve or 34-mm Evolut R valve for symptomatic severe native aortic stenosis from January 2014 to September 2017 in the Transcatheter Valve Therapy Registry underwent propensity score matching using baseline demographics, clinical and frailty measures, and procedural variables. Procedural characteristics, in-hospital and 30-day clinical and echocardiographic outcomes were compared. Of 4545 patients implanted with a 31-mm CoreValve and 3036 patients with a 34-mm Evolut R valve, matching resulted in 1813 patient sets. Most patients were male (>92%), elderly (∼80 years) with the Society of Thoracic Surgeons score of 6.6%. Use of the 34-mm versus 31-mm valve resulted in shorter median procedural time (113.0 [85.0, 150.0] vs 93.0 [71.0, 126.0] min, p <0.001), higher device success (98.1% vs 93.9%, p <0.001), fewer pacemakers (16.7% vs 24.6%, p <0.001), less ≥moderate AR with the 34-mm (5.5% vs 13.7%), p <0.001) and shorter hospital stay (3.0 [2.0, 4.0] vs 4.0 [3.0, 6.0] days, p <0.001). In conclusion, this largest experience with the 34-mm Evolut R valve showed higher device success, reduced hospital stay, lower pacemaker rates and less ≥moderate AR compared with the 31-mm CoreValve bioprosthesis.

Durability and Clinical Outcomes of Transcatheter Aortic Valve Replacement for Failed Surgical Bioprostheses

Background:

Valve-in-valve transcatheter aortic valve replacement (TAVR) is an option when a surgical valve demonstrates deterioration and dysfunction. This study reports 3-year results following valve-in-valve with self-expanding TAVR.

Methods:

The CoreValve US Expanded Use Study is a prospective, nonrandomized, single-arm study that evaluates safety and effectiveness of TAVR in extreme risk patients with symptomatic failed surgical biologic aortic valves. Study end points include all-cause mortality, need for valve reintervention, hemodynamic changes over time, and quality of life through 3 years. Patients were stratified by presence of preexisting surgical valve prosthesis-patient mismatch.

Results:

From March 2013 to May 2015, 226 patients deemed extreme risk (STS-PROM [Society of Thoracic Surgeons Predicted Risk of Mortality] 9.0±7%) had attempted valve-in-valve TAVR. Preexisting surgical valve prosthesis-patient mismatch was present in 47.2% of the cohort. At 3 years, all-cause mortality or major stroke was 28.6%, and 93% of patients were in New York Heart Association I or II heart failure. Valve performance was maintained over 3 years with low valve reintervention rates (4.4%), an improvement in effective orifice area over time and a 2.7% rate of severe structural valve deterioration. Preexisting severe prosthesis-patient mismatch was not associated with 3-year mortality but was associated with significantly less improvement in quality of life at 3-year follow-up ( P =0.01).

Conclusions:

Self-expanding TAVR in patients with failed surgical bioprostheses at extreme risk for surgery was associated with durable hemodynamics and excellent clinical outcomes. Preexisting surgical valve prosthesis-patient mismatch was not associated with mortality but did limit patient improvement in quality of life over 3-year follow-up.

Clinical Trial Registration:

URL: http://www.clinicaltrials.gov . Unique identifier: NCT01675440.

Transcatheter aortic valve replacement versus surgery for symptomatic severe aortic stenosis: A reconstructed individual patient data meta-analysis

OBJECTIVES

We wished to undertake a reconstructed individual patient data meta-analysis of randomized clinical trials comparing transcatheter aortic valve replacement (TAVR) and surgery for patients with severe symptomatic aortic stenosis.

BACKGROUND

TAVR and surgery are both well-established methods for treating patients with symptomatic severe aortic stenosis who are at low, intermediate, and high risk for surgery.

METHODS

Data were identified by searches of Medline, Embase, CENTRAL and ClinicalTrials.gov for all randomized clinical trials, which compared TAVR and surgery that had published at least 1 year of follow-up. Individual patient data were reconstructed from Kaplan-Meier curves.

RESULTS

A total of 7,770 patients from seven randomized clinical trials were included in this meta-analysis. At 1 year, TAVR was associated with a lower risk of death from any cause (hazard ratio [HR], 0.85, 95% confidence interval [CI], 0.73-0.98; p = .03), disabling stroke (HR, 0.71; 95% CI, 0.54-0.93; p = .01) and the composite end point of death or disabling stroke (HR, 0.79; 95% CI, 0.67-0.92; p = .002). Significant interactions were found for access suitability, with TAVR associated with a lower risk of these end points in patients suitable for transfemoral access. TAVR was associated with a lower risk of periprocedural events, whereas the risk of late events was similar between TAVR and surgery.

CONCLUSIONS

At 1 year, TAVR was associated with a lower risk of death, disabling stroke and the composite end point, when compared with surgery. These associations were strongest within the subgroup of patients in whom transfemoral access was feasible.