Early clinical and echocardiographic outcomes after SAPIEN 3 transcatheter aortic valve replacement in inoperable, high-risk and intermediate-risk patients with aortic stenosis

SOURCE 3 Registry

Background:

The SOURCE 3 Registry (SAPIEN Aortic Bioprosthesis European Outcome) is a European multicenter, observational registry of the latest generation of transcatheter heart valve, the SAPIEN 3 (Edwards Lifesciences, Irvine, CA). Its purpose is to document outcomes of clinical safety and performance after European approval was given.

Methods:

Here, we present the 30-day outcome of the SOURCE 3 Registry. All data are self-reported, and all participating centers have committed to support their consecutive experience with the SAPIEN 3 transcatheter heart valve, dependent on patient consent, before the start of the study. Adverse events are defined with Valve Academic Research Consortium 2 criteria and adjudicated by an independent clinical events committee.

Results:

A total of 1950 patients from 80 centers in 10 countries were enrolled between July 2014 and October 2015. Of those, 1947 patients underwent transcatheter aortic valve implantation (TAVI) with the SAPIEN 3 (mean age, 81.6±6.6 years; 48.1% female). Main comorbidities included coronary artery disease (51.5%), renal insufficiency (27.4%), diabetes mellitus (29.5%), chronic obstructive pulmonary disease (16.0%), and a mean logistic EuroSCORE of 18.3±13.2. Transfemoral access was used in 87.1% (n=1695); nontransfemoral, in 252 patients. Conscious sedation was used in 59.9% of transfemoral procedures, and in 50% of patients, TAVI was performed without aortic balloon valvuloplasty. Implantation success (1 valve in the intended location) was 98.3%. Conversion to conventional surgery (0.6%) and use of cardiopulmonary bypass (0.7%) were rare. Adverse events were low, with site-reported 30-day all-cause mortality of 2.2%, cardiovascular mortality of 1.1%, stroke of 1.4%, major vascular complications of 4.1%, life-threatening bleeding of 5%, and post-TAVI pacemaker implantation of 12%. Moderate or greater paravalvular regurgitation was observed in 3.1% of reporting patients.

Conclusions:

Results from the SOURCE 3 Registry demonstrate contemporary European trends and good outcomes of TAVI in daily practice when this third-generation TAVI device is used.

Sex-Related Differences in the Physiology, Risk, and Outcomes of Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) is a less-invasive alternative to surgical aortic valve replacement (SAVR) for the management of symptomatic severe aortic stenosis in patients with inoperable, high, or intermediate surgical risk. Females undergoing TAVR exhibit distinct physiology and baseline characteristics from their male counterparts. Although rates of procedural complications are higher, medium-term survival appears better for females than males. These sex-based differences are discussed in depth in this review of TAVR in the female population.

Predictors of Paravalvular Regurgitation After Transcatheter Aortic Valve Implantation for Aortic Stenosis Using New-Generation Balloon-Expandable SAPIEN 3

Paravalvular regurgitation (PVR) is a common and serious complication after transcatheter aortic valve implantation (TAVI). New-generation balloon-expandable SAPIEN 3 has an outer sealing skirt to minimize PVR. However, the predictors of PVR after SAPIEN 3 transcatheter heart valve (THV) implantation have not been well investigated. We sought to clarify the determinants of PVR after TAVI using SAPIEN 3 with quantitative multidetector computed tomography (MDCT) assessment. This study analyzed 281 patients with severe symptomatic aortic stenosis who underwent TAVI using SAPIEN 3. Quantitative assessment of aortic root dimensions and calcium volume for leaflet, annulus, and left ventricular outflow tract were retrospectively performed with MDCT. MDCT nominal area oversizing was calculated using the following formula: % oversizing = (THV nominal area/MDCT derived annular area - 1) × 100. Logistic regression analysis was performed to determine the predictors of PVR greater than or equal to mild. PVR greater than or equal to mild was observed in 19% (53 of 281). Quantity and asymmetry of aortic valve calcium of annulus, left ventricular outflow tract, and leaflet were associated with higher incidence of PVR greater than or equal to mild, except leaflet asymmetry. Lower percentage of THV oversizing was also associated with PVR. Multivariable logistic regression analysis showed that larger calcification volume of annulus and lower percentage of THV oversizing were independent predictors of PVR greater than or equal to mild. These results suggest that prosthesis/annulus incongruence and aortic annulus calcification predicted PVR greater than or equal to mild after TAVI using SAPIEN 3.

Transcaval Access and Closure for Transcatheter Aortic Valve Replacement: A Prospective Investigation

BACKGROUND

Transcaval access may enable fully percutaneous transcatheter aortic valve replacement (TAVR) without the hazards and discomfort of transthoracic (transapical or transaortic) access.

OBJECTIVES

The authors performed a prospective, independently adjudicated, multicenter, single-arm trial of transcaval access for TAVR in patients who were ineligible for femoral artery access and had high or prohibitive risk of complications from transthoracic access.

METHODS

A total of 100 patients underwent attempted percutaneous transcaval access to the abdominal aorta by electrifying a caval guidewire and advancing it into a pre-positioned aortic snare. After exchanging for a rigid guidewire, conventional TAVR was performed through transcaval introducer sheaths. Transcaval access ports were closed with nitinol cardiac occluders. A core laboratory analyzed pre-discharge and 30-day abdominal computed tomograms. The Society of Thoracic Surgeons predicted risk of mortality was 9.6 ± 6.3%.

RESULTS

Transcaval access was successful in 99 of 100 patients. Device success (access and closure with a nitinol cardiac occluder without death or emergency surgical rescue) occurred 98 of 99 patients; 1 subject had closure with a covered stent. Inpatient survival was 96%, and 30-day survival was 92%. Second Valve Academic Research Consortium (VARC-2) life-threatening bleeding and modified VARC-2 major vascular complications possibly related to transcaval access were 7% and 13%, respectively. Median length of stay was 4 days (range 2 to 6 days). There were no vascular complications after discharge.

CONCLUSIONS

Transcaval access enabled TAVR in patients who were not good candidates for transthoracic access. Bleeding and vascular complications, using permeable nitinol cardiac occluders to close the access ports, were common but acceptable in this high-risk cohort. Transcaval access should be investigated in patients who are eligible for transthoracic access. Purpose-built closure devices are in development that may simplify the procedure and reduce bleeding. (Transcaval Access for Transcatheter Aortic Valve Replacement in People With No Good Options for Aortic Access; NCT02280824).

Clinical Outcomes and Bioprosthetic Valve Function After Transcatheter Aortic Valve Implantation Under Dual Antiplatelet Therapy vs. Aspirin Alone

BACKGROUND

Dual antiplatelet therapy (DAPT) is commonly used after transcatheter aortic valve implantation (TAVI); however, the supporting evidence is limited. To determine if aspirin alone is a better alternative to DAPT, we compared the outcomes of patients treated with DAPT or aspirin alone after TAVI.Methods and Results:We analyzed a total of 144 consecutive patients (92 females, mean age 83±6 years) who underwent implantation of a balloon-expandable transcatheter valve (SAPIEN or SAPIEN XT, Edwards Lifesciences). Patients were divided into DAPT (n=66) or aspirin-alone treatment groups (n=78). At 1 year after TAVI, the composite endpoint, which consisted of all-cause death, myocardial infarction, stroke, and major or life-threatening bleeding complications, occurred significantly less frequently (Kaplan-Meier analysis) in the aspirin-alone group (15.4%) than in the DAPT group (30.3%; P=0.031). Valve function assessed by echocardiography was similar between the 2 treatment groups with respect to effective orifice area (1.78±0.43 cm²in DAPT vs. 1.91±0.46 cm²in aspirin-alone group; P=0.13) and transvalvular pressure gradient (11.1±3.5 mmHg in DAPT vs. 10.3±4.1 mmHg in aspirin-alone group; P=0.31).

CONCLUSIONS

Treatment with aspirin alone after TAVI had greater safety benefits and was associated with similar valve function as DAPT. These results suggest that treatment with aspirin alone is an acceptable regimen for TAVI patients.

Transcatheter Versus Surgical Aortic Valve Replacement in Patients With Lower Surgical Risk Scores: A Systematic Review and Meta-Analysis of Early Outcomes

BACKGROUND

The results from the PARTNER 2 trial showed the feasibility of transcatheter aortic valve replacement (TAVR) in intermediate surgical risk patients. Although low risk clinical trials will take time to conclude, some data has emerged comparing TAVR with surgical aortic valve replacement (SAVR) in lower risk patients.

METHODS

A Medline search was conducted using standard methodology to search for studies reporting results comparing TAVR and SAVR. Studies were included if the overall mean Society of Thoracic Surgeons Score was less than 4% (or equivalent Euroscore). A meta-analysis comparing the 30-day risk of clinical outcomes between TAVR and SAVR in the lower surgical risk population was conducted.

RESULTS

A total of four studies, including one clinical trial and three propensity-matched cohort studies met the inclusion criteria. Compared to SAVR, TAVR had a lower risk of 30-day mortality (RR 0.67, 95% CI 0.41, 1.10), stroke (RR 0.60, 95% CI 0.30, 1.22), bleeding complications (RR 0.51, 95% CI 0.40, 0.67) and acute kidney injury (RR 0.66, 95% CI 0.47, 0.94). However, a higher risk of vascular complications (RR 11.72, 95% CI 3.75, 36.64), moderate or severe paravalvular leak (RR 5.04, 95% CI 3.01, 8.43), and permanent pacemaker implantations (RR 4.62, 95% CI 2.63, 8.12) was noted for TAVR.

CONCLUSION

Among lower risk patients, TAVR and SAVR appear to be comparable in short term outcomes. Additional high quality studies among patients classified as low risk are needed to further explore the feasibility of TAVR in all surgical risk patients.

Late Paravalvular Aortic Regurgitation: Migration of the Valve or Late Recoil?

A 79-year-old man underwent trans-catheter aortic valve replacement for symptomatic severe aortic stenosis with a 26-mm Edwards SAPIEN XT valve. Immediately after valve deployment there was moderate amount of paravalvular leak. Post-dilation was performed with an additional 2 cc of volume, and the paravalvular leak was reduced to trace. Nine months later, trans-thoracic echocardiography revealed moderate to severe paravalvular leak and possible aortic migration of the valve. The patient was brought back for the treatment of the paravalvular leak which was suspected to be due to valve migration. However, fluoroscopy and trans-esophageal echocardiography showed good valve position. Measurement of late valve recoil in the Coplanar view using cine-angiographic analysis software showed that the lower third of the valve had the greatest late recoil (-1.74 mm, 6.55%), which presumably accounted for the progression of the paravalvular leak. Valve-in-valve trans-catheter aortic valve replacement was performed with a 26-mm SAPIEN 3 valve and the paravalvular leak was reduced to trace. This case displays late recoil as a likely mechanism for development of paravalvular leak after SAPIEN XT valve implantation. Our case illustrates that late recoil needs to be systematically evaluated in future studies, especially when trans-catheter aortic valve replacement is being expanded to lower risk and younger patients for whom the longevity and long-term performance of these valves is of critical importance.

A Glimpse into the Future: In 2020, Which Patients will Undergo TAVI or SAVR?

Transcatheter aortic valve implantation (TAVI) has evolved into a safe and effective procedure to treat symptomatic patients with severe aortic stenosis (AS), with predictable and reproducible results. Rates of important complications such as vascular complications, strokes and paravalvular leaks are lower than ever, because of improved patient selection, systematic use of multidector computer tomography, increasing operator experience and device iteration. Accumulating data suggest that transfemoral TAVI with newer generation transcatheter heart valves and delivery systems is superior to conventional surgical aortic valve replacement among intermediate- and high-risk patients with severe symptomatic AS with regard to all-cause mortality and stroke. One can anticipate that by 2020, the majority of patients with severe symptomatic AS will undergo TAVI as first line therapy, regardless of surgical risk.

Impact of Methodologic Differences in Three-Dimensional Echocardiographic Measurements of the Aortic Annulus Compared with Computed Tomographic Angiography Before Transcatheter Aortic Valve Replacement

BACKGROUND

Three-dimensional (3D) echocardiographic (3DE) imaging is an alternative to multi-detector row computed tomography (MDCT) for aortic annular measurement before transcatheter aortic valve replacement (TAVR). A commonly used direct planimetry from a reconstructed short-axis view has not been compared with semiautomated 3DE methods. Typically accepted optimal cutoffs for percent prosthesis-area oversizing of the balloon-expandable SAPIEN or SAPIEN XT valve to native annular size are approximately 5% to 15%. The aim of this study was to compare semiautomated and direct planimetric 3DE methods for aortic annular sizing with a gold standard of MDCT to determine predictive value for paravalvular regurgitation (PVR) and balloon postdilatation.

METHODS

In this retrospective analysis, aortic annular cross-sectional area was measured from pre-TAVR imaging using (1) MDCT (CT_Area), (2) a 3D transesophageal echocardiographic (TEE) semiautomated method (3DE_Area_SA), and (3) a 3D TEE direct planimetric method (3DE_Area_Direct). Annular area percent oversizing was calculated. PVR after TAVR was assessed from intraoperative TEE imaging. Need for balloon postdilatation was recorded.

RESULTS

One hundred patients who underwent TAVR with either the SAPIEN or SAPIEN XT balloon-expandable prosthesis were analyzed. Twenty-three patients had mild or greater PVR after TAVR. CT_Area was 442 ± 79 mm², 3DE_Area_SA was 435 ± 81 mm², and 3DE_Area_Direct was 429 ± 82 mm². Both 3DE_Area_SA and 3DE_Area_Direct underestimated MDCT (P < .05). All methods were highly correlative (R = 0.88-0.93, P < .0001). Percent oversizing obtained by the three methods significantly predicted mild or greater PVR and need for balloon postdilatation by receiver operating characteristic analysis, with optimal cutoffs for CT_Area (9%-10%) and 3DE_Area_SA (14%) within the recommended ranges for the studied transcatheter valves and for 3DE_Area_Direct higher than the recommended range (18%-19%). Inter- and intraobserver reproducibility were lowest for 3DE_Area_Direct.

CONCLUSIONS

Caution must be used when using 3D TEE direct planimetry of the aortic annulus, as optimal percent oversizing ranges approach the level associated with root injury, and measurements are less reproducible. Therefore, semiautomated 3DE planimetry is preferred to 3DE direct planimetry for aortic annulus sizing.

Role of echocardiography for catheter-based management of valvular heart disease

Catheter-based treatment of valvular heart disease, such as transvalvular aortic valve replacement (TAVR) or mitral clip procedure, has been increasingly accepted as a treatment choice for the past several years. Such new treatment options have been changing the management of patients with valvular heart disease drastically while socio-economic factors regarding their application need to be taken into consideration. The use of echocardiography, including transesophageal echocardiography (TEE), for such catheter-based treatments is essential for the success of the procedures. Severe hypotension after TAVR is a life-threatening emergency. Rapid assessment and diagnosis in the catheterization or hybrid laboratory is essential for safety and a positive outcome. Possible diagnoses in this critical situation would include severe left ventricular dysfunction due to coronary obstruction, cardiac tamponade, aortic rupture, acute severe aortic and/or mitral valve regurgitation, and hypovolemia due to bleeding. Although new types of TAVR valves reduce para-valvular aortic regurgitation (AR) significantly, it is still important to judge the severity of para-valvular AR correctly in the laboratory. As for mitral clip procedure, TEE is vital for guiding and monitoring the entire process. Accurate identification of the location and the geometry of the regurgitant orifice is necessary for proper placement of the clip. Real-time 3D TEE provides helpful en face view of the mitral valve and clip together to this end. Residual mitral regurgitation (MR) after the first clip is not uncommon. Quick and precise imaging of the residual MR (location and severity) with TEE is extremely important for the interventionist to place the second clip and possibly third clip properly. After the completion of the clip procedure, mitral valve stenosis and also iatrogenic atrial septal defect need to be checked by TEE. Echocardiography, especially TEE, is also vital for the success of other newer trans-catheter procedures such as device closure of para-valvular MR of the artificial valve, valve in valve procedure, and native valve replacement.

Frequency of and Prognostic Significance of Atrial Fibrillation in Patients Undergoing Transcatheter Aortic Valve Implantation

The prognostic implications of preexisting atrial fibrillation (AF) and new-onset AF (NOAF) in transcatheter aortic valve implantation (TAVI) remain uncertain. This study assesses the epidemiology of AF in patients treated with TAVI and evaluates their outcomes according to the presence of preexisting AF or NOAF. A retrospective analysis of 708 patients undergoing TAVI from 2 heart hospitals was performed. Patients were divided into 3 study groups: sinus rhythm (n = 423), preexisting AF (n = 219), and NOAF (n = 66). Primary outcomes of interest were all-cause death and stroke both at 30-day and at 1-year follow-up. Preexisting AF was present in 30.9% of our study population, whereas NOAF was observed in 9.3% of patients after TAVI. AF and NOAF patients showed a higher rate of 1-year all-cause mortality compared with patients in sinus rhythm (14.6% vs 6.5% for preexisting AF and 16.3% vs 6.5% for NOAF, p = 0.007). No differences in 30-day mortality were observed between groups. In patients with AF (either preexisting and new-onset), those discharged with single antiplatelet therapy displayed higher mortality rates at 1 year (42.9% vs 11.7%, p = 0.006). Preexisting AF remained an independent predictor of mortality at 1-year follow-up (hazard ratio [HR] 2.34, 95% CI 1.22 to 4.48, p = 0.010). Independent predictors of NOAF were transapical and transaortic approach as well as balloon postdilatation (HR 3.48, 95% CI 1.66 to 7.29, p = 0.001; HR 5.08, 95% CI 2.08 to 12.39, p <0.001; HR 2.76, 95% CI 1.25 to 6.08, p = 0.012, respectively). In conclusion, preexisting AF is common in patients undergoing TAVI and is associated with a twofold increased risk of 1-year mortality. This negative effect is most pronounced in patients discharged with single antiplatelet therapy compared with other antithrombotic regimens.

Time to Explore Transcatheter Aortic Valve Replacement in Younger, Low-Risk Patients

During the last decade transcatheter aortic valve replacement (TAVR) has been established as a treatment for patients with severe aortic stenosis, who are at particularly high surgical risk. As compared with surgical aortic valve replacement (SAVR), TAVR has been associated with lower early risk of mortality, atrial fibrillation, acute kidney injury, and bleeding. Furthermore, device and periprocedural improvements have addressed most of the initial limitations for TAVR, including the Achilles' heel, paravalvular leakage. Supported by this as well as preliminary data among lower-risk patients, TAVR is currently being evaluated in prospective randomized trials against SAVR in younger low-risk patients. Although durability of the TAVR device may be of concern in younger patients given their longer life expectancy, intermediate-term controlled data does not reveal any difference between TAVR and SAVR devices.

Transcatheter versus surgical aortic valve replacement in patients with severe aortic stenosis at low and intermediate risk: systematic review and meta-analysis

OBJECTIVE

 To examine the effect of transcatheter aortic valve implantation (TAVI) versus surgical replacement of an aortic valve (SAVR) in patients with severe aortic stenosis at low and intermediate risk of perioperative death.

DESIGN

 Systematic review and meta-analysis DATA SOURCES:  Medline, Embase, and Cochrane CENTRAL.

STUDY SELECTION

 Randomized trials of TAVI compared with SAVR in patients with a mean perioperative risk of death <8%.

REVIEW METHODS

 Two reviewers independently extracted data and assessed risk of bias for outcomes important to patients that were selected a priori by a parallel guideline committee, including patient advisors. We used the GRADE system was used to quantify absolute effects and quality of evidence.

RESULTS

 4 trials with 3179 patients and a median follow-up of two years were included. Compared with SAVR, transfemoral TAVI was associated with reduced mortality (risk difference per 1000 patients: -30, 95% confidence interval -49 to -8, moderate certainty), stroke (-20, -37 to 1, moderate certainty), life threatening bleeding (-252, -293 to -190, high certainty), atrial fibrillation (-178, -150 to -203, moderate certainty), and acute kidney injury (-53, -39 to -62, high certainty) but increased short term aortic valve reintervention (7, 1 to 21, moderate certainty), permanent pacemaker insertion (134, 16 to 382, moderate certainty), and moderate or severe symptoms of heart failure (18, 5 to 34, moderate certainty). Compared with SAVR, transapical TAVI was associated higher mortality (57, -16 to 153, moderate certainty, P=0.015 for interaction between transfemoral versus transapical TAVI) and stroke (45, -2 to 125, moderate certainty, interaction P=0.012). No study reported long term follow-up, which is particularly important for structural valve deterioration.

CONCLUSIONS

 Many patients, particularly those who have a shorter life expectancy or place a lower value on the risk of long term valve degeneration, are likely to perceive net benefit with transfemoral TAVI versus SAVR. SAVR, however, performs better than transapical TAVI, which is of interest to patients who are not candidates for transfemoral TAVI.

SYSTEMATIC REVIEW REGISTRATION

 PROSPERO CRD42016042879.

The effect of a whole heart motion-correction algorithm on CT image quality and measurement reproducibility in Pre-TAVR aortic annulus evaluation

BACKGROUND

Motion correction (MC) algorithms have been shown to improve image quality, interpretability and diagnostic accuracy in coronary CT angiography. We sought to determine whether MC extended to the whole heart would demonstrate improved image quality and reproducibility of aortic annular measurements in pre-TAVR CT.

MATERIALS AND METHODS

Twenty-two consecutive contrast enhanced CT data sets acquired for pre TAVR evaluation using retrospective ECG synchronization during a single heart beat were retrospectively identified. Image data sets were obtained from raw data acquired at 35% and 75% of the R-R interval using both standard (STD) and motion corrected (MC) reconstruction algorithms. Four data sets (2 STD, 2 MC) per patient were analyzed by 2 independent, blinded readers for aortic annular area, short and long axis, perimeter and average diameter. Image quality was graded using a 5 point Likert score (1 and 2 non diagnostic, 5 excellent). Statistical analysis was performed using Wilcoxon matched paired tests, Bland-Altman (B-A) plots and Lin's concordance coefficient comparing 35% STD to 35% MC, and 75% STD to 75% MC.

RESULTS

Eighty-eight datasets were analyzed (44 STD, 44 MC). At 35%, there was a significant improvement in image quality for MC (Likert score 3.3 ± 0.9 STD vs. 3.9 ± 0.7 MC, p < 0.007). While B-A analysis demonstrated narrower interobserver agreement for aortic annular area (bias 0.03 vs 0.02 cm(2), range -0.32 to 0.39 cm(2) vs -0.50 to 0.55 cm(2)), and perimeter (bias 0.3 vs 0.3 mm, range -3.1 to 3.8 mm vs -4.6 to 5.3 mm), this was not statistically significant by concordance correlation coefficient. At 75%, there was no significant difference in image quality (Likert score 3.3 ± 0.9 vs. 3.5 ± 0.76, p = 0.454) or annular measurement agreement intervals.

CONCLUSION

Motion correction algorithms may yield significant improvements of image quality in systolic CT data sets of the heart. Further validation studies are required to determine the effect on annular measurements and translation into clinical practice.

One-Year Clinical Outcomes With SAPIEN 3 Transcatheter Aortic Valve Replacement in High-Risk and Inoperable Patients With Severe Aortic Stenosis

Background:

In the initial PARTNER trial (Placement of Aortic Transcatheter Valves) of transcatheter aortic valve replacement for high-risk (HR) and inoperable patients, mortality at 1 year was 24% in HR and 31% in inoperable patients. A recent report of the 30-day outcomes with the low-profile SAPIEN 3 transcatheter aortic valve replacement system demonstrated very low rates of adverse events, but little is known about the longer-term outcomes with this device.

Methods:

Between October 2013 and September 2014, 583 HR (65%) or inoperable (35%) patients were treated via the transfemoral (84%) or transapical/transaortic (16%) access route at 29 US sites. Major clinical events at 1 year were adjudicated by an independent clinical events committee, and echocardiographic results were analyzed by a core laboratory.

Results:

Baseline characteristics included age of 83 years, 42% female, and median Society of Thoracic Surgeons score of 8.4%. At the 1-year follow-up, survival (all-cause) was 85.6% for all patients, 87.3% in the HR subgroup, and 82.3% in the inoperable subgroup. Survival free of all-cause and cardiovascular mortality in the transfemoral patients from the HR cohort was 87.7% and 93.3%, respectively. There was no severe paravalvular leak. Moderate paravalvular leak (2.7%) was associated with an increase in mortality at 1 year, whereas mild paravalvular leak had no significant association with mortality. Symptomatic improvement as assessed by the percentage of patients in New York Heart Association class III and IV (90.1% to 7.7% at 1 year; P <0.0001) and by Kansas City Cardiomyopathy Questionnaire overall summary score (improved from 46.9 to 72.4; P <0.0001) was marked. Multivariable predictors of 1-year mortality included alternative access, Society of Thoracic Surgeons score, and disabling stroke.

Conclusions:

In this large, adjudicated registry of SAPIEN 3 HR and inoperable patients, the very low rates of important complications resulted in a strikingly low mortality rate at 1 year. Between 30 and 365 days, the incidence of moderate paravalvular aortic regurgitation did not increase, and no association between mild paravalvular leak and 1-year mortality was observed, although a small increase in disabling stroke occurred. These results, which likely reflect device iteration and procedural evolution, support the use of transcatheter aortic valve replacement as the preferred therapy in HR and inoperable patients with aortic stenosis.

Clinical Trial Registration

: URL: http://www.clinicaltrials.gov . Unique identifier: NCT01314313.

Practical considerations for optimizing cardiac computed tomography protocols for comprehensive acquisition prior to transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) is performed frequently in patients with severe, symptomatic aortic stenosis who are at high risk or inoperable for open surgical aortic valve replacement. Computed tomography angiography (CTA) has become the gold standard imaging modality for pre-TAVR cardiac anatomic and vascular access assessment. Traditionally, cardiac CTA has been most frequently used for assessment of coronary artery stenosis, and scanning protocols have generally been tailored for this purpose. Pre-TAVR CTA has different goals than coronary CTA and the high prevalence of chronic kidney disease in the TAVR patient population creates a particular need to optimize protocols for a reduction in iodinated contrast volume. This document reviews details which allow the physician to tailor CTA examinations to maximize image quality and minimize harm, while factoring in multiple patient and scanner variables which must be considered in customizing a pre-TAVR protocol.

Transcatheter aortic valve replacement versus surgical valve replacement in intermediate-risk patients: a propensity score analysis

BACKGROUND

Transcatheter aortic valve replacement (TAVR) with the SAPIEN 3 valve demonstrates good 30 day clinical outcomes in patients with severe aortic stenosis who are at intermediate risk of surgical mortality. Here we report longer-term data in intermediate-risk patients given SAPIEN 3 TAVR and compare outcomes to those of intermediate-risk patients given surgical aortic valve replacement.

METHODS

In the SAPIEN 3 observational study, 1077 intermediate-risk patients at 51 sites in the USA and Canada were assigned to receive TAVR with the SAPIEN 3 valve [952 [88%] via transfemoral access) between Feb 17, 2014, and Sept 3, 2014. In this population we assessed all-cause mortality and incidence of strokes, re-intervention, and aortic valve regurgitation at 1 year after implantation. Then we compared 1 year outcomes in this population with those for intermediate-risk patients treated with surgical valve replacement in the PARTNER 2A trial between Dec 23, 2011, and Nov 6, 2013, using a prespecified propensity score analysis to account for between-trial differences in baseline characteristics. The clinical events committee and echocardiographic core laboratory methods were the same for both studies. The primary endpoint was the composite of death from any cause, all strokes, and incidence of moderate or severe aortic regurgitation. We did non-inferiority (margin 7·5%) and superiority analyses in propensity score quintiles to calculate pooled weighted proportion differences for outcomes.

FINDINGS

At 1 year follow-up of the SAPIEN 3 observational study, 79 of 1077 patients who initiated the TAVR procedure had died (all-cause mortality 7·4%; 6·5% in the transfemoral access subgroup), and disabling strokes had occurred in 24 (2%), aortic valve re-intervention in six (1%), and moderate or severe paravalvular regurgitation in 13 (2%). In the propensity-score analysis we included 963 patients treated with SAPIEN 3 TAVR and 747 with surgical valve replacement. For the primary composite endpoint of mortality, strokes, and moderate or severe aortic regurgitation, TAVR was both non-inferior (pooled weighted proportion difference of -9·2%; 90% CI -12·4 to -6; p<0·0001) and superior (-9·2%, 95% CI -13·0 to -5·4; p<0·0001) to surgical valve replacement.

INTERPRETATION

TAVR with SAPIEN 3 in intermediate-risk patients with severe aortic stenosis is associated with low mortality, strokes, and regurgitation at 1 year. The propensity score analysis indicates a significant superiority for our composite outcome with TAVR compared with surgery, suggesting that TAVR might be the preferred treatment alternative in intermediate-risk patients.

FUNDING

None.

Management strategies and future challenges for aortic valve disease

The management of aortic valve disease has been improved by accurate diagnosis and assessment of severity by echocardiography and advanced imaging techniques, efforts to elicit symptoms or objective markers of disease severity and progression, and consideration of optimum timing of aortic valve replacement, even in elderly patients. Prevalence of calcific aortic stenosis is growing in ageing populations. Conventional surgery remains the most appropriate option for most patients who require aortic valve replacement, but the transcatheter approach is established for high-risk patients or poor candidates for surgery. The rapid growth of transcatheter aortic valve replacement has been fuelled by improved technology, evidence-based clinical research, and setting up of multidisciplinary heart teams. Aortic regurgitation can be difficult to diagnose and quantify. Left ventricular dysfunction often precedes symptoms, needing active surveillance by echocardiography to determine the optimum time for aortic valve replacement. Development of transcatheter approaches for aortic regurgitation is challenging, owing to the absence of valvular calcification and distortion of aortic root anatomy in many patients.

Primary Cytomegalovirus Syndrome: An Unexpected Cause of Donor Morbidity Shortly After Right Lobectomy for Living-Donor Liver Transplant

We present a case of initially unexplained fever in a living right liver lobe transplant donor that turned out to be due to primary cytomegalovirus infection.