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Ayyad M, Jabri A, Khalefa BB, Al-Abdouh A, Madanat L, Albandak M, Alhuneafat L, Sukhon F, Shahrori Z, Mourid MR, Mhanna M, Giustino G, Wang DD, Hanson ID, Abbas AE, AlQarqaz M, Villablanca P. Efficacy and safety of TAVR versus SAVR in patients with small aortic annuli: A systematic review and meta-analysis. Int J Cardiol 2024; 411:132243. [PMID: 38851542 DOI: 10.1016/j.ijcard.2024.132243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 05/05/2024] [Accepted: 06/05/2024] [Indexed: 06/10/2024]
Abstract
INTRODUCTION Patients with a small aortic annulus (SAA) undergoing aortic valve replacement are at increased risk of patient-prosthesis mismatch (PPM), which adversely affects outcomes. Transcatheter aortic valve replacement (TAVR) has shown promise in mitigating PPM compared to surgical aortic valve replacement (SAVR). METHODS We conducted a systematic review and meta-analysis following PRISMA guidelines to compare clinical outcomes, mortality, and PPM between SAA patients undergoing TAVR and SAVR. Eligible studies were identified through comprehensive literature searches and assessed for quality and relevance. RESULTS Nine studies with a total of 2476 patients were included. There was no significant difference in 30-day Mortality between TAVR vs SAVR groups (OR = 0.65, 95% CI [ 0.09-4.61], P = 0.22). There was no difference between both groups regarding myocardial infarction at 30 days (OR = 0.63, 95% CI [0.1-3.89], P = 0.62). TAVR was associated with a significantly lower 30-day major bleeding and 2-year major bleeding, Pooled studies were homogeneous (OR = 0.44, 95% CI [0.31-0.64], P < 0.01, I2 = 0, P = 0.89), (OR = 0.4 ,95% CI [0.21-0.77], P = 0.03, I2 = 0%, P = 0.62) respectively. TAVR was associated with a lower rate of moderate PPM (OR = 0.6, 95% CI [ 0.44-0.84], p value = 0.01, i2 = 0%, p value = 0.44). The overall effect estimate did not favor any of the two groups regarding short-term Mild AR (OR = 5.44, 95% CI [1.02-28.91], P = 0.05) and Moderate/severe AR (OR = 4.08, 95% CI [ 0.79-21.02], P = 0.08, I2 = 0%, P = 0.59). CONCLUSION Our findings suggest that both TAVR and SAVR are viable options for treating AS in patients with a small aortic annulus. TAVR offers advantages in reducing PPM and major bleeding, while SAVR performs better in terms of pacemaker implantation. Future studies should focus on comparing newer generation TAVR techniques and devices with SAVR. Consideration of patient characteristics is crucial in selecting the optimal treatment approach for AS.
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Affiliation(s)
- Mohammed Ayyad
- Department of Internal Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Ahmad Jabri
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI, USA; Michigan State University, College of Human Medicine, USA
| | | | - Ahmad Al-Abdouh
- Division of hospital medicine, University of Kentucky, Lexington, KY, USA
| | - Luai Madanat
- Department of Cardiovascular Medicine, William Beaumont University Hospital, Royal Oak, MI, USA; Oakland University William Beaumont School of Medicine, USA
| | - Maram Albandak
- Division of hospital medicine, University of Kentucky, Lexington, KY, USA; Department of Internal Medicine, University of Toledo, Toledo, Ohio, USA
| | - Laith Alhuneafat
- Cardiovascular Division, University of Minnesota, Minneapolis, MN, USA
| | - Fares Sukhon
- Heart and Vascular Center, Metrohealth Medical Center, Cleveland, OH, United States of America
| | - Zaid Shahrori
- Case Western Reserve University/Metrohealth Medical Center Cleveland, OH, USA
| | | | - Mohammed Mhanna
- Division of Cardiovascular Medicine, University of Iowa, IA, USA
| | - Gennaro Giustino
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI, USA; Michigan State University, College of Human Medicine, USA
| | - Dee Dee Wang
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI, USA; Michigan State University, College of Human Medicine, USA
| | - Ivan D Hanson
- Department of Cardiovascular Medicine, William Beaumont University Hospital, Royal Oak, MI, USA; Oakland University William Beaumont School of Medicine, USA
| | - Amr E Abbas
- Department of Cardiovascular Medicine, William Beaumont University Hospital, Royal Oak, MI, USA; Oakland University William Beaumont School of Medicine, USA
| | - Mohammad AlQarqaz
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI, USA; Michigan State University, College of Human Medicine, USA
| | - Pedro Villablanca
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI, USA; Michigan State University, College of Human Medicine, USA.
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Bacco LD, D’Alonzo M, Eusanio MD, Rosati F, Solinas M, Baudo M, Folliguet T, Benussi S, Fischlein T, Muneretto C. Sutureless Aortic Valve Replacement vs. Transcatheter Aortic Valve Implantation in Patients with Small Aortic Annulus: Clinical and Hemodynamic Outcomes from a Multi-Institutional Study. Braz J Cardiovasc Surg 2024; 39:e20230155. [PMID: 39038084 PMCID: PMC11259373 DOI: 10.21470/1678-9741-2023-0155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 08/21/2023] [Indexed: 07/24/2024] Open
Abstract
OBJECTIVE This study aimed to compare hemodynamic performances and clinical outcomes of patients with small aortic annulus (SAA) who underwent aortic valve replacement by means of sutureless aortic valve replacement (SUAVR) or transcatheter aortic valve implantation (TAVI). METHODS From 2015 to 2020, 622 consecutive patients with SAA underwent either SUAVR or TAVI. Through a 1:1 propensity score matching analysis, two homogeneous groups of 146 patients were formed. Primary endpoint: all cause-death at 36 months. Secondary endpoints: incidence of moderate to severe patient-prosthesis mismatch (PPM) and incidence of major adverse cardiovascular and cerebrovascular events (MACCEs). RESULTS All-cause death at three years was higher in the TAVI group (SUAVR 12.2% vs. TAVI 21.0%, P=0.058). Perioperatively, comparable hemodynamic performances were recorded in terms of indexed effective orifice area (SUAVR 1.12 ± 0.23 cm2/m2 vs. TAVI 1.17 ± 0.28 cm2/m2, P=0.265), mean transvalvular gradients (SUAVR 12.9 ± 5.3 mmHg vs. TAVI 12.2 ± 6.2 mmHg, P=0.332), and moderate-to-severe PPM (SUAVR 4.1% vs. TAVI 8.9%, P=0.096). TAVI group showed a higher cumulative incidence of MACCEs at 36 months (SUAVR 18.1% vs. TAVI 32.6%, P<0.001). Pacemaker implantation (PMI) and perivalvular leak ≥ 2 were significantly higher in TAVI group and identified as independent predictors of mortality (PMI: hazard ratio [HR] 3.05, 95% confidence interval [CI] 1.34-6.94, P=0.008; PPM: HR 2.72, 95% CI 1.25-5.94, P=0.012). CONCLUSION In patients with SAA, SUAVR and TAVI showed comparable hemodynamic performances. Moreover, all-cause death and incidence of MACCEs at follow-up were significantly higher in TAVI group.
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Affiliation(s)
- Lorenzo Di Bacco
- Department of Cardiac Surgery, ASST Spedali Civili di Brescia,
University of Brescia, Brescia, Italy
| | - Michele D’Alonzo
- Department of Cardiac Surgery, ASST Spedali Civili di Brescia,
University of Brescia, Brescia, Italy
| | - Marco Di Eusanio
- Cardiovascular Surgery Department, Ospedali Riuniti, Ancona, Italy
| | - Fabrizio Rosati
- Department of Cardiac Surgery, ASST Spedali Civili di Brescia,
University of Brescia, Brescia, Italy
| | - Marco Solinas
- Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital,
Massa, Italy
| | - Massimo Baudo
- Department of Cardiac Surgery, ASST Spedali Civili di Brescia,
University of Brescia, Brescia, Italy
| | - Thierry Folliguet
- Cardiac surgery, Centre Hospitalier Universitaire Mondor,
Créteil, France
| | - Stefano Benussi
- Department of Cardiac Surgery, ASST Spedali Civili di Brescia,
University of Brescia, Brescia, Italy
| | - Theodor Fischlein
- Department of Cardiac Surgery, Klinikum Nürnberg, Nuremberg,
Germany
| | - Claudio Muneretto
- Department of Cardiac Surgery, ASST Spedali Civili di Brescia,
University of Brescia, Brescia, Italy
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3
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Modine T, Forrest JK, Van Mieghem NM, Deeb GM, Yakubov SJ, Ali WB, Tchétché D, Lam KY, Oh JK, Huang J, Mehran R, Reardon MJ. Transcatheter or Surgical Aortic Valve Replacement in Women With Small Annuli at Low or Intermediate Surgical Risk. Am J Cardiol 2024; 223:147-155. [PMID: 38641189 DOI: 10.1016/j.amjcard.2024.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 03/20/2024] [Accepted: 04/06/2024] [Indexed: 04/21/2024]
Abstract
There are limited data from randomized controlled trials assessing the impact of transcatheter aortic valve replacement (TAVR) or surgery in women with aortic stenosis and small aortic annuli. We evaluated 2-year clinical and hemodynamic outcomes after aortic valve replacement to understand acute valve performance and early and midterm clinical outcomes. This post hoc analysis pooled women enrolled in the randomized, prospective, multicenter Evolut Low Risk and Surgical Replacement and Transcatheter Aortic Valve Implantation (SURTAVI) intermediate risk trials. Women with severe aortic stenosis at low or intermediate surgical risk who had a computed tomography-measured annular perimeter of ≤72.3 mm were included and underwent self-expanding, supra-annular TAVR or surgery. The primary end point was 2-year all-cause mortality or disabling stroke rate. The study included 620 women (323 TAVR, 297 surgery) with a mean age of 78 years. At 2 years, the all-cause mortality or disabling stroke was 6.5% for TAVR and 8.0% for surgery, p = 0.47. Pacemaker rates were 20.0% for TAVR and 8.3% for surgery, p <0.001. The mean effective orifice area at 2 years was 1.9 ± 0.5 cm2 for TAVR and 1.6 ± 0.5 cm2 for surgery and the mean gradient was 8.0 ± 4.1 versus 12.7 ± 6.0 mm Hg, respectively (both p <0.001). Moderate or severe patient-prothesis mismatch at discharge occurred in 10.9% of patients who underwent TAVR and 33.2% of patients who underwent surgery, p <0.001. In conclusion, in women with small annuli, the clinical outcomes to 2 years were similar between self-expanding, supra-annular TAVR and surgery, with better hemodynamics in the TAVR group and fewer pacemakers in the surgical group.
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Affiliation(s)
- Thomas Modine
- Department of Cardiac Surgery, Cardiologique de Haut Lévèque - (CHU) de Bordeaux, France.
| | - John K Forrest
- Department of Internal Medicine (Cardiology), Yale University School of Medicine, New Haven, Connecticut
| | - Nicolas M Van Mieghem
- Department of Interventional Cardiology, Cardiovascular Institute, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - G Michael Deeb
- Department of Cardiothoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Steven J Yakubov
- Department of Interventional Cardiology, Riverside Methodist - OhioHealth, Columbus, Ohio
| | - Walid Ben Ali
- Department of Surgery, Montreal Heart Institute, Montreal, Canada
| | - Didier Tchétché
- Department of Interventional Cardiology, Clinique Pasteur, Toulouse, France
| | - Ka Yan Lam
- Department of Cardiothoracic Surgery, Catharina Ziekenhuis, Eindhoven, The Netherlands
| | - Jae K Oh
- Department of Medicine (Echocardiography), Mayo Clinic, Rochester, Minnesota
| | - Jian Huang
- Structural Heart and Aortic, Medtronic, Minneapolis, Minnesota
| | - Roxana Mehran
- Department of Medicine (Cardiology), Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michael J Reardon
- Department of Cardiothoracic Surgery, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas
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Baudo M, Sicouri S, Yamashita Y, Ridwan K, Kadri A, Goldman SM, Rodriguez R, Gnall EM, Coady PM, Reardon MJ, Gada H, Gray WA, Ramlawi B. Improved Hemodynamics With Self-Expanding Compared to Balloon-Expandable Transcatheter Aortic Valve Implantation in Small Annulus Patients: A Propensity-Matched Analysis. Am J Cardiol 2024; 221:9-18. [PMID: 38636627 DOI: 10.1016/j.amjcard.2024.03.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 02/28/2024] [Accepted: 03/30/2024] [Indexed: 04/20/2024]
Abstract
Patients with small aortic annuli (SAA) pose a challenge in patients undergoing aortic valve replacement because of the potential for prosthesis-patient mismatch (PPM). This study aimed to compare the clinical and hemodynamic outcomes of self-expandable valve (SEV) versus balloon-expandable valve (BEV) transcatheter aortic valve implantation (TAVI) in patients with severe aortic stenosis and SAA. All patients who underwent TAVI for severe native aortic stenosis with a SAA between January 2018 and December 2022 were retrospectively included in the study from a single center. Propensity score matching was performed to balance the baseline characteristics. Bioprosthesis valve dysfunction was based on modified Valve Academic Research Consortium 3 criteria. A total of 1,170 TAVI procedures were performed between 2018 and 2022. After applying the exclusion criteria, 332 patients reported a SAA at computed tomography scan, and the matching created 109 balanced pairs. Echocardiographic data at discharge showed higher mean transvalvular gradients (p <0.001), higher grades of mitral regurgitation (p = 0.029), and lower ejection fraction (p <0.043) in BEVs than SEVs. At follow-up, significant differences favoring the SEV group regarding bioprosthesis valve dysfunction were observed (p = 0.002), especially in terms of severe PPM (p = 0.046) and at least moderate structural valve deterioration (p = 0.040). In conclusion, TAVI in patients with SAA using a BEV was associated with lower valve areas, higher mean pressure gradients, and PPM (including severe) than a SEV. Short- and midterm all-cause and cardiac-related mortality did not differ between the 2 groups. Future randomized studies with extended follow-ups are warranted to validate these outcomes.
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Affiliation(s)
- Massimo Baudo
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, Pennsylvania; Department of Cardiac Surgery, Lankenau Heart Institute, Main Line Health, Wynnewood, Pennsylvania.
| | - Serge Sicouri
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, Pennsylvania
| | - Yoshiyuki Yamashita
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, Pennsylvania; Department of Cardiac Surgery, Lankenau Heart Institute, Main Line Health, Wynnewood, Pennsylvania
| | - Khalid Ridwan
- Department of Cardiac Surgery, Lankenau Heart Institute, Main Line Health, Wynnewood, Pennsylvania
| | - Amer Kadri
- Department of Interventional Cardiology, Lankenau Heart Institute, Main Line Health, Wynnewood, Pennsylvania
| | - Scott M Goldman
- Department of Cardiac Surgery, Lankenau Heart Institute, Main Line Health, Wynnewood, Pennsylvania
| | - Roberto Rodriguez
- Department of Cardiac Surgery, Lankenau Heart Institute, Main Line Health, Wynnewood, Pennsylvania
| | - Eric M Gnall
- Department of Interventional Cardiology, Lankenau Heart Institute, Main Line Health, Wynnewood, Pennsylvania
| | - Paul M Coady
- Department of Interventional Cardiology, Lankenau Heart Institute, Main Line Health, Wynnewood, Pennsylvania
| | - Michael J Reardon
- Department of Cardiovascular Surgery, Methodist DeBakey Heart and Vascular Center, Houston, Texas
| | - Hemal Gada
- Structural Heart Program, University of Pittsburgh Medical Center Pinnacle Health, Harrisburg, Pennsylvania
| | - William A Gray
- Department of Interventional Cardiology, Lankenau Heart Institute, Main Line Health, Wynnewood, Pennsylvania
| | - Basel Ramlawi
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, Pennsylvania; Department of Cardiac Surgery, Lankenau Heart Institute, Main Line Health, Wynnewood, Pennsylvania
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5
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Yamamoto M, Yashima F, Shirai S, Tada N, Naganuma T, Yamawaki M, Yamanaka F, Mizutani K, Noguchi M, Ueno H, Takagi K, Ohno Y, Izumo M, Nishina H, Suzuyama H, Yamasaki K, Nishioka K, Hachinohe D, Fuku Y, Otsuka T, Asami M, Watanabe Y, Hayashida K, Ocean-Tavi Investigators OBOT. Performance and outcomes of the SAPIEN 3 Ultra RESILIA transcatheter heart valve in the OCEAN-TAVI registry. EUROINTERVENTION 2024; 20:579-590. [PMID: 38726714 PMCID: PMC11067722 DOI: 10.4244/eij-d-23-00996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/14/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND Data on the performance of the latest-generation SAPIEN 3 Ultra RESILIA (S3UR) valve in patients who undergo transcatheter aortic valve replacement (TAVR) are scarce. AIMS We aimed to assess the clinical outcomes, including valve performance, of the S3UR. METHODS Registry data of 618 consecutive patients with S3UR and of a historical pooled cohort of 8,750 patients who had a SAPIEN 3 (S3) valve and underwent TAVR were collected. The clinical outcomes and haemodynamics, including patient-prosthesis mismatch (PPM), were compared between the 2 groups and in a propensity-matched cohort. RESULTS The incidence of in-hospital death, vascular complications, and new pacemaker implantation was similar between the S3UR and the S3 groups (allp>0.05). However, both groups showed significant differences in the degrees of paravalvular leakage (PVL) (none-trivial: 87.0% vs 78.5%, mild: 12.5% vs 20.5%, ≥moderate: 0.5% vs 1.1%; p<0.001) and the incidence of PPM (none: 94.3% vs 85.1%, moderate: 5.2% vs 12.8%, severe: 0.5% vs 2.0%; p<0.001). The prevalence of a mean pressure gradient ≥20 mmHg was significantly lower in the S3UR group (1.6% vs 6.2%; p<0.001). Better haemodynamics were observed with the smaller 20 mm and 23 mm S3UR valves. The results were consistent in a matched cohort of patients with S3UR and with S3 (n=618 patients/group). CONCLUSIONS The S3UR has equivalent procedural complications to the S3 but with lower rates of PVL and significantly better valve performance. The better valve performance of the S3UR, particularly in smaller valve sizes, overcomes the remaining issue of balloon-expandable valves after TAVR.
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Affiliation(s)
- Masanori Yamamoto
- Department of Cardiology, Toyohashi Heart Center, Toyohashi, Japan
- Department of Cardiology, Nagoya Heart Center, Nagoya, Japan
- Department of Cardiology, Gifu Heart Center, Gifu, Japan
| | - Fumiaki Yashima
- Department of Cardiology, Saiseikai Utsunomiya Hospital, Utsunomiya, Japan
| | - Shinichi Shirai
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Norio Tada
- Department of Cardiology, Sendai Kosei Hospital, Sendai, Japan
| | - Toru Naganuma
- Department of Cardiology, New Tokyo Hospital, Chiba, Japan
| | - Masahiro Yamawaki
- Department of Cardiology, Saiseikai Yokohama City Eastern Hospital, Yokohama, Japan
| | - Futoshi Yamanaka
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Kazuki Mizutani
- Department of Medicine, Division of Cardiology, Kindai University, Osaka, Japan
| | - Masahiko Noguchi
- Department of Cardiology, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Japan
| | - Hiroshi Ueno
- Second Department of Internal Medicine, Toyama University Hospital, Toyama, Japan
| | - Kensuke Takagi
- Department of Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yohei Ohno
- Department of Cardiology, Tokai University School of Medicine, Isehara, Japan
| | - Masaki Izumo
- Department of Cardiology, St Marianna University School of Medicine, Kawasaki, Japan
| | - Hidetaka Nishina
- Department of Cardiology, Tsukuba Medical Center Hospital, Tsukuba, Japan
| | - Hiroto Suzuyama
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | - Kazumasa Yamasaki
- Department of Cardiology, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | - Kenji Nishioka
- Department of Cardiology, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Daisuke Hachinohe
- Cardiovascular Medicine, Sapporo Heart Center, Sapporo Cardiovascular Clinic, Sapporo, Japan
| | - Yasushi Fuku
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Toshiaki Otsuka
- Department of Hygiene and Public Health, Nippon Medical School, Tokyo, Japan
- Center for Clinical Research, Nippon Medical School Hospital, Tokyo, Japan
| | - Masahiko Asami
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Yusuke Watanabe
- Department of Cardiology, Teikyo University School of Medicine, Tokyo, Japan
| | - Kentaro Hayashida
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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Carter-Storch R, Hahn RT, Abbas AE, Daubert MA, Douglas PS, Elmariah S, Zhao Y, Mack MJ, Leon MB, Pibarot P, Clavel MA. Effect of Sex and Flow Status on Outcomes After Surgical or Transcatheter Aortic Valve Replacement. JACC. ADVANCES 2024; 3:100853. [PMID: 38938841 PMCID: PMC11198680 DOI: 10.1016/j.jacadv.2024.100853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 11/13/2023] [Accepted: 11/29/2023] [Indexed: 06/29/2024]
Abstract
Background Low stroke volume index <35 ml/m2 despite preserved ejection fraction (paradoxical low flow [PLF]) is associated with adverse outcomes in patients with aortic stenosis undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). However, whether the risk associated with PLF is similar in both sexes is unknown. Objectives The purpose of this study was to analyze the risk associated with PLF in severe aortic stenosis for men and women randomized to TAVR or SAVR. Methods Patients with ejection fraction ≥50% from the PARTNER (Placement of Aortic Transcatheter Valves) 2 and 3 trials were stratified by sex and treatment arm. The impact of PLF on the 2-year occurrence of the composite of death or heart failure hospitalization (primary endpoint) and of all-cause mortality alone (secondary endpoint) was analyzed. Analysis of variance was used to assess baseline differences between groups. Multivariate Cox regression analysis was used to identify predictors of the endpoint. Results Out of 2,242 patients, PLF was present in 390 men and 239 women (30% vs 26%, P = 0.06). PLF was associated with a higher rate of NYHA functional class III to IV dyspnea (60% vs 54%, P < 0.001) and a higher prevalence of atrial fibrillation (39% vs 24%, P < 0.001). PLF was a significant predictor of the primary endpoint among women undergoing SAVR in multivariate analysis (adjusted HR: 2.25 [95% CI: 1.14-4.43], P = 0.02) but was not associated with a worse outcome in any of the other groups (all P > 0.05). Conclusions In women with PLF, TAVR may improve outcomes compared to SAVR. PLF appears to have less impact on outcomes in men.
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Affiliation(s)
- Rasmus Carter-Storch
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Quebec Heart and Lung Institute, Laval University, Quebec, Quebec, Canada
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Rebecca T. Hahn
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Amr E. Abbas
- Corewell Health, William Beaumont University Hospital, Royal Oak, Michigan, USA
| | | | | | - Sammy Elmariah
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Yanglu Zhao
- Edwards Lifesciences, Irvine, California, USA
| | | | | | - Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Quebec Heart and Lung Institute, Laval University, Quebec, Quebec, Canada
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Quebec Heart and Lung Institute, Laval University, Quebec, Quebec, Canada
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7
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Hosseinpour A, Gupta R, Kamalpour J, Hosseinpour H, Chaturvedi A, Agrawal A, Patel NC, Patel C. Balloon-Expandable Versus Self-Expanding Transcatheter Aortic Valve Implantation in Patients With Small Aortic Annulus: A Meta-Analysis. Am J Cardiol 2023; 204:257-267. [PMID: 37562191 DOI: 10.1016/j.amjcard.2023.07.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/12/2023] [Accepted: 07/14/2023] [Indexed: 08/12/2023]
Abstract
Although transcatheter aortic valve implantation (TAVI) is considered a superior option to surgery in patients with small aortic annulus (SAA), it is not clear which type of transcatheter heart valve (THV) has better results in terms of echocardiographic hemodynamics and clinical outcomes. A random-effects meta-analysis was performed comparing balloon-expandable valves (BEVs) and self-expanding valves (SEVs) in patients with SAA who underwent TAVI regarding their impact on hemodynamic and clinical outcomes at short- and midterm follow-up. Relative risk (RR) and mean difference (MD) with 95% confidence interval (95% CI) were measured for the outcomes, as appropriate. Subgroup analyses were performed based on the generation type of devices and study designs. A total of 16 articles comprising 1 randomized trial, 3 propensity-matched studies, and 12 observational studies including 4,341 patients (1,967 in BEV and 2,374 in the SEV group) with SAA were included. The implantation of BEVs correlated with a lower indexed effective orifice area (MD -0.19 [-0.25 to -0.13]) and higher transvalvular mean pressure gradient (MD 3.91, 95% CI 2.96 to 4.87). Compared with SEVs, BEVs had increased risk of prosthesis-patient mismatch (PPM; RR 2.09, 95% CI 1.79 to 2.45) and severe PPM (RR 2.16, 95% CI 1.48 to 3.15). However, BEV had lower moderate and severe paravalvular leak (RR 0.45, 95% CI 0.29 to 0.69), risk of stroke (RR 0.57, 95% CI 0.42 to 0.76), and permanent pacemaker implantation (RR 0.63, 95% CI 0.44 to 0.91). The 1-year all-cause mortality (RR 1.13, 95% CI 0.86 to 1.49) and cardiac-related mortality (RR 1.53, 95% CI 0.24 to 9.81) were not different between the 2 groups. In conclusion, SEVs were associated with larger indexed effective orifice area and lower PPM but higher paravalvular leak. In contrast, patients with SEVs were more likely to develop stroke and required permanent pacemaker implantation. Both THVs did not show difference in terms of early and midterm all-cause and cardiac mortality. Because both types of THVs show similar results regarding mortality data, hemodynamics should be among the factors considered in decision making for patients with SAA who underwent TAVI.
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Affiliation(s)
| | - Rahul Gupta
- Lehigh Valley Heart and Vascular Institute, Lehigh Valley Health Network, Allentown, Pennsylvania.
| | | | | | - Abhishek Chaturvedi
- Pauley Heart Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Ankit Agrawal
- Department of Hospital Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Nainesh C Patel
- Lehigh Valley Heart and Vascular Institute, Lehigh Valley Health Network, Allentown, Pennsylvania
| | - Chirdeep Patel
- Lehigh Valley Heart and Vascular Institute, Lehigh Valley Health Network, Allentown, Pennsylvania
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Tirado-Conte G, Rodés-Cabau J, Oteo JF, Pan M, Muñoz E, Witberg G, Cheema AN, Alpieri A, Lopez D, Amat-Santos IJ, Akodad M, Ojeda S, Serra V, Garcia-Blas S, Alfonso F, De Backer O, Asmarats L, Muñoz A, Hamdan A, Toggweiler S, Del Valle R, Salido L, Cruz-González I, Estevez-Loureiro R, Martin Alfaro LE, Gheorge L, Dabrowski M, Berenguer A, Arzamendi D, Saia F, Webb JG, Sondergaard L, Nombela-Franco L. Transcatheter aortic valve implantation in patients with extra-small aortic annuli. EUROINTERVENTION 2023; 19:e340-e351. [PMID: 37334654 PMCID: PMC10333922 DOI: 10.4244/eij-d-23-00011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 05/01/2023] [Indexed: 06/20/2023]
Abstract
BACKGROUND A small aortic annulus (SAA) is a risk factor for prosthesis-patient mismatch (PPM) in patients undergoing surgical or transcatheter aortic valve implantation (TAVI). Data regarding TAVI in patients with extra-SAA are scarce. AIMS The aim of this study was to analyse the safety and efficacy of TAVI in patients with extra-SAA. METHODS A multicentre registry study including patients with extra-SAA (defined as an aortic annulus area <280 mm2 and/or perimeter <60 mm) undergoing TAVI was established. Primary efficacy and safety endpoints were defined as device success and early safety at 30 days, respectively, using the Valve Academic Research Consortium-3 criteria, and were analysed according to valve type: self-expanding (SEV) versus balloon-expandable (BEV). RESULTS A total of 150 patients were included, of which 139 (92.7%) were women, and 110 (73.3%) received an SEV. Intraprocedural technical success was 91.3%, with a higher rate in patients receiving an SEV (96.4% vs 77.5% with BEV; p=0.001). Overall, 30-day device success was 81.3%, (85.5% with SEV vs 70.0% with BEV; p=0.032). The primary safety endpoint occurred in 72.0% of patients (with no difference between groups; p=0.118). Severe PPM occurred in 12% (9.0% with SEV and 24.0% with BEV; p=0.039), with no impact on all-cause mortality, cardiovascular mortality, or heart failure readmission at 2-year follow-up. CONCLUSIONS TAVI is a safe and feasible treatment in patients with extra-SAA with a high rate of technical success. The use of SEV was associated with a lower rate of intraprocedural complications, higher device success at 30 days and better haemodynamic outcomes compared to BEV.
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Affiliation(s)
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec, QC, Canada
| | - Juan F Oteo
- Department of Cardiology, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | - Manuel Pan
- Hospital Universitario Reina Sofia, Córdoba, Spain and Universidad de Cordoba (IMIBIC), Córdoba, Spain
| | - Erika Muñoz
- CIBERCV Cardiology Department, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Guy Witberg
- Cardiology Department, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel and The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Asim N Cheema
- St Michael's Hospital, Toronto, ON, Canada
- Division of Cardiology, Southlake Regional Health Centre, Newmarket, ON, Canada
| | - Alberto Alpieri
- Quebec Heart and Lung Institute, Laval University, Quebec, QC, Canada
| | - Diego Lopez
- Hospital Clínico Universitario de Santiago, CIBERCV, Santiago, Spain
| | - Ignacio J Amat-Santos
- CIBERCV, Instituto de Ciencias del Corazón (ICICOR), Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | | | - Soledad Ojeda
- Hospital Universitario Reina Sofia, Córdoba, Spain and Universidad de Cordoba (IMIBIC), Córdoba, Spain
| | | | - Sergio Garcia-Blas
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, CIBERCV, Valencia, Spain
| | - Fernando Alfonso
- Department of Cardiology, Hospital Universitario La Princesa, IIS-IP, CIBERCV, Madrid, Spain
| | - Ole De Backer
- Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Antonio Muñoz
- CIBERCV Cardiology Department, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Ashraf Hamdan
- Cardiology Department, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel and The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | | | - Luisa Salido
- Cardiology Department, Hospital Ramón y Cajal, Madrid, Spain
| | - Ignacio Cruz-González
- Department of Cardiology, Complejo Asistencial Universitario Salamanca, CIBERCV, IBSAL, Salamanca, Spain
| | | | | | | | - Maciec Dabrowski
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warsaw, Poland
| | - Alberto Berenguer
- Cardiology Department, Hospital General Universitario de Valencia, Valencia, Spain
| | - Dabit Arzamendi
- Department of Cardiology, Hospital Universitario La Princesa, IIS-IP, CIBERCV, Madrid, Spain
| | - Francesco Saia
- Cardiology Unit, Cardio-Thoracic-Vascular Department, University Hospital of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - John G Webb
- CIBERCV, Instituto de Ciencias del Corazón (ICICOR), Hospital Clínico Universitario de Valladolid, Valladolid, Spain
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Singh GK, Delgado V, Delgado V. Multimodality Imaging to Explore Sex Differences in Aortic Stenosis. Eur Cardiol 2022; 17:e26. [PMID: 36845220 PMCID: PMC9947932 DOI: 10.15420/ecr.2022.26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 09/30/2022] [Indexed: 02/11/2023] Open
Abstract
The aim of this article is to review sex differences in aortic stenosis (AS) assessed with multimodality imaging. Echocardiography remains the mainstay imaging technique to diagnose AS and provides important insights into the differences between men and women in relation to valve haemodynamic and left-ventricular response. However, echocardiography does not have adequate resolution to provide important insights into sex differences in the degenerative, calcific pathophysiological process of the aortic valve. CT shows that women with AS have more fibrotic changes of the aortic valve whereas men show more calcific deposits. Cardiac magnetic resonance shows that women have left ventricles that are less hypertrophic and smaller compared with those of men, while men have more replacement myocardial fibrosis. These differences may lead to different responses to aortic valve replacement because myocardial diffuse fibrosis but not replacement myocardial fibrosis may regress after the procedure. Sex differences in the pathophysiological process of AS can be assessed using multimodality imaging, assisting in decisionmaking in these patients.
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Affiliation(s)
- Gurpreet K Singh
- Department of Cardiology, Leiden University Medical CenterLeiden, the Netherlands
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical CenterLeiden, the Netherlands,Heart Institute, Department of Cardiology, Hospital University Germans Trias i PujolBarcelona, Spain
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Abd Elmaksoud TR. Incidence, Outcomes and Predictors of Aortic Regurgitation After Transcatheter Aortic Valve Replacement in Al Azhar University Hospitals and National Heart Institute, Egypt. JOURNAL OF CARDIOLOGY AND CARDIOVASCULAR RESEARCH 2022. [DOI: 10.37191/mapsci-jccr-3(3)-065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
Background: Aortic regurgitation (AR), which has ill-defined predictors and an unknown long-term influence on outcomes, is a significant transcatheter aortic valve replacement (TAVR) constraint.
Objective: this research aimed to assess the prevalence, identify predictors, and evaluate the outcomes of aortic regurgitation following trans catheter aortic valve implantation (TAVI).
1. To calculate the prevalence of aortic regurgitation in elderly patients receiving trans catheter aortic valve implantation who have severe symptomatic aortic stenosis.
2. To determine aortic regurgitation risk factors after trans catheter aortic valve implantation.
Methods: From November 2017 to November 2020, this prospective observational study was done in the National Heart Institute on severe aortic valve stenosis patients above 65 years who were candidates for aortic valve replacement from the outpatient department.
Results: LVEF significantly improved. Compared to before TAVI (55.08 ± 9.71), LVEF elevated to 58.9 ± 8.8 (P<0.001). Twenty-five patients (83.3%) showed class III/IV, four patients (13.3%) showed class II, and one patient (3.3%) showed class I before TAVI. While after TAVI, three patients (10%) only showed NYHA class III/IV, six patients (20 %) in class II, and 21 patients (70%) improved to be in class I. The left ventricular mass index mean was 158 ±32.37 before TAVI and 133.50 ±21.96 after TAVI (p<0.001). Compared to before TAVI (0.75 ± 0.2), mean aortic valve area was improved to 2.0 ± 0.2 following TAVI (P<0.001). A significant reduction in the mean pressure gradient from 47 ± 11.08 mmHg across the native valve prior to TAVI to 10.28 ± 3.21 mmHg across the prosthetic valve following TAVI (P <0.001).
Expert commentary: The clinical and results of TAVR devices were clearly outlined in literature study. The study showed a high incidence of pacemaker implantation with Core valve and aortic regurgitation. This information strongly supports the need for a randomized trial with sufficient power to compare the most recent self-expandable valve generation to balloon expandable valves. In the 2019 PARTNER 3 prospective randomized trial, it was discovered that, when compared to surgical management, low-risk patients (defined as STS 4%) had a lower risk of the composite outcome of stroke, death, and rehospitalization at 1 year. Additionally, it was shown that TAVR had a lower risk of stroke and required less time in the hospital (3 days as opposed to 7, P0.001) than surgery [1]. In addition, despite an elevated permanent pacemaker implantation rate, the 2019 Medtronic Evolut Transcatheter Aortic Valve Replacement revealed no inferiority for composite all-cause stroke and death, as well as a statistically significant decrease in the rates of life-threatening bleeding, acute kidney injury and atrial fibrillation, compared with SAVR at 30 days following the procedure [2].
Conclusion: According to the study in high-risk patients with severe symptomatic aortic stenosis, TAVI is alternative, viable, safe, and successful therapy compared to traditional open-heart surgery.
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Herrmann HC, Pibarot P, Wu C, Hahn RT, Tang GHL, Abbas AE, Playford D, Ruel M, Jilaihawi H, Sathananthan J, Wood DA, De Paulis R, Bax JJ, Rodes-Cabau J, Cameron DE, Chen T, Del Nido PJ, Dweck MR, Kaneko T, Latib A, Moat N, Modine T, Popma JJ, Raben J, Smith RL, Tchetche D, Thomas MR, Vincent F, Yoganathan A, Zuckerman B, Mack MJ, Leon MB. Bioprosthetic Aortic Valve Hemodynamics: Definitions, Outcomes, and Evidence Gaps: JACC State-of-the-Art Review. J Am Coll Cardiol 2022; 80:527-544. [PMID: 35902177 DOI: 10.1016/j.jacc.2022.06.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 05/19/2022] [Accepted: 06/01/2022] [Indexed: 12/23/2022]
Abstract
A virtual workshop was organized by the Heart Valve Collaboratory to identify areas of expert consensus, areas of disagreement, and evidence gaps related to bioprosthetic aortic valve hemodynamics. Impaired functional performance of bioprosthetic aortic valve replacement is associated with adverse patient outcomes; however, this assessment is complicated by the lack of standardization for labelling, definitions, and measurement techniques, both after surgical and transcatheter valve replacement. Echocardiography remains the standard assessment methodology because of its ease of performance, widespread availability, ability to do serial measurements over time, and correlation with outcomes. Management of a high gradient after replacement requires integration of the patient's clinical status, physical examination, and multimodality imaging in addition to shared patient decisions regarding treatment options. Future priorities that are underway include efforts to standardize prosthesis sizing and labelling for both surgical and transcatheter valves as well as trials to characterize the consequences of adverse hemodynamics.
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Affiliation(s)
- Howard C Herrmann
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Philippe Pibarot
- Department of Medicine, Québec Heart and Lung Institute, Laval University, Québec City, Quebec, Canada
| | - Changfu Wu
- U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Rebecca T Hahn
- Columbia University Medical Center, New York, New York, USA
| | | | - Amr E Abbas
- Beaumont Hospital Royal Oak, Royal Oak, Michigan, USA
| | - David Playford
- The University of Notre Dame, Fremantle, Western Australia, Australia
| | - Marc Ruel
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Hasan Jilaihawi
- Heart Valve Center, NYU Langone Health, New York, New York, USA
| | - Janarthanan Sathananthan
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - David A Wood
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Jeroen J Bax
- Leiden University Medical Centre, Leiden, the Netherlands
| | - Josep Rodes-Cabau
- Department of Medicine, Québec Heart and Lung Institute, Laval University, Québec City, Quebec, Canada
| | - Duke E Cameron
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Tiffany Chen
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Pedro J Del Nido
- Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Marc R Dweck
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Tsuyoshi Kaneko
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Azeem Latib
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Neil Moat
- Abbott Structural Heart, Santa Clara, California, USA
| | - Thomas Modine
- Hopital Cardiologique de Haut Leveque, Bordeaux, France
| | | | - Jamie Raben
- U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Robert L Smith
- Baylor Scott and White, The Heart Hospital, Plano, Texas, USA
| | | | | | | | - Ajit Yoganathan
- Georgia Institute of Technology and Emory University, Atlanta, Georgia, USA
| | - Bram Zuckerman
- U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Michael J Mack
- Baylor Scott and White, The Heart Hospital, Plano, Texas, USA
| | - Martin B Leon
- Columbia University Medical Center, New York, New York, USA
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12
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Herrmann HC, Abdel-Wahab M, Attizzani GF, Batchelor W, Bleiziffer S, Verdoliva S, Chang Y, Gada H, Gillam L, Guerrero M, Mahoney PD, Petronio AS, Rogers T, Rovin J, Szerlip M, Whisenant B, Mehran R, Tchetche D. Rationale and design of the SMall Annuli Randomized To Evolut or SAPIEN Trial (SMART Trial). Am Heart J 2022; 243:92-102. [PMID: 34587510 DOI: 10.1016/j.ahj.2021.09.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 09/20/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND The SMall Annuli Randomized To Evolut or SAPIEN (SMART) Trial was designed to compare the performance of the two most widely available commercial transcatheter aortic valve replacement (TAVR) devices in patients with symptomatic severe native aortic stenosis with a small aortic valve annulus undergoing transfemoral TAVR. Patients with small aortic valve annuli are typically female and are often underrepresented in clinical trials. METHODS The SMART Trial is an international, prospective, multi-center, randomized controlled, post-market trial. The trial will be conducted in approximately 700 subjects at approximately 90 sites globally. Inclusion criteria include severe aortic stenosis, aortic valve annulus area of ≤430 mm2 based on multi-detector computed tomography, and appropriate anatomy for both the Medtronic Evolut PRO/PRO+ self-expanding and Edwards SAPIEN 3/3 Ultra balloon-expandable devices. The primary clinical outcome composite endpoint is defined as mortality, disabling stroke or heart failure rehospitalization at 12 months. The co-primary valve function composite endpoint is defined as bioprosthetic valve dysfunction at 12 months which includes hemodynamic structural valve dysfunction, defined as a mean gradient ≥20 mmHg, non-structural valve dysfunction, defined as severe prothesis-patient mismatch or ≥moderate aortic regurgitation, thrombosis, endocarditis, and aortic valve re-intervention. Powered secondary endpoints will be assessed hierarchically. CONCLUSIONS The SMART trial will be the largest head-to-head comparative trial of transfemoral TAVR using the two most widely available contemporary TAVR devices in the setting of small aortic annuli and the largest trial to enroll primarily women. CLINICAL TRIAL REGISTRATION URL: www.clinicaltrials.gov, Unique identifier: NCT04722250.
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13
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Bienjonetti-Boudreau D, Fleury MA, Voisine M, Paquin A, Chouinard I, Tailleur M, Duval R, Magnan PO, Beaudoin J, Salaun E, Clavel MA. Impact of sex on the management and outcome of aortic stenosis patients. Eur Heart J 2021; 42:2683-2691. [PMID: 34023890 DOI: 10.1093/eurheartj/ehab242] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 03/02/2021] [Accepted: 04/08/2021] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE The aim of this study was to assess the impact of sex on the management and outcome of patients according to aortic stenosis (AS) severity. INTRODUCTION Sex differences in the management and outcome of AS are poorly understood. METHODS Doppler echocardiography data of patients with at least mild-to-moderate AS [aortic valve area (AVA) ≤1.5 cm2 and peak jet velocity (VPeak) ≥2.5 m/s or mean gradient (MG) ≥25 mmHg] were prospectively collected between 2005 and 2015 and retrospectively analysed. Patients with reduced left ventricular ejection fraction (<50%), or mitral or aortic regurgitation >mild were excluded. RESULTS Among 3632 patients, 42% were women. The mean indexed AVA (0.48 ± 0.17 cm2/m2), VPeak (3.74 ± 0.88 m/s), and MG (35.1 ± 18.2 mmHg) did not differ between sexes (all P ≥ 0.18). Women were older (72.9 ± 13.0 vs. 70.1 ± 11.8 years) and had more hypertension (75% vs. 70%; P = 0.0005) and less coronary artery disease (38% vs. 55%, P < 0.0001) compared to men. After inverse-propensity weighting (IPW), female sex was associated with higher mortality (IPW-HR: 1.91 [1.14-3.22]; P = 0.01) and less referral to valve intervention (competitive model IPW-HR: 0.88 [0.82-0.96]; P = 0.007) in the whole cohort. This excess mortality in women was blunted in concordant non-severe AS initially treated conservatively (IPW-HR = 1.03 [0.63-1.68]; P = 0.88) or in concordant severe AS initially treated by valve intervention (IPW-HR = 1.25 [0.71-2.21]; P = 0.43). Interestingly, the excess mortality in women was observed in discordant low-gradient AS patients (IPW-HR = 2.17 [1.19-3.95]; P = 0.01) where women were less referred to valve intervention (IPW-Sub-HR: 0.83 [0.73-0.95]; P = 0.009). CONCLUSION In this large series of patients, despite similar baseline hemodynamic AS severity, women were less referred to AVR and had higher mortality. This seemed mostly to occur in the patient subset with discordant markers of AS severity (i.e. low-gradient AS) where women were less referred to AVR.
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Affiliation(s)
- David Bienjonetti-Boudreau
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), 2725 Chemin Sainte-Foy, Quebec, QC G1V-4G5, Canada
| | - Marie-Ange Fleury
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), 2725 Chemin Sainte-Foy, Quebec, QC G1V-4G5, Canada
| | - Martine Voisine
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), 2725 Chemin Sainte-Foy, Quebec, QC G1V-4G5, Canada
| | - Amélie Paquin
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), 2725 Chemin Sainte-Foy, Quebec, QC G1V-4G5, Canada
| | - Isabelle Chouinard
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), 2725 Chemin Sainte-Foy, Quebec, QC G1V-4G5, Canada
| | - Mathieu Tailleur
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), 2725 Chemin Sainte-Foy, Quebec, QC G1V-4G5, Canada
| | - Raphael Duval
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), 2725 Chemin Sainte-Foy, Quebec, QC G1V-4G5, Canada
| | - Pierre-Olivier Magnan
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), 2725 Chemin Sainte-Foy, Quebec, QC G1V-4G5, Canada
| | - Jonathan Beaudoin
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), 2725 Chemin Sainte-Foy, Quebec, QC G1V-4G5, Canada
| | - Erwan Salaun
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), 2725 Chemin Sainte-Foy, Quebec, QC G1V-4G5, Canada
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), 2725 Chemin Sainte-Foy, Quebec, QC G1V-4G5, Canada
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Hahn RT, Douglas PS, Jaber WA, Leipsic J, Kapadia S, Thourani VH, Makkar R, Kodali S, Clavel MA, Khalique OK, Weissman NJ, Blanke P, Chen Y, Smith CR, Mack MJ, Leon MB, Pibarot P. Doppler Velocity Index Outcomes Following Surgical or Transcatheter Aortic Valve Replacement in the PARTNER Trials. JACC Cardiovasc Interv 2021; 14:1594-1606. [PMID: 34217631 DOI: 10.1016/j.jcin.2021.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/02/2021] [Accepted: 04/06/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The aim of this study was to assess the association between Doppler velocity index (DVI) and 2-year outcomes for balloon-expandable SAPIEN 3 transcatheter aortic valve replacement (TAVR) and for surgical aortic valve replacement (SAVR). BACKGROUND DVI >0.35 is normal for a prosthetic valve, but recent studies suggest that DVI <0.50 is associated with poor outcomes following TAVR. METHODS Patients with severe aortic stenosis enrolled in the PARTNER (Placement of Aortic Transcatheter Valve) 2 (intermediate surgical risk) or PARTNER 3 (low surgical risk) trial undergoing TAVR (n = 1,450) or SAVR (n = 1,303) were included. Patients were divided into 3 DVI groups on the basis of core laboratory-assessed discharge or 30-day echocardiograms: DVILOW (≤0.35), DVIINTERMEDIATE (>0.35 to ≤0.50), and DVIHIGH (>0.50). Two-year outcomes were assessed. RESULTS Following TAVR, there were no differences among the 3 DVI groups in composite outcomes of death, stroke, or rehospitalization or in any individual components of 2-year outcomes (P > 0.70 for all). Following SAVR, there was no difference among DVI groups in the composite outcome (P = 0.27), but there was a significant association with rehospitalization (P = 0.02). Restricted cubic-spline analysis for combined outcomes showed an increased risk with post-SAVR DVI ≤0.35 but no relationship post-TAVR. DVI ≤0.35 was associated with increased 2-year composite outcome for SAVR (HR: 1.81; 95% CI: 1.29-2.54; P < 0.001), with no adverse outcomes for TAVR (P = 0.86). CONCLUSIONS In intermediate- and low-risk cohorts of the PARTNER trials, DVI ≤0.35 predicted worse 2-year outcomes following SAVR, driven primarily by rehospitalization, with no adverse outcomes associated with DVI following TAVR with the balloon-expandable SAPIEN 3 valve.
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Affiliation(s)
- Rebecca T Hahn
- Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York, USA.
| | - Pamela S Douglas
- Duke University Medical Center and Duke Clinical Research Institute, Durham, North Carolina, USA
| | | | - Jonathon Leipsic
- University of British Columbia and St. Paul's Hospital, Vancouver, British Columbia, Canada
| | | | | | - Raj Makkar
- Cedars Sinai, Los Angeles, California, USA
| | - Susheel Kodali
- Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York, USA
| | | | - Omar K Khalique
- Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York, USA
| | | | - Philipp Blanke
- University of British Columbia and St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Yanjun Chen
- Edwards Lifesciences, Irvine, California, USA
| | - Craig R Smith
- Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York, USA
| | | | - Martin B Leon
- Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York, USA
| | - Philippe Pibarot
- Department of Medicine, Laval University, Quebec City, Quebec, Canada
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15
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Eng MH, Abbas AE, Hahn RT, Lee J, Wang DD, Eleid MF, O'Neill WW. Real world outcomes using 20 mm balloon expandable SAPIEN 3/ultra valves compared to larger valves (23, 26, and 29 mm)-a propensity matched analysis. Catheter Cardiovasc Interv 2021; 98:1185-1192. [PMID: 33984182 DOI: 10.1002/ccd.29756] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 03/30/2021] [Accepted: 05/03/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE/BACKGROUND Small balloon expandable valves have higher echocardiographic transvalvular gradients and rates of prosthesis-patient mismatch (PPM) compared to larger valves. However, the impact of these echocardiographic findings on clinical outcomes is unknown. We sought to determine the clinical outcomes of 20 mm SAPIEN 3 (S3 BEV) compared to larger S3 BEV in relation to echocardiographic hemodynamics. METHODS Using the STS/ACC transcatheter valve registry, we performed a propensity-matched comparison of patients undergoing treatment of native aortic valve stenosis using transfemoral, balloon-expandable implantation of 20 mm and ≥ 23 mm S3 BEVs. Baseline and procedure characteristics, echocardiographic variables and survival were analyzed. Multivariable logistic regression was used to identify predictors of 1-year mortality. RESULTS After propensity matching of the 20 mm and ≥ 23 mm SAPIEN 3 valves, 3,931 pairs with comparable baseline characteristics were identified. Small valves were associated with significantly higher echocardiographic gradients at discharge (15.7 ± 7.1 mmHg vs. 11.7 ± 5.5 mmHg, p < 0.0001) and severe PPM rates (21.5% vs. 9.7%, p < 0.0001). There was no significant difference in 1-year all-cause mortality (20 mm: 13.0% vs. ≥23 mm: 12.7%, p = 0.72) or other major adverse event rates and outcomes between the two cohorts. Based on a multivariable analysis, elevated discharge mean gradient (>20 mmHg), severe PPM and the use of 20 mm versus ≥23 mm were not independent predictors of 1-year mortality. CONCLUSION SAPIEN 3 20 mm valves were associated with higher echocardiographic gradients, and severe PPM rates compared to larger valves but these factors were not associated with significant differences in 1-year all-cause mortality or rehospitalization.
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Affiliation(s)
- Marvin H Eng
- Department of Medicine, Center for Structural Heart Disease, Henry Ford Health System, Detroit, Michigan, USA
| | - Amr E Abbas
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan, USA
| | - Rebecca T Hahn
- New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - James Lee
- Department of Medicine, Center for Structural Heart Disease, Henry Ford Health System, Detroit, Michigan, USA
| | - Dee Dee Wang
- Department of Medicine, Center for Structural Heart Disease, Henry Ford Health System, Detroit, Michigan, USA
| | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - William W O'Neill
- Department of Medicine, Center for Structural Heart Disease, Henry Ford Health System, Detroit, Michigan, USA
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16
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Vaidya YP, Cavanaugh SM, Sandhu AA. Surgical aortic valve replacement in small aortic annulus. J Card Surg 2021; 36:2502-2509. [PMID: 33821514 DOI: 10.1111/jocs.15555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although aortic valve replacement (AVR) has been the standard of treatment for severe aortic stenosis, a small aortic annulus (SAA) poses significant challenges. Improvements in valve designs and evolution in surgical techniques have led to improved outcomes, however, the ideal prosthetic valve remains elusive. METHODS We performed a comprehensive literature review to discuss the surgical management of aortic stenosis, with a special focus on patients with SAA. RESULTS Stentless valves and root replacement techniques have been shown to overcome the hemodynamic challenges associated with conventional stented bioprostheses, but are technically challenging and require longer cross-clamp times. Sutureless and rapid deployment valves mitigate the long operative time while maintaining the hemodynamic advantages. The use of transcatheter AVR has emerged as another reasonable alternative and has shown promise among patients with SAA, however, long-term outcomes are awaited. CONCLUSION There is no consensus regarding the type of valve prosthesis or replacement technique among patients with SAA. Consideration of patient comorbidities and valvular anatomy is paramount in planning the optimal strategy for AVR. Further long-term clinical trials are necessary to assess outcomes and achieve progress toward the development of the ideal prosthesis.
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Affiliation(s)
- Yash P Vaidya
- Department of Surgery, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Shaelyn M Cavanaugh
- Department of Surgery, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Aqeel A Sandhu
- Department of Cardiothoracic Surgery, SUNY Upstate Medical University, Syracuse, New York, USA
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17
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Hase H, Yoshijima N, Yanagisawa R, Tanaka M, Tsuruta H, Shimizu H, Fukuda K, Naganuma T, Mizutani K, Yamawaki M, Tada N, Yamanaka F, Shirai S, Tabata M, Ueno H, Takagi K, Watanabe Y, Yamamoto M, Hayashida K. Transcatheter aortic valve replacement with Evolut R versus Sapien 3 in Japanese patients with a small aortic annulus: The OCEAN-TAVI registry. Catheter Cardiovasc Interv 2020; 97:E875-E886. [PMID: 32926552 DOI: 10.1002/ccd.29259] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 08/20/2020] [Accepted: 08/21/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To compare safety, efficacy, and hemodynamics of transfemoral transcatheter aortic valve replacement (TAVR) using self-expanding and balloon-expandable transcatheter heart valves (THVs) in patients with a small aortic annulus. BACKGROUND Few studies have directly compared TAVR outcomes using third-generation THVs, focusing on patients with small aortic annuli. METHODS In a multicenter TAVR registry, we analyzed data from 576 patients with a small annulus and who underwent transfemoral TAVR using third-generation THVs. Propensity score matching was used to adjust baseline clinical characteristics. RESULTS The device success rate in the overall cohort was 92.0% (Evolut R: 92.1% vs. Sapien 3:92.0%, p = 0.96). One year after TAVR, patients treated with Evolut R maintained a lower mean pressure gradient (mPG) and a higher indexed effective orifice area (iEOA) in the matched cohort {mPG: 9.0 [interquartile range (IQR): 6.0-11.9] vs. 12.0 [IQR: 9.9-16.3] mmHg, p < .001; iEOA: 1.20 [IQR: 1.01-1.46] vs. 1.08 [IQR: 0.90-1.28] cm2 /m2 , p < .001}. However, no significant differences were reported in the incidence of severe prosthesis-patient mismatch and aortic regurgitation at 1 year. Furthermore, both groups showed comparable outcomes with no differences in terms of all-cause mortality (log-lank test, p = .81). CONCLUSIONS TAVR for patients with a small annulus using third-generation THVs was associated with high device success. Evolut R seems to be superior to Sapien 3 in hemodynamic performance for patients with a small annulus and body surface area up to 1 year after TAVR. Nevertheless, all-cause mortality at 1 year was similar between both groups.
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Affiliation(s)
- Hiromu Hase
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Nobuhiro Yoshijima
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Ryo Yanagisawa
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Makoto Tanaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Hikaru Tsuruta
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Hideyuki Shimizu
- Department of Cardiovascular Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | | | - Kazuki Mizutani
- Department of Cardiology, Osaka City General Hospital, Osaka, Japan
| | | | | | | | | | - Minoru Tabata
- Department of Cardiovascular Surgery, Tokyo Bay Urayasu-Ichikawa Medical Center, Chiba, Japan
| | | | | | | | - Masanori Yamamoto
- Toyohashi Heart Center, Toyohashi, Japan.,Nagoya Heart Center, Nagoya, Japan
| | - Kentaro Hayashida
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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18
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Costa G, Criscione E, Reddavid C, Barbanti M. Balloon-expandable versus self-expanding transcatheter aortic valve replacement: a comparison and evaluation of current findings. Expert Rev Cardiovasc Ther 2020; 18:697-708. [DOI: 10.1080/14779072.2020.1807326] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Giuliano Costa
- Division of Cardiology, Policlinico-Vittorio Emanuele Hospital, C.A.S.T., University of Catania, Catania, Italy
| | - Enrico Criscione
- Division of Cardiology, Policlinico-Vittorio Emanuele Hospital, C.A.S.T., University of Catania, Catania, Italy
| | - Claudia Reddavid
- Division of Cardiology, Policlinico-Vittorio Emanuele Hospital, C.A.S.T., University of Catania, Catania, Italy
| | - Marco Barbanti
- Division of Cardiology, Policlinico-Vittorio Emanuele Hospital, C.A.S.T., University of Catania, Catania, Italy
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19
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Joffe DC, Sheu R, Keeshan BC, Burbano-Vera N. The Role of Novel Transcatheter Procedures in Patients With Congenital Heart Disease. J Cardiothorac Vasc Anesth 2020; 35:2180-2193. [PMID: 32758406 DOI: 10.1053/j.jvca.2020.07.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/03/2020] [Accepted: 07/04/2020] [Indexed: 02/02/2023]
Abstract
The development of percutaneous structural interventions in patients with acquired heart disease is happening at an exponential rate, and some of this technology is being used to treat patients with congenital heart disease. This review describes the pathophysiology of valvular abnormalities specific to congenital heart disease and discusses the application of structural procedures in this population. Although the overall experience has been encouraging, especially in high-risk patients, this article will highlight the reasons that a cautious approach to adoption of this technology is necessary in these patients.
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Affiliation(s)
- Denise C Joffe
- Department of Anesthesiology and Pain Medicine, University of Washington Medical Center and Seattle Children's Hospital, Seattle, WA.
| | - Richard Sheu
- Department of Anesthesiology and Pain Medicine, University of Washington Medical Center and Seattle Children's Hospital, Seattle, WA
| | - Britton C Keeshan
- Yale University Department of Pediatrics, Division of Pediatric Cardiology, Yale New Haven Hospital, New Haven, CT
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