Excellent Outcomes for Transcatheter Aortic Valve Replacement Within 1 Year of Opening a Low-Volume Centre and Consideration of Requirements

Surgical versus trans-catheter aortic valve replacement (SAVR vs TAVR) in patients with aortic stenosis: Experience in a community hospital

Trans-catheter aortic valve replacement (TAVR) has become an alternative to surgical aortic valve replacement (SAVR) in high and intermediate risk patients with aortic stenosis. TAVR programs are spreading from large referral centers and being established in community based institutions. The purpose of this study was to compare the outcomes of TAVR to those of SAVR in a community hospital.A historical cohort study of patients with aortic stenosis and pre-post procedure echocardiography data who underwent SAVR or TAVR in Cape Cod Hospital between January 2014 and December 2016. Patient characteristics and procedure outcomes were compared between the two procedures.The study included 230 patients, of them 111 underwent SAVR and 119 underwent TAVR. None of the patients died during the 30 days after the procedure. TAVR patients had higher rates of postoperative mild+ aortic regurgitation (AR) (29.4% vs 12.6%, P = .002), postoperative atrial ventricular blocks (11.8% vs 0.9%, P = .001), and more often need an implantation of pacemaker (16.8% vs 0.9%, P < .001). Postoperative mean gradient of SAVR patients was higher (median 14 vs 11 mm Hg, P = .001) and atrial fibrillation postoperatively was more frequent (18.9% vs 2.5%, P < .001). Length of stay after procedure was shorter in TAVR patients (median 2 vs 4 days, P < .001).After controlling for confounders, the use of TAVR was associated with an increased risk for postoperative pacemaker implantation (OR = 16.3, 95%CI 1.91-138.7, P = .011), lower mean gradient (-4.327, 95%CI -7.68 to -0.98, P = .011), and lower risk for atrial fibrillation (OR = 0.11, 95%CI 0.03-0.38, P = .001), but not with postoperative AR (OR = 0.84, 95%CI 0.22-3.13, P = .789).In conclusion, short-term mortality was not reported in SAVR or TAVR patients. However, TAVR was associated with an increased risk for postoperative pacemaker implantation but with a lower risk for atrial fibrillation. Aortic valves implanted through a trans-catheter approach are also associated with a better hemodynamic performance.

Platelet and coagulation disorders in newly diagnosed patients with pulmonary arterial hypertension

There is a complex and not fully elucidated association between pulmonary arterial hypertension (PAH) and coagulation disorders. The goal of this study was to evaluate platelet function, coagulation and fibrinolysis in PAH patients at diagnosis, before PAH-specific treatment initiation. We enrolled 20 healthy controls and 30 PAH patients (20 with connective tissue disease (CTD-PAH) and 10 idiopathic (iPAH)). None of the participants was on any antiplatelet or anticoagulation therapy. Blood samples from PAH patients were collected during the initial right heart catheterization. All subjects were assessed with platelet function analyzer-100 (PFA-100), epinephrine (Epi) and ADP-induced light transmission aggregometry (LTA), thromboelastometry (ROTEM) and endogenous thrombin potential (ETP). Our results showed that Epi and ADP-LTA values were significantly lower in newly diagnosed PAH patients compared to controls. Disaggregation was present in 73% of patients, a characteristic not seen in healthy individuals. In ROTEM assay, CT and CFT measurements were significantly higher and a angle lower compared to controls. ETP testing revealed significantly reduced outcomes in AUC, Cmax and Tmax. When CTD-PAH and iPAH patient groups were compared, iPAH ADP-LTA values were significantly decreased compared to CTD-PAH. In conclusion, newly diagnosed PAH patients presented with decreased platelet aggregation, clot propagation and thrombin generation, along with delayed initiation of the coagulation process. These hemostatic deficits could indicate an "exhaustion" of the coagulation process that could be caused by endothelial dysfunction and chronic activation of the procoagulant pathways. Further studies are warranted to confirm these laboratory findings and assess their potential clinical significance.

New-onset arrhythmias following transcatheter aortic valve implantation: a systematic review and meta-analysis

Objective

To evaluate the prevalence and clinical impact of new-onset arrhythmias in patients following transcatheter aortic valve implantation (TAVI).

Method

We systematically identified studies reporting new-onset arrhythmias after TAVI other than atrioventricular conduction disturbances. We summarised monitoring strategies, type and prevalence of arrhythmias and estimated their effect on risk of death or cerebrovascular events by using random-effects meta-analysis. The study is registered withInternational prospective register of systematic reviews (PROSPERO) (CRD42017058053).

Results

Sixty-five studies (43 506 patients) reported new-onset arrhythmias following TAVI. The method of arrhythmia detection was specified only in 31 studies (48%). New-onset atrial fibrillation (NOAF) (2641 patients), bradyarrhythmias (182 patients), supraventricular arrhythmias (29 patients), ventricular arrhythmias (28 patients) and non-specified major arrhythmias (855 patients) were reported. In most studies (52 out of 65), new-onset arrhythmia detection was limited to the first month following TAVI. The most frequently documented arrhythmia was NOAF with trend of increasing summary prevalence of 11%, 14%, 14% and 25% during inhospital, 30-day, 1-year and 2-year follow-ups, respectively (P for trend=0.011). Summary prevalence estimates of NOAF at 30-day follow-up differ significantly between studies of prospective and retrospective design (8% and 21%, respectively, P=0.002). New episodes of bradyarrhythmias were documented with a summary crude prevalence of 4% at 1-year follow-up. NOAF increased the risk of death (relative risk 1.61, 95% CI 1.35 to 1.98, I2=47%) and cerebrovascular events (1.79, 95% CI 1.24 to 2.64, I2=0%). No study commented on therapeutic modifications following the detection of new-onset arrhythmias.

Conclusions

Systematic identification of new-onset arrhythmias following TAVI may have considerable impact on subsequent therapeutic management and long-term prognosis in this patient population.

Vascular complications associated with transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) is now an accepted pathway for aortic valve replacement for patients who are at prohibitive, severe and intermediate risk for traditional aortic valve surgery. However, with this rising uptrend and adaptation of this new technology, vascular complications and their management remain an Achilles heel for percutaneous aortic valve replacement. The vascular complications are an independent predictor of mortality for patients undergoing TAVR. Early recognition of these complications and appropriate management is paramount. In this article, we review the most commonly encountered vascular complications associated with currently approved TAVR devices and their optimal percutaneous management techniques.

Early Hemodynamic Results in Patients with Small Aortic Annulus after Aortic Valve Replacement

Objective

Patients with a small aortic annulus (≤21 mm) have an increased risk of patient-prosthesis mismatch after valve replacement. The aim of this study was to compare the early hemodynamic performance of the balloon-expandable transaortic valve implantation Edwards system (SAPIEN) and the sutureless Perceval prostheses.

Methods

Fifty patients underwent transcatheter aortic valve implantation, and 113 patients underwent sutureless aortic valve replacement. Mean ± SD aortic annulus diameter was 19.7 ± 1 mm, with no significant difference between groups. SAPIEN valve size was 23 mm in 40 patients (80%) and 26 mm in 10 patients (20%). Perceval valve size was small in 45 patients (40%), medium in 62 patients (55%), and large in 6 patients (5%). Transthoracic Doppler echocardiographic images were collected at baseline and before discharge.

Results

There were no significant difference in predischarge effective orifice area (SAPIEN: 1.5 ± 0.5 cm2 and Perceval: 1.48 ± 0.34 cm2, P = 0.58) and indexed effective orifice areas (SAPIEN: 0.93 ± 0.32 cm2/m2 and Perceval: 0.88 ± 0.22 cm2/m2, P = 0.42). Predischarge mean ± SD transaortic gradient was lower with the SAPIEN than with Perceval valves (12 ± 6 and 17 ± 6 mm Hg, respectively, P < 0.001). Rates of moderate and severe prosthesis-patient mismatch were similar (SAPIEN: 44% and 10% and Perceval: 50% and 14%, P = 0.53 and 0.75, respectively). There were no moderate-severe paravalvular leaks.

Conclusions

Although indexed effective orifice areas were similar, transcatheter aortic valve implantation with the balloon-expandable SAPIEN system yielded lower predischarge transaortic mean gradients than the surgically implanted Perceval, in patients with a small annulus.