Survival in elderly patients with severe aortic stenosis is dramatically improved by aortic valve replacement: Results from a cohort of 277 patients aged > or =80 years

Gender differences in the presentation and management of patients with severe aortic stenosis at specialist versus primary/secondary care centres: A sub-analysis of the IMPULSE enhanced registry

BACKGROUND

Management and treatment of severe aortic stenosis (AS) may differ considerably in European countries. To investigate these differences in France, Germany, and the UK, the IMPULSE enhanced registry was established. Previous data revealed differences in how patients were managed in specialist (hub) versus primary/secondary care (satellite) centres.

METHODS

The IMPULSE enhanced registry sub-analysis aimed to determine if there were gender-specific differences for patients with severe AS at centres with and without access to intervention.

RESULTS

Among the 790 patients, 594 and 196 were recruited at hub and satellite centres, respectively; 44 % of patients were female. In both settings, women were older than men (hubs: 78.7 vs. 76.2, p = 0.007; satellites: 79.8 vs. 75.1, p = 0.002). Symptoms at the presentation were comparable. Males had more often undergone previous cardiac surgery. Females had a smaller left ventricular (LV) outflow tract, smaller LV cavities, and, more often, a preserved ejection fraction (>50 %). There was no gender-based difference in time to intervention. At one year, the cumulative incidence of aortic valve replacement in females was higher than in males in hubs (p = 0.012) but not in satellites (p = 0.600); surgical AVR was more common in males in hubs only (p = 0.008), while transcatheter aortic valve implantation was more common in females in both settings (hubs: p < 0.001; satellites: p = 0.022). One-year survival was comparable in both genders, regardless of setting.

CONCLUSIONS

A better understanding of gender-specific differences in patients with severe AS, according to the diagnostic setting, could improve patient stratification and earlier diagnosis.

Clot lysis time and thrombin generation in patients undergoing transcatheter aortic valve implantation

BACKGROUND

Aortic valve stenosis (AS) is the most prevalent valvular heart disease and is associated with a significant increase in mortality. AS has been shown to be linked with numerous coagulation system abnormalities, including increased fibrin deposition on the stenotic aortic valves. Transcatheter aortic valve implantation (TAVI) is the primary treatment method for patients at high surgical risk.

OBJECTIVES

The aim of the study was to assess the impact of treating severe AS with TAVI on thrombin generation and clot lysis time (CLT).

METHODS

We studied 135 symptomatic AS patients recommended for TAVI by the local Heart Team. All measurements were performed before and 5-7 days after TAVI. Alongside clinical assessment and echocardiographic analysis, we assessed clot lysis time (CLT) and thrombin generation parameters, including lag time, peak thrombin generation, time to peak thrombin generation (ttPeak), and endogenous thrombin potential (ETP).

RESULTS

70 patients were included in the final analysis. After TAVI, there was a significant 9% reduction in CLT despite a 12% increase in fibrinogen concentration. We observed significant increase in lag time and ttPeak (20% and 12%, respectively), and 13% decrease in peak thrombin concentration compared to pre-procedural levels. Multivariable linear regression analysis demonstrated that baseline CLT and C-reactive protein (CRP) levels were independent predictors of significant reduction in mean aortic gradient, defined as TAVI procedure success.

CONCLUSIONS

CLT and peak thrombin concentration decreased, while Lag time and ttPeak increased significantly after TAVI. Multivariable linear regression analysis demonstrated CLT and CRP levels as independent predictors of achieving a reduction in mean aortic gradient, defining TAVI procedure success.

Prognostic value of high-sensitive troponin T in patients with severe aortic stenosis undergoing valve replacement surgery

BACKGROUND

Aortic stenosis (AS) is a well-known cause of mortality. We aimed to assess the prognostic value of high-sensitive troponin T (hs-TnT) in symptomatic patients with severe AS and preserved left ventricular ejection fraction (LVEF) after surgical aortic valve replacement (AVR).

PATIENTS AND METHODS

The study recruited patients with severe symptomatic AS fulfilling the inclusion criteria in the period between April 2020 and February 2022. Comprehensive echocardiography was done. The following parameters were assessed: AS severity, LV mass index (LVMI), left atrium volume index (LAVI), and LVEF. E/e' and LVEF were calculated using the biplane method of Simpsons. Global longitudinal strain (GLS) was assessed by speckle tracking echocardiography. Peripheral blood samples were collected for hs-TnT measurement. All patients underwent surgical AVR. The patients were followed for the following 6 months for major adverse cardiovascular events (MACE). MACE was defined as cardiac death, re-admission for congestive heart failure (CHF) and fatal arrhythmia.

RESULTS

One hundred and eight patients (mean age = 58.7 ± 7.68 years) with severe AS were recruited. Seventeen patients presented with MACE including 8 cardiac deaths. We divided the patients into two groups based on the normal hs-TnT values. The Kaplan-Meier curve revealed a statistically significant difference in MACE rate among troponin groups (log-rank test = 5.06, p = 0.025). There was significant difference between both groups regarding GLS with smaller GLS in negative hs-TnT group. In multivariate analysis, GLS and hs-TnT were significantly associated with MACE (p = 0.022 and < 0.01 respectively). The cutoff value of hs-TnT of 238.25 had a sensitivity of 70% and a specificity of 81% for predicting future MACE. There was a significant correlation between GLS and troponin (p < 0.001).

CONCLUSIONS

hs-TnT is associated with bad short-term prognosis after AVR. hs-TnT and GLS could be significant predictors for future MACE in patients with severe symptomatic AS and preserved LVEF who underwent AVR. Elevated hs-TnT and impaired GLS could set an indication of early intervention in asymptomatic severe AS.

Direct deep learning-based survival prediction from pre-interventional CT prior to transcatheter aortic valve replacement

PURPOSE

To investigate survival prediction in patients undergoing transcatheter aortic valve replacement (TAVR) using deep learning (DL) methods applied directly to pre-interventional CT images and to compare performance with survival models based on scalar markers of body composition.

METHOD

This retrospective single-center study included 760 patients undergoing TAVR (mean age 81 ± 6 years; 389 female). As a baseline, a Cox proportional hazards model (CPHM) was trained to predict survival on sex, age, and the CT body composition markers fatty muscle fraction (FMF), skeletal muscle radiodensity (SMRD), and skeletal muscle area (SMA) derived from paraspinal muscle segmentation of a single slice at L3/L4 level. The convolutional neural network (CNN) encoder of the DL model for survival prediction was pre-trained in an autoencoder setting with and without a focus on paraspinal muscles. Finally, a combination of DL and CPHM was evaluated. Performance was assessed by C-index and area under the receiver operating curve (AUC) for 1-year and 2-year survival. All methods were trained with five-fold cross-validation and were evaluated on 152 hold-out test cases.

RESULTS

The CNN for direct image-based survival prediction, pre-trained in a focussed autoencoder scenario, outperformed the baseline CPHM (CPHM: C-index = 0.608, 1Y-AUC = 0.606, 2Y-AUC = 0.594 vs. DL: C-index = 0.645, 1Y-AUC = 0.687, 2Y-AUC = 0.692). Combining DL and CPHM led to further improvement (C-index = 0.668, 1Y-AUC = 0.713, 2Y-AUC = 0.696).

CONCLUSIONS

Direct DL-based survival prediction shows potential to improve image feature extraction compared to segmentation-based scalar markers of body composition for risk assessment in TAVR patients.

Transcatheter aortic valve implantation vs. surgical aortic valve replacement for aortic stenosis in Taiwan: A population-based cohort study

OBJECTIVE

Aortic stenosis (AS) is a heart valve disease characterized by left ventricular outflow fixed obstruction. It can be managed by surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI). However, real-world evidence for TAVI or SAVR outcomes is lacking in Taiwan. This study aimed to compare the clinical outcomes of TAVI and SAVR for treating of AS in Taiwan.

MATERIALS AND METHODS

The National Health Insurance Research Database is a nationally representative cohort that contains detailed registry and claims data from all 23 million residents of Taiwan. This retrospective cohort study used this database to compare patients who underwent SAVR (bioprosthetic valves) or TAVI from 2017 to 2019. Survival outcomes and length of hospital stay (LOS) and intensive care unit (ICU) stay between TAVI and SAVR in the matched cohort. A Cox proportional hazards model was performed to identify the effect of treatment type on survival rates while controlling variables including age, gender, and comorbidities.

RESULTS

We identified 475 and 1605 patients who underwent TAVI and SAVR with a bioprosthetic valve, respectively. Patients who underwent TAVI were older (82.19 vs. 68.75 y/o) and more likely to be female (55.79% vs. 42.31%) compared with patients who underwent SAVR. Propensity score matching (PSM) on age, gender, and Elixhauser Comorbidity Index (ECI) score revealed that 375 patients who underwent TAVI were matched with patients who underwent SAVR. A significant difference was found in survival rates between TAVI and SAVR. The 1-year mortality rate was 11.44% with TAVI and 17.55% with SAVR. Both the mean total LOS (19.86 vs. 28.24 days) and mean ICU stay (6.47 vs. 11.12 days) for patients who underwent TAVI were shorter than those who underwent SAVR.

CONCLUSION

Patients who had undergone TAVI had better survival outcomes and shorter LOS compared with patients who had undergone SAVR in Taiwan.

Similar clinical outcomes with transcatheter aortic valve implantation and surgical aortic valve replacement in octogenarians with aortic stenosis

Background

Transcatheter aortic valve implantation (TAVI) is the preferred treatment option for severe aortic stenosis in the elderly and in patients with comorbidities. We sought to compare outcomes after TAVI and surgical aortic valve replacement (SAVR) in octogenarians.

Methods

In this retrospective cohort study conducted at our tertiary center, clinical data were gathered before and after TAVI and SAVR procedures performed from January 2013 to May 2019; follow-up completed in March 2021. The primary outcome was 1-year mortality. Patients were stratified according to Society of Thoracic Surgeons (STS) score and procedure type. Propensity score-based matching was also performed.

Results

Of 542 patients who matched the inclusion criteria, 273 underwent TAVI and 269 SAVR. TAVI patients were older (85.8 ± 3.0 vs. 82.2 ± 2.2 years; P &lt; 0.001) and had a higher mean STS score (5.0 ± 4.0 vs. 2.8 ± 1.3; P &lt; 0.001) and EuroSCORE II (5.3 ± 4.1 vs. 2.8 ± 6.0; P &lt; 0.001). Rates of postoperative permanent pacemaker insertion (15.0% vs. 9.3%; P = 0.040) and paravalvular leak (9.9% vs. 0.8%; P &lt; 0.001) were higher and acute kidney injury lower (8.8% vs. 32.7%; P &lt; 0.001) after TAVI, with no difference between treatment groups for major bleeding (11.0% vs. 6.7%; P = 0.130) or 30-day mortality (5.5% vs. 3.7%; P = 0.315). A statistically significant difference was found between TAVI and SAVR in low- and intermediate-risk groups when it came to occurrence of paravalvular leak, acute kidney injury, and new onset AF (all P &lt; 0.001).

Conclusion

This analysis of an octogenarian “real-life” population undergoing TAVI or SAVR (with a biological valve) showed similar outcomes regarding clinical endpoints in low- and medium-risk (STS score) groups.

Prosthetic Valve Function after Aortic Valve Replacement for Severe Aortic Stenosis by Transcatheter Procedure versus Surgery

Background This study compared the clinical outcomes of transcatheter (TAVR) and surgical (SAVR) aortic valve replacements, focusing on postoperative valvular performance assessed by echocardiography. Method and Results A total of 425 patients who underwent TAVR (230 patients) or SAVR (195 patients) were included. Postoperative effective orifice area index (EOAI) was higher in the TAVR group (1.27 ± 0.35 cm2/m2) than in the SAVR group (1.06 ± 0.27 cm2/m2, p < 0.001), and patient−prosthesis mismatch (PPM) was more frequent in the SAVR group (22.6%) than in the TAVR group (8.7%, p < 0.001). Mild or greater paravalvular leakage (PVL) was more frequent in the TAVR group (21.3%) than in the SAVR group (0%, p < 0.001). Moreover, there was no difference in freedom from all-cause death, stroke, or rehospitalization between the groups. Patients with moderate or greater PPM (EOAI < 0.85 cm2/m2) had lower freedom from composite events than those without this PPM criterion (p = 0.008). Patients with mild or greater PVL also had lower freedom from composite events than those without this PVL criterion (p = 0.017). Conclusions Postoperative valvular performance of TAVR was superior to that of SAVR in terms of EOAI. This merit was counterbalanced by the significantly lower rates of PVL in patients who underwent SAVR. The overall clinical outcomes were similar between the study groups.

Preoperative red cell distribution width to lymphocyte ratio as biomarkers for prolonged intensive care unit stay among older patients undergoing cardiac surgery: a retrospective longitudinal study

Introduction: Our aim was to use the red cell distribution width-lymphocyte ratio (RLR) as a novel biomarker to predict prolonged intensive care unit (ICU) length of stay (LOS) among older patients undergoing cardiovascular surgery. Methods: This longitudinal study included older patients admitted to a tertiary cardiovascular surgery hospital between January 2017 and January 2022. Results: A total of 574 patients were studied, including 83 patients (14.5%) who had prolonged ICU LOS and 471 (85.5%) control subjects. After adjustment for the European System for Cardiac Operative Risk Evaluation 2, the RLR score showed a 10% increased risk of prolonged ICU LOS (odds ratio: 1.10; CI: 1.05-1.16; p = 0.01). Conclusion: Preoperative RLR can be used to predict the risk of long-term intensive care stay in older cardiac surgery patients.

Single-cell transcriptomics reveal cellular diversity of aortic valve and the immunomodulation by PPARγ during hyperlipidemia

Valvular inflammation triggered by hyperlipidemia has been considered as an important initial process of aortic valve disease; however, cellular and molecular evidence remains unclear. Here, we assess the relationship between plasma lipids and valvular inflammation, and identify association of low-density lipoprotein with increased valvular lipid and macrophage accumulation. Single-cell RNA sequencing analysis reveals the cellular heterogeneity of leukocytes, valvular interstitial cells, and valvular endothelial cells, and their phenotypic changes during hyperlipidemia leading to recruitment of monocyte-derived MHC-II^hi macrophages. Interestingly, we find activated PPARγ pathway in Cd36⁺ valvular endothelial cells increased in hyperlipidemic mice, and the conservation of PPARγ activation in non-calcified human aortic valves. While the PPARγ inhibition promotes inflammation, PPARγ activation using pioglitazone reduces valvular inflammation in hyperlipidemic mice. These results show that low-density lipoprotein is the main lipoprotein accumulated in the aortic valve during hyperlipidemia, leading to early-stage aortic valve disease, and PPARγ activation protects the aortic valve against inflammation.

Identifying the mechanisms underlying the early inflammatory phase of aortic valve disease is crucial for disease prevention. Here the authors perform single-cell RNA sequencing to show the immunomodulatory role of PPARγ in valvular endothelial cells during hyperlipidemia.

Silent Brain Infarction, Delirium, and Cognition in Three Invasive Cardiovascular Procedures: a Systematic Review

Silent brain infarctions (SBIs) are brain lesions noted on neuroimaging that are not associated with clinical symptoms. SBIs are associated with a number of vascular risk factors and are common following invasive cardiovascular procedures such as atrial fibrillation (AF) ablation, coronary artery bypass graft (CABG), and transcatheter aortic valve replacement (TAVR). Although not eliciting signs of clinical stroke, SBIs are associated with increased frailty, and motor and mood features. Less is known, however, about the relationship between SBI, cognition, and delirium following invasive cardiac procedures and most investigations into these relationships have been reported in large-scale epidemiological studies. In the current paper, we conducted a systematic review to evaluate evidence of a relationship between SBI, delirium, and cognitive decline following CABG, AF ablation, and TAVR. Twenty studies met inclusion criteria. In general, our review identified conflicting results for each cardiac procedure, with some studies suggesting a relationship between SBI, cognitive impairment, and delirium, whereas others showed no relationship between SBI, cognitive impairment, and delirium. Potential reasons for this discrepancy as well as suggestions for future research are discussed.

Case Report: Osmotic Demyelination Syndrome After Transcatheter Aortic Valve Replacement: Case Report and Review of Current Literature

Background

Osmotic demyelination syndrome (ODS) has a low incidence but is a life-threatening neurological disorder whose common cause is rapid overcorrection of chronic hyponatremia. Transcatheter aortic valve replacement (TAVR) is a new and important therapy for patients with aortic valve stenosis. In this article, we discuss the case of a 64-year-old woman who developed ODS after TAVR and provide a literature review.

Case Presentation

A 64-year-old female patient was admitted to the hospital with chest tightness, shortness of breath, and fatigue for 2 months, with worsening of symptoms for 3 days prior to presentation. Auscultation revealed crackles in the lung fields, and systolic murmurs could be easily heard in the aortic area. Echocardiography showed severe aortic stenosis. Chest X-ray showed pulmonary oedema. Laboratory examinations showed that her serum sodium was 135 mmol/L. The patient received a diuretic to relieve her symptoms but showed little benefit. Her symptoms worsened, and her blood pressure dropped. Then, she underwent emergency TAVR under extracorporeal membrane oxygenation (ECMO) support. After the operation, her urine output increased markedly, and serum sodium increased sharply from 140 to 172 mmol/L. An MRI scan showed multiple lesions in the pons suggestive of ODS.

Conclusion

To date, this is the first reported case of a patient who developed ODS after receiving TAVR. In current clinical practice, diuretics are often used in aortic stenosis patients because of pulmonary oedema. After a patient receives TAVR, kidney perfusion pressure quickly returns to normal, and with the residual effect of a high-dose diuretic, balances of fluid volume and electrolyte levels in this phase are quite fragile and must be carefully managed. If a patient has neurological symptoms/signs during this phase, ODS should be considered, and MRI might be necessary.

Transaxillary Versus Transaortic Transcatheter Aortic Valve Implantation in the Treatment of Aortic Stenosis: An Updated Systematic Review and Meta-Analysis

Transcatheter aortic valve replacement (TAVR) is a technique that can be performed through multiple approaches, and the benefits of one approach over another are still being evaluated to make sure patients receive the best possible care. Our meta-analysis aims to compare clinical and procedural outcomes of the transaxillary (TAx) and transaortic (TAo) approaches to validate the more optimal procedure.

The systematic literature search was done via PubMed/MEDLINE, Embase, and the Cochrane Central databases from inception to December 2021, to identify articles reporting data on both TAx TAVR and TAo TAVR. In addition, we checked ClinicalTrials.gov for more published or unpublished trials. Baseline patient characteristics, procedure results, and clinical results were extracted from the article and pooled for analysis. A quantitative meta-analysis was conducted using Review Manager (RevMan) version 5.3 (Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark). The outcomes extracted included blood transfusion, conversion to sternotomy, tamponade, contrast amount, procedure time, bleeding incidents (minor, major, or life-threatening), length of stay (LOS), vascular complications (minor or major), acute kidney injury (AKI), paravalvular leak (PVL), permanent pacemaker (PPM) implantation, 30-day mortality, one-year mortality, 30-day stroke, and device success.

The final analysis included 11 articles, consisting of 10 observational studies and a pivotal trial. Cumulative results revealed that the TAo approach had a significantly lower incidence of vascular complications (RR = 2.30; 95% CI = 1.22 to 4.35), and the need for implantation of a permanent pacemaker (RR = 1.82; 95% CI = 1.30 to 2.54) along with a lower amount of contrast (mean difference (MD) = 27.40; 95% CI = 3.73 to 51.08) needed to be used. The TAx group was associated with a significantly lower 30-day mortality (RR = 0.46; 95% CI = 0.31 to 0.69), AKI (RR = 0.47; 95% CI = 0.33 to 0.67), and length of hospital stay (MD = −1.95; 95% CI = −2.51 to −1.38). No significant difference was observed between the outcomes of 30-day stroke (RR = 1.38; 95% CI = 0.81 to 2.33), PVL (RR = 1.05; 95% CI = 0.50 to 2.18), tamponade (RR = 0.71; 95% CI = 0.12 to 4.03), conversion to sternotomy (RR = 0.51; 95% CI = 0.06 to 4.30), device success (RR = 0.97; 95% CI = 0.88 to 1.07), the incidence of bleeding (RR = 0.75; 95% CI = 0.51 to 1.10), and procedure time (MD = 4.44; 95% CI = −96.30 to 105.17).

Both the procedures were associated with their benefits and risks. Although most of the outcomes favored TAx transcatheter aortic valve implantation (TAVI), it is too early to say if it would be better than TAo TAVI. To authenticate the findings concluded in this meta-analysis and further improve our understanding of the efficacy, safety, and risk profile between TAx and TAo approaches for TAVI, large sample randomized clinical trials are required on a wide scale.

The transcatheter aortic valve implantation: an assessment of the generalizability of the economic evidences following a systematic review

OBJECTIVES

Scientific literature debates on the economic affordability of transcatheter aortic valve implantation (TAVI) in order to give a useful support to decision makers aiming at establishing a reimbursement scheme for TAVI. For this reason, it is important to assess the quality and the generalizability of the existing economic evidences.

METHODS

The first step was to run a literature search according to a predefined population, intervention, comparator, and outcome on the cost and effectiveness of the TAVI procedure in comparison to medical therapy and traditional surgery. Second, a manual search was carried out on the Web sites of the main HTA agencies. Third, the checklist developed by Augustovski et al. was applied in order to assess the quality and the generalizability of the articles resulting from the selection process.

RESULTS

Overall, 106 articles were obtained. Of these, sixty-five articles were excluded since the title was not consistent with the objective. Further selection took place after abstract and full-text reading. In the end, thirty-one documents were included for the review. According to the checklist, none of the articles was considered generalizable and only one was considered transferable which compares the TAVI procedure with Medical Management in inoperable patients.

CONCLUSIONS

Despite the overall quality of the selected studies was considered good, there is still a lack of evidence on whether evidences generated in different contexts can be considered generalizable. Further research on resource consumption and preferences is needed in order to provide decision makers with more robust evidences.

Interventional heart failure therapy: A new concept fighting against heart failure

Heart failure is a progressive disease that is associated with repeated exacerbations and hospitalizations. The rapid increase in the number of heart failure patients is a global health problem known as the 'heart failure pandemic'. To control the pandemic, multifaceted approaches are essential, ranging from prevention of onset to long-term disease management. Especially in patients with moderate to severe heart failure (stages C and D), surgical and catheter-based interventions are prerequisites for saving lives, preserving cardiac function, improving quality of life (QOL), and prognosis. In addition, various new medical technologies for these interventions have been clinically applied and have been shown to be effective against symptoms and improve the QOL and prognosis of patients with heart failure. Furthermore, the concept of interventional heart failure (IHF) therapy, which considers heart recovery and prevention of worsening of heart failure via multidisciplinary treatment using surgical, catheter interventions, and mechanical circulatory support devices, has been proposed worldwide. This review discusses the importance of IHF therapy in heart failure management, recent changes in interventional technologies and strategies for patients with heart failure, and worldwide education attempts for IHF specialists.

Effect of Availability of Transcatheter Aortic-Valve Implantation on Survival for all Patients With Severe Aortic Stenosis

Clinical outcomes for the overall severe aortic stenosis (AS) patient population are not well described because those medically managed are not included in procedural registries, and AS severity is not identifiable from administrative data. We aim to assess whether transcatheter aortic valve implantation (TAVI) availability has been associated with overall changes in survival for the whole AS patient population. This is important because patients with AS in real-world practice may differ from those included in randomized controlled trials, potentially attenuating the purported treatment efficacy estimated in trials. Classic severe AS patients (mean gradient ≥40 mmHg) were identified from an echocardiography database. Survival was defined as time since severe AS diagnosis until death. We first compared survival among all patients before and after TAVI availability in 2008. To further understand mechanism, we then assessed whether any survival changes were attributable to TAVI with extended Cox regression models comparing survival among TAVI, surgical aortic valve replacement, and medically managed patients. 3663 classic severe AS patients were included in the study. Median survival years for all patients were greater during the TAVI-era than Pre-TAVI-era (>11.5 vs 6.8, 5-year-HR = 0.8, time-varying effect p <0.0001), and increased median survival was greatest for patients age 65 to74 (>11.5 vs 9.5, 5-year-HR = 0.7, time-varying effect p = 0.045). TAVI patients age 65 to 74 had the lowest risk of death compared to medically managed patients (HR = 0.2, 95% CI = [0.1, 0.3], p <0.0001). In conclusion, in the TAVI-era, overall survival for patients with severe AS has doubled. This improvement is most marked for patients 65 to 74 years of age.

Percutaneous versus Surgical Intervention for Severe Aortic Valve Stenosis: A Systematic Review

Aortic stenosis is a disease that is increasing in prevalence and manifests as decreased cardiac output, which if left untreated can result in heart failure and ultimately death. It is primarily a disease of the elderly who often have multiple comorbidities. The advent of transcatheter aortic valve therapies has changed the way we treat these conditions. However, long-term results of these therapies remain uncertain. Recently, there has been an increasing number of studies examining the role of both surgical aortic valve replacement and transcatheter aortic valve replacement. We therefore performed a systematic review using Ovid MEDLINE, Ovid Embase, and the Cochrane Library. Two investigators searched papers published between January 1, 2007, and to date using the following terms: "aortic valve stenosis," "aortic valve operation," and "transcatheter aortic valve therapy." Both strategies in aortic stenosis treatment highlighted specific indications alongside the pitfalls such as structural valve degeneration and valve thrombosis which have a bearing on clinical outcomes. We propose some recommendations to help clinicians in the decision-making process as technological improvements make both surgical and transcatheter therapies viable options for patients with aortic stenosis. Finally, we assess the role of finite element analysis in patient selection for aortic valve replacement. THVT and AVR-S are both useful tools in the armamentarium against aortic stenosis. The decision between the two treatment strategies should be best guided by a strong robust evidence base, ideally with a long-term follow-up. This is best performed by the heart team with the patient as the center of the discussion.

Cost-effectiveness analysis of the SAPIEN 3 transcatheter aortic valve implant in patients with symptomatic severe aortic stenosis

INTRODUCTION AND OBJECTIVES

Transcatheter aortic valve implant has become a widely accepted treatment for inoperable patients with aortic stenosis and patients at high surgical risk. Its indications have recently been expanded to include patients at intermediate and low surgical risk. Our aim was to evaluate the efficiency of SAPIEN 3 vs conservative medical treatment (CMT) or surgical aortic valve replacement (SAVR) in symptomatic inoperable patients at high or intermediate risk.

METHODS

We conducted a cost-effectiveness analysis of SAPIEN 3 vs SAVR/CMT, using a Markov model (monthly cycles) with 8 states defined by the New York Heart Association and a time horizon of 15 years, including major complications and management after hospital discharge, from the perspective of the National Health System. Effectiveness parameters were based on the PARTNER trials. Costs related to the procedure, hospitalization, complications, and follow-up were included (euros in 2019). An annual discount rate of 3% was applied to both costs and benefits. Deterministic and probabilistic sensitivity analyses (Monte Carlo) were performed.

RESULTS

Compared with SAVR (high and intermediate risk) and CMT (inoperable), SAPIEN 3 showed better clinical results in the 3 populations and lower hospital stay. Incremental cost-utility ratios (€/quality-adjusted life years gained) were 5471 (high risk), 8119 (intermediate risk) and 9948 (inoperable), respectively. In the probabilistic analysis, SAPIEN 3 was cost-effective in more than 75% of the simulations in the 3 profiles.

CONCLUSIONS

In our health system, SAPIEN 3 facilitates efficient management of severe aortic stenosis in inoperable and high- and intermediate-risk patients.

Long-term survival after surgical aortic valve replacement in patients aged 80 years and over

 

OBJECTIVES

Surgical aortic valve replacement can be safely performed in people aged 80 years and older with early benefits on both symptomatic and prognostic ground. While new approaches are advocated to treat this elderly and frail population, data on long-term outcomes are not available.

METHODS

We conducted a retrospective analysis of 1870 patients aged 80 years and over who underwent first time surgical aortic valve replacement during the period 2000-2019. The Kaplan-Meier method was used to calculate survival and comparisons among groups were performed by log-rank test. Cox analysis was used to determine the independent risk factors for late mortality.

RESULTS

The patients' mean age was 84 years and 53% were male. Isolated aortic valve replacement was performed in 42% of the patients, and coronary artery bypass grafting (n = 956), mitral valve (n = 94) or aortic surgery (n = 69) were associated in the remaining cases. One hundred eighty-one patients (8%) sustained at least 1 postoperative complication (reopening for bleeding or tamponade 3%, renal replacement therapy 3%, new cerebral stroke 1.5%). In-hospital mortality was 3.2% in the overall population (60/1870) and 2.2% after isolated aortic valve replacement (18/790). Survival was 90%, 66%, 31% and 14% at 1, 5, 10 and 15 years, respectively, and was similar to the expected survival of a sex- and age-matched population (log-rank P = 0.96). A complicated postoperative course was an independent risk factor for mortality during the follow-up [hazard ratio 1.32 (1.03, 1.68), P = 0.026].

CONCLUSIONS

Surgical aortic valve replacement can be performed with an acceptable early mortality rate and provides excellent long-term survival in people aged 80 years and older.

Surgical Aortic Valve Replacement in the Elderly: It Is Worth It!

To evaluate survival and quality of life of octogenarians after surgical aortic valve replacement (SAVR), up to 10 year of follow-up. Retrospective observational study on octogenarians operated for an isolated or combined SAVR in 2 centers between 2005 and 2011. Preoperative data were collected for each patient and updated regularly with last follow-up on July 2018. Early postoperative course was assessed for all patients. The primary outcome was late survival after discharge. Health-related quality of life was evaluated in all surviving patients using the Short-Form 12 questionnaire. Nine hundred and nine patients were included. The median age was 82 ± 2.6 years, with 400/909 females (44%). Isolated AVR was performed in 452/909 patients (49.7%). Early in-hospital mortality occurred in 71/909 patients (7.8%). Mean follow-up was 5.9 ± 3.4 years. Survival at 2, 5, and 10 years in the overall cohort was 89%, 70%, and 28%, respectively, without significant difference between isolated or combined AVR. Survival was significantly higher in patients with a Euroscore <8% (P< 0.0001). Multivariate analysis found that older age at surgery, diabetes, history of myocardial infarction, atrial fibrillation and chronic renal failure were predictors of long-term mortality. Finally, the SF-12 physical score was 40.7 ± 10.4 and mental and emotional score was 52.7 ± 8.6 at last follow-up, which falls within the expected range for the general population (50 ± 10) with comparable age. SAVR remains an effective treatment for aortic valve disease in octogenarians, not only increasing life expectancy but also conferring a long-standing quality of life with excellent valve durability.

The Myval Transcatheter Heart Valve System for the Treatment of Severe Aortic Stenosis - Current Evidence and Future Directions

Transcatheter aortic valve replacement has revolutionised the treatment of aortic valve disease. The Myval™ device (Meril Life Sciences Pvt. Ltd., Gujarat, India) is a CE-marked, next-generation balloon-expandable transcatheter heart valve, designed for the treatment of severe aortic valve stenosis. This review illustrates the salient technical features of this transcatheter valve, pre-clinical studies and evidence from the first-in-human trial. We also provide a brief overview of planned clinical trials and registries.

Myval transcatheter heart valve system in the treatment of severe symptomatic aortic stenosis

The transcatheter aortic valve replacement (TAVR) is an established treatment for patients with severe symptomatic aortic stenosis (AS) at prohibitive risk for surgery. It is an alternative treatment to surgical aortic valve replacement in patients with AS at intermediate- and high-surgical risk. Although regulatory authorities extend the indications of TAVR to treat patients at low-surgical risk, the limitations of earlier-generation transcatheter heart valve (THV) systems accelerate the development of improved newer generation of THV systems. Myval™ THV (Meril Life Sciences Pvt. Ltd., Vapi, Gujarat, India) is a newer-generation, balloon-expandable TAVR system with features that facilitate accurate positioning of the bioprosthetic valve and favorable procedural and clinical outcomes. This review summarizes existing preclinical and clinical data on Myval THV for the intervention of symptomatic native AS and lays out the plan for future research program.

Unsupervised Cluster Analysis of Patients With Aortic Stenosis Reveals Distinct Population With Different Phenotypes and Outcomes

BACKGROUND

There is a lack of studies investigating the heterogeneity of patients with aortic stenosis (AS). We explored whether cluster analysis identifies distinct subgroups with different prognostic significances in AS.

METHODS

Newly diagnosed patients with moderate or severe AS were prospectively enrolled between 2013 and 2016 (n=398, mean 71 years, 55% male). Among demographics, laboratory, and echocardiography parameters (n=32), 11 variables were selected through dimension reduction and used for unsupervised clustering. Phenotypes and causes of mortality were compared between the clusters.

RESULTS

Three clusters with markedly different features were identified. Cluster 1 (n=60) was predominantly associated with cardiac dysfunction, cluster 2 (n=86) consisted of elderly with comorbidities, especially end-stage renal disease, whereas cluster 3 (n=252) demonstrated neither cardiac dysfunction nor comorbidities. Although AS severity did not differ, there was a significant difference in adverse outcomes between the clusters during a median 2.4 years follow-up (mortality rate, 13.3% versus 19.8% versus 6.0% for cluster 1, 2, and 3, P<0.001). Particularly, compared with cluster 3, cluster 1 was associated with only cardiac mortality (adjusted hazard ratio, 7.37 [95% CI, 2.00-27.13]; P=0.003), whereas cluster 2 was associated with higher noncardiac mortality (adjusted hazard ratio, 3.35 [95% CI, 1.26-8.90]; P=0.015). Phenotypes and association of clusters with specific outcomes were reproduced in an independent validation cohort (n=262).

CONCLUSIONS

Unsupervised cluster analysis of patients with AS revealed 3 distinct groups with different causes of death. This provides a new perspective in the categorization of patients with AS that takes into account comorbidities and extravalvular cardiac dysfunction.

Current status of transcatheter aortic valve replacement in India

Transcatheter aortic valve replacement (TAVR) has proven to be the cornerstone therapy for patients with severe aortic stenosis (AS). India is currently overburdened with AS, both rheumatic and non-rheumatic. Although TAVR has revolutionized the treatment of non-rheumatic AS it does offer a ray of hope for rheumatic AS in future. It is difficult to measure the actual burden of AS in India due to lack of epidemiological studies in this population. Variable estimates have been given indicating a large number of patients eligible for TAVR. Despite its enormous potential, TAVR is still beyond the reach of an average Indian citizen. The progress for TAVR in India remains rather slow with obstacles at multiple levels. These include high costs, lack of coverage by insurance companies, continuous ignorance in government policies, lack of sufficient trained TAVR performing operators and lack of healthcare providers trained in post-TAVR care. Additionally, unique anatomical factors such as smaller body surface area, smaller annulus size, low coronary ostia take-off, smaller calibre of iliac and common femoral arteries pose unique challenges in terms of need for smaller hardware and increased chances of complications. It is crucial that the policy makers and healthcare personnel wake up to the benefits of this innovation and take appropriate steps to ease the dissemination of TAVR across the country.

In-Hospital Outcomes After Transcatheter Versus Surgical Aortic Valve Replacement in Octogenarians

Background

Octogenarians have low physiologic reserve and may benefit more from transcatheter aortic valve replacement (TAVR) than surgical aortic valve replacement (SAVR).

Methods and Results

This retrospective cohort study based on the National Inpatient Sample included octogenarians who underwent TAVR or SAVR from 2012 to 2015. Crude and standardized‐morbidity‐ratio‐weighted regression models were used to compare in‐hospital outcomes. Among 19 145 TAVR and 9815 SAVR hospitalizations, TAVR patients had higher Charlson Comorbidity Index (CCI) scores (2.0 versus 0.8, P<0.0001) than SAVR patients. Before weighting, TAVR was associated with significantly shorter length of stay, more home discharges, and lower incidences of acute kidney injury, bleeding, and cardiogenic shock. Associations were consistent across Charlson Comorbidity Index, except for TAVR being associated with greater length of stay reductions among patients with Charlson Comorbidity Index ≥2, compared with Charlson Comorbidity Index <2 (change in estimate −3.56 versus −2.61 days, P=0.004). After weighting, TAVR patients had significantly shorter length of stay (change in estimate −3.29 days, 95% CI −3.82, −2.75) and lower odds of transfer to skilled nursing facility (odds ratio 0.34, 95% CI 0.29, 0.41), acute kidney injury (odds ratio 0.55, 95% CI 0.45, 0.68), bleeding (odds ratio 0.44, 95% CI 0.37, 0.53), and cardiogenic shock (odds ratio 0.55, 95% CI 0.33, 0.92), compared with SAVR patients. Odds of permanent pacemaker implantation, transient ischemic attack/stroke, vascular complications, and in‐hospital mortality were not significantly different.

Conclusions

TAVR may be preferred over SAVR in high‐risk octogenarians because of shorter length of stay, better discharge disposition, and less acute kidney injury, and bleeding. All octogenarians may benefit more from TAVR, irrespective of comorbidity burden, but additional research is needed to confirm our findings.

See Editorial by Himbert et al

Transcatheter aortic valve replacement: clinical safety and performance data

Introduction: Patients with severe aortic stenosis and regurgitation who are inoperable or at high-risk for surgery can be treated with transcatheter aortic valve replacement (TAVR). The aim of this study was to provide a comprehensive overview of the literature of TAVR and reported clinical and performance outcomes. Areas covered: A total of 16 devices, described in 204 articles describing clinical and performance outcomes, were included. The most frequently observed outcome was 30-day mortality, ranging between 0-23%. Other commonly reported clinical outcomes were 30-day stroke, ranging between 0-14.3% and pacemaker implantation, ranging from 0-44.9%. The most common valve performance outcome was aortic valve regurgitation, however, mostly reported at 7 days follow-up. Next to a follow-up period of 30 days, numerous articles reported outcomes at 6 months and 1 year. The numbers of articles describing outcomes with a longer follow-up as well as including intermediate and low-risk patients were limited. Expert commentary: This literature review provided a clear overview of the reported clinical and performance outcomes of TAVR devices. Despite the frequently used VARC-2 definitions, we identified a huge variation across studies. Future studies using standardized definitions of study set-ups and outcomes are essential and might lead to better insights of TAVR.

Propensity score-matched analysis of patients with severe aortic stenosis undergoing surgical aortic valve replacement

Objective

Severe aortic stenosis (AS) is one of the most serious valve conditions. Patient demography and the aetiology of AS have substantially changed in the past several decades along with a drastic improvement of surgical aortic valve replacement (SAVR) and its associated procedures. Contemporary patients with severe AS have multiple comorbidities and live much longer. We aimed to elucidate the treatment effects of SAVR on long-term outcome in propensity score (PS)-matched and the entire patient populations.

Methods

We retrospectively reviewed 570 patients with severe AS defined as an aortic valve area of 1.0 cm² or less. Systemic differences in 39 baseline characteristics between non-SAVR and SAVR groups were adjusted using PS matching method. The endpoints included all-cause mortality and cardiovascular events that included heart failure, non-fatal stroke, syncope and acute coronary syndrome.

Results

Overall, 55% of the entire population (mean age 78 years; males 41%) were symptomatic. During 3.9 years of the median follow-up, 210 (36%) patients underwent SAVR and 231 (41%) died. Cumulative incidences of mortality and both mortality and cardiovascular events were significantly higher in the non-SAVR group than in the other group (p<0.001, each). Among 101 PS-matched pairs, SAVR correlated with a lower mortality risk (HR 0.35; 95% CI 0.21 to 0.59; p<0.001)) and mortality and cardiovascular events combined (HR 0.62; 95% CI 0.42 to 0.92; p=0.02). However, survival difference between both groups was markedly smaller among asymptomatic patients in the subgroup of matched patients.

Conclusion

Patients with AS undergoing SAVR exhibit a lower incidence of all-cause mortality and major cardiovascular events than those not undergoing surgical interventions, even after the baseline characteristics are balanced by the PS matching. The correlation between SAVR and survival from cardiovascular events is less evident among asymptomatic patients.

Relation of Clinical Presentation of Aortic Stenosis and Survival Following Transcatheter Aortic Valve Implantation

Although the natural history of aortic stenosis (AS) depends on the severity of symptoms, the prognostic significance of AS clinical progression in patients who underwent aortic valve replacement is less clear. Here, we studied the correlation between the severity of AS presenting symptoms and survival after transcatheter aortic valve implantation (TAVI). We evaluated long-term survival of a consecutive cohort of severe AS patients (n = 862, mean Society of Thoracic Surgeons score 4.16 ± 2.9) who underwent transfemoral TAVI from 2009 to 2016. Patients were classified as having severe symptoms (i.e., angina, syncope, or heart failure, n = 424) or mild symptoms (i.e., dizziness, fatigue, effort dyspnea, chest discomfort, n = 438). No differences in device success nor in-hospital complications were found between groups. During a median follow-up of 2.84 (1.9 to 4.5) years, survival at 1, 3, and 5 years in the entire cohort, was 89% ± 1.1%, 75% ± 1.6%, and 59% ± 2.1%, respectively. Severe symptoms were associated with higher mortality (hazard ratio 1.54, 95% confidence intervals 1.230 to 1.939, p <0.001). The 1-, 3-, and 5-year survival was 94% ± 1.9%, 81% ± 3.3%, and 71% ± 4.3% in patients with angina, 92% ± 3.3%, 75% ± 5.6%, and 56% ± 8.2% in patients with syncope and 77% ± 3%, 54% ± 3.7%, and 41% ± 4.1% in patients with heart failure, respectively, (p <0.001). Heart failure symptoms emerged as independent predictor of mortality (hazard ratio 1.66, 1.28 to 2.17, p <0.001), regardless of left ventricular ejection fraction. The severity of AS symptoms affects survival after TAVI and overt heart failure independently predicts early mortality. Early intervention after diagnosis of severe AS is crucial to reduce the unfavorable effects of clinical progression on survival after TAVI.

Beating aortic valve replacement surgery as an alternative to transcatheter aortic valve implantation in a patient with severe aortic stenosis and left ventricular dysfunction

Background

Transcatheter aortic valve implantation (TAVI) is the standard treatment for high-risk patients with aortic stenosis (AS); however, alternative treatments for patients who are ineligible for TAVI are controversial.

Case presentation

56 year-old female who required 6 γ dobutamine support due to congestive heart failure was diagnosed as severe aortic stenosis with bicuspid valve. Echocardiography revealed left ventricular ejection fraction (LVEF) was 15%. The patient was relatively young for TAVI, and TAVI was not licensed for patient presenting with a bicuspid aortic valve in places other than the limited institutions in Japan. On pump beating aortic valve replacement (AVR) was performed with selective antegrade coronary artery blood perfusion. She resumed a completely normal lifestyle by 3 weeks after the operation.

Conclusions

A relatively young patient for TAVI who was diagnosed as aortic stenosis with severely reduced ejection fraction and bicuspid valve is reported. Beating AVR with a continuously selective antegrade-perfusion was achieved safely with good clinical results in a patient with severely reduced left ventricular (LV) function. Beating AVR can be considered as a potential alternative for patients who are ineligible for conventional surgical aortic valve replacement (SAVR) and TAVI.

Bioprosthetic aortic valve replacement in elderly patients: Meta-analysis and microsimulation

OBJECTIVE

To support decision-making in aortic valve replacement (AVR) in elderly patients, we provide a comprehensive overview of outcome after AVR with bioprostheses.

METHODS

A systematic review was conducted of studies reporting clinical outcome after AVR with bioprostheses in elderly patients (mean age ≥70 years; minimum age ≥65 years) published between January 1, 2000, to September 1, 2016. Reported event rates and time-to-event data were pooled and entered into a microsimulation model to calculate life expectancy and lifetime event risks.

RESULTS

Forty-two studies reporting on 34 patient cohorts were included, encompassing a total of 12,842 patients with 55,437 patient-years of follow-up (pooled mean follow-up 5.0 ± 3.3 years). Pooled mean age was 76.5 ± 5.5 years. Pooled early mortality risk was 5.42% (95% confidence interval [CI], 4.49-6.55), thromboembolism rate was 1.83%/year (95% CI, 1.28-3.61), and bleeding rate was 0.75%/year (95% CI, 0.50-1.11). Structural valve deterioration (SVD) was based on pooled time to SVD data (Gompertz; shape: 0.124, rate: 0.003). For a 75-year-old patient, this translated to an estimated life expectancy of 9.8 years (general population: 10.2 years) and lifetime risks of bleeding of 7%, thromboembolism of 17%, and reintervention of 9%.

CONCLUSIONS

The low risks of SVD and reintervention support the use of bioprostheses in elderly patients in need of AVR. The estimated life expectancy after AVR was comparable with the general population. The results of this study inform patients and clinicians about the expected outcomes after bioprosthetic AVR and thereby support treatment decision-making. Furthermore, our results can be used as a benchmark for long-term outcomes after transcatheter aortic valve implantation in patients who were eligible for surgery and other (future) alternative treatments (eg, tissue-engineered heart valves).

Aortic valve bypass surgery in severe aortic valve stenosis: Insights from cardiac and brain magnetic resonance imaging

OBJECTIVE

To investigate and describe the distribution of aortic and cerebral blood flow (CBF) in patients with severe valvular aortic stenosis (AS) before and after aortic valve bypass (AVB) surgery.

METHODS

We enrolled 10 consecutive patients who underwent AVB surgery for severe AS. Cardiovascular magnetic resonance imaging (CMR) and brain magnetic resonance imaging were performed as baseline before surgery and twice after surgery. Quantitative flow measurements were obtained using 1.5-T magnetic resonance imaging (MRI) scanner phase-contrast images of the ascending aorta, descending thoracic aorta (3 cm proximally and distally from the conduit-to-aorta anastomosis), and ventricular outflow portion of the conduit. The evaluation of CBF was performed using 3.0-T MRI scanner arterial spin labeling (ASL) through sequences acquired at the gray matter, dorsal default-mode network, and sensorimotor levels.

RESULTS

Conduit flow, expressed as the percentage of total antegrade flow through the conduit, was 63.5 ± 8% and 67.8 ± 7% on early and mid-term postoperative CMR, respectively (P < .05). Retrograde perfusion from the level of the conduit insertion in the descending thoracic aorta toward the aortic arch accounted for 6.9% of total cardiac output and 11% of total conduit flow. We did not observe any significant reduction in left ventricular stroke volume at postoperative evaluation compared with preoperative evaluation (P = .435). No differences were observed between preoperative and postoperative CBF at the gray matter, dorsal default-mode network, and sensorimotor levels (P = .394).

CONCLUSIONS

After AVB surgery in patients with severe AS, cardiac output is split between the native left ventricular outflow tract and the apico-aortic bypass, with two-thirds of the total antegrade flow passing through the latter and one-third passing through the former. In our experience, CBF assessment confirms that the flow redistribution does not jeopardize cerebral blood supply.

Early Clinical Experience with Sutureless Aortic Valve Replacement for Severe Aortic Stenosis

Background

Sutureless aortic valve replacement (SU-AVR) has been developed as an alternative surgical treatment for patients with symptomatic severe aortic stenosis (AS). The aim of this study was to evaluate the clinical outcomes of SU-AVR through an assessment of hemodynamic performance and safety.

Methods

From December 2014 to June 2016, a total of 12 consecutive patients with severe AS underwent SU-AVR. The endpoints were overall survival and valve-related complications (paravalvular leakage, valve thrombosis, migration, endocarditis, and permanent pacemaker implantation). The mean follow-up duration was 18.1±8.6 months.

Results

The mean age of the patients was 77.1±5.8 years and their mean Society of Thoracic Surgeons score was 9.2±17.7. The mean cardiopulmonary bypass and aortic cross-clamp times were 94.5±37.3 minutes and 54.9±12.5 minutes, respectively. Follow-up echocardiography showed good prosthesis function with low transvalvular pressure gradients (mean, 13.9±8.6 mm Hg and peak, 27.2±15.0 mm Hg) at a mean of 9.9±4.2 months. No cases of primary paravalvular leakage, valve thrombosis, migration, or endocarditis were reported. A new permanent pacemaker was implanted in 1 patient (8.3%). The 1-year overall survival rate was 83.3%±10.8%.

Conclusion

Our initial experience with SU-AVR demonstrated excellent early clinical outcomes with good hemodynamic results. However, there was a high incidence of permanent pacemaker implantation compared to the rate for conventional AVR, which is a problem that should be solved.

Ideal Cardiovascular Health and the Prevalence and Severity of Aortic Stenosis in Elderly Patients

Background

The relationship between ideal cardiovascular health reflected in the cardiovascular health score (CVHS) and valvular heart disease is not known. The purpose of this study was to determine the association of CVHS attainment through midlife to late life with aortic stenosis prevalence and severity in late life.

Methods and Results

The following 6 ideal cardiovascular health metrics were assessed in ARIC (Atherosclerosis Risk in Communities) Study participants at 5 examination visits between 1987 and 2013 (visits 1–4 in 1987–1998 and visit 5 in 2011–2013): smoking, body mass index, total cholesterol, blood pressure, physical activity, and blood glucose. Percentage attained CVHS was calculated in 6034 participants as the sum of CVHS at each visit/the maximum possible score. Aortic stenosis was assessed by echocardiography at visit 5 on the basis of the peak aortic valve velocity. Aortic stenosis was categorized sclerosis, mild stenosis, and moderate‐to‐severe stenosis. Mean age was 76±5 years, 42% were men, and 22% were black. Mean percentage attained CVHS was 63±14%, and the prevalence of aortic stenosis stages were 15.9% for sclerosis, 4.3% for mild stenosis, and 0.7% for moderate‐to‐severe stenosis. Worse percentage attained CVHS was associated with higher prevalence of aortic sclerosis (P<0.001 for trend), mild stenosis (P<0.001), and moderate‐to‐severe stenosis (P=0.002), adjusting for age, sex, and race.

Conclusions

Greater attainment of ideal cardiovascular health in midlife to late life is associated with a lower prevalence of aortic sclerosis and stenosis in late life in a large cohort of older adults.

Reduced inflammatory response by transcatheter, as compared to surgical aortic valve replacement

OBJECTIVES

The inflammatory response to on-pump cardiac surgery is well known. Systemic inflammatory response syndrome after transcatheter valve implantation (TAVI) has been reported. The objective of this study was to study the inflammatory response during TAVI, and compare with the response during surgical aortic valve replacement.

METHODS

Eighteen patients undergoing transcatheter implantation, either by a transfemoral (n = 9) or transaortal (n = 9) approach were compared with eighteen patients admitted for surgical replacement. Blood samples per- and postoperatively were analysed for C3bc, terminal complement complex, myeloperoxidase, macrophage inflammatory protein-1β, monocyte chemo-attractant peptide-1, eotaxin, IL-6 and troponin-T. All markers were measured at defined time points and the areas under the curve were compared.

RESULTS

Activation of complement, granulocytes, monocytes and eosinophils were significantly lower in the transcatheter group as compared to the surgical group (<0.01). There was no difference in generation of troponin T and IL-6. A small difference in complement activation was observed between the transfemoral and transaortal placement of TAVI. There was no significant difference in clinical outcomes between the TAVI and surgical groups.

DISCUSSION

Activation and release of inflammatory markers was significantly less during with TAVI as compared to SAVR, particularly for markers associated with extracorporeal circulation. TAVI and SAVR generated the same degree of IL-6 and troponin T, indicating that the burden on the myocardial tissue was the same. Clinical Trials: Gov ID: NCT03074838 Unique protocol ID: 2012/7919.

From CoreValve to Evolut PRO: Reviewing the Journey of Self-Expanding Transcatheter Aortic Valves

Transcatheter aortic valve replacement (TAVR) has become standard therapy for patients with severe aortic stenosis who are deemed at least intermediate risk for surgical valve replacement. Over the past decade, several technological advances have taken place to improve the quality and safety of these devices. The current commercially available valves are broadly grouped into balloon expandable and self-expandable valves. The latest iteration of the self-expandable valve is Medtronic's repositionable valve known as the Evolut PRO system. In this review, we highlight the evidence behind the use of TAVR, improvement in devices over previous generations, clinical evidence behind the CoreValve Evolut PRO system, and the future of TAVR.

Outcomes of Aortic Valve Replacement According to Surgical Approach in Intermediate and Low Risk Patients: A Propensity Score Analysis

BACKGROUND

Previous trials have shown that, among high-risk patients with aortic stenosis, survival rates are similar for transcatheter aortic-valve implantation (TAVI) and surgical aortic valve replacement. The study aimed to compare the outcomes of aortic valve replacement according to the adopted surgical approach in intermediate and low risk patients.

METHODS

This is a retrospective, observational, cohort study of prospectively collected data from 421 patients undergoing isolated aortic valve replacement between 2011 and 2015. A multinomial logit propensity score model based on preoperative risk factors was used to match patients 1:1:1 between conventional replacement (CAVR), minimally invasive (MIAVR) and TAVI groups, resulting in 50 matched three cohorts.

RESULTS

After multinomial logit propensity score, the three groups were comparable in terms of preoperative characteristics. Mean age and Logistic EuroSCORE I of CAVR, MIAVR and TAVI groups were (84.2±5.1 vs. 82.3±4.8 vs. 85.6±4.9 years; p=0.002) and (11.4±3.6% vs. 8.3±3.4% vs. 15.8±5.4%; p<0.001) respectively. Overall mortality rates were similar for the three patient cohorts at one year. There were no significant differences related to stroke to 30 days. In the TAVI cohort, pacemaker implantation for new-onset total atrioventricular block became necessary in 30% of patients (p<0.001) and 16% of patients had some degree of paravalvular aortic regurgitation, which was more than mild (p<0.001). Total length of stay was shorter in the TAVI group when compared with surgical groups (11.5±5.3 vs. 10.1±6.9 vs 8.5±3.7 days; p=0.023). After discharge, the survival rate follow-up (average follow up: 46.7 months) was 70%, 84% and 72% for three cohorts (log Rank x²=2.40, p=0.3).

CONCLUSIONS

In our experience, the three aortic valve replacement approaches offer very good results. Differences in the rate of complications were found between groups. Depending on patient's characteristics the Heart-Team group must offer the best surgical approach for each patient.

The economic value of rapid deployment aortic valve replacement via full sternotomy

Aim: To compare the economic value of EDWARDS INTUITY Elite™ (EIE) valve system for rapid-deployment aortic valve replacement (RDAVR) in a full sternotomy (FS) approach (EIE-FS-RDAVR) versus FS-AVR using conventional stented bioprosthesis. Data & methods: A simulation model to compare each treatment's 30-day inpatient utilization and complication rates utilized: clinical end points obtained from the TRANSFORM trial patient subset (EIE-FS-RDAVR) and a best evidence review of the published literature (FS-AVR); and costs from the Premier database and published literature. Results: EIE-FS-RDAVR costs $800 less than FS-AVR per surgery episode attributable to lowered complication rates and utilization. Combined with the lower mortality, EIE-FS-RDAVR was a superior (dominant) technology versus FS-AVR. Conclusion: This preliminary investigation of EIE-FS-RDAVR versus conventional FS-AVR found the EIE valve offered superior economic value over a 30-day period. Real-world analyses with additional long-term follow-up are needed to evaluate if this result can be replicated over a longer timeframe.

Transcatheter Aortic Valve Replacement: Comprehensive Review and Present Status

Aortic stenosis is the most common valvular heart disease in the developed world. About 7% of the population over age 65 years suffers from degenerative aortic stenosis. The prognosis of patients with symptomatic severe aortic stenosis is dismal without valve replacement. Even though the American College of Cardiology recommends aortic valve replacement to treat this condition as a class I recommendation, approximately one third of these patients over the age of 75 years are not referred for surgery. Typically, this is from concern about prohibitive surgical risk associated with patient frailty, comorbidities, age, and severe left ventricular dysfunction. The advent in France of transcatheter aortic valve replacement has raised the hope in the United States for an alternative, less invasive treatment for aortic stenosis. Two recent trials-the Placement of AoRTic TraNscathetER Valve Trial Edwards SAPIEN Transcatheter Heart Valve (Partner) and the CoreValve US Pivotal-have established transcatheter aortic valve replacement as the preferred approach in patients who are at high or prohibitive surgical risk. The more recently published Partner 2 trial has shown the feasibility of transcatheter aortic valve replacement in intermediate-surgical-risk patients as well. With a profile that promises easier use and better valve performance and delivery, newer-generation valves have shown their potential for further improvement in safety profile and overall outcomes. We review the history and status of this topic.