Transcatheter Versus Surgical Aortic Valve Replacement in Low-Risk Patients

Native Sinus Hemodynamics and Thrombosis in Transcatheter Heart Valve: Effect of Implant Depth and Coronary Flow

BACKGROUND

This study aimed to investigate the hemodynamic and anatomic factors associated with sinus thrombosis following transcatheter aortic valve replacement (TAVR), integrating in vivo patient data analysis and in vitro experiments.

METHODS AND RESULTS

Postprocedural, 4-dimensional, multiphase computed tomography data from 211 patients enrolled in the ADAPT-TAVR (Anticoagulation Versus Dual Antiplatelet Therapy for Prevention of Leaflet Thrombosis and Cerebral Embolization After Transcatheter Aortic Valve Replacement) study were analyzed. The prevalence of native sinus thrombosis was examined in relation to valve type, implant depth, and anatomic features. In vitro experiments used particle image velocimetry to observe changes in sinus flow based on the transcatheter heart valves (23-mm SAPIEN3, Edwards Lifesciences; and 29-mm CoreValve, Medtronic) height and coronary artery flow. Native sinus thrombosis was more common in self-expanding valves (39.1% versus 14.9%, P=0.004). In per-cusp analysis of in vivo patient data, adjusted transcatheter heart valve implant depth (odds ratio, 1.2 [95% CI, 1.1-1.3]; P<0.001), noncoronary sinus of Valsalva (odds ratio, 4.0 [95% CI, 2.0-7.8]; P<0.001), sinus inflow diameter (odds ratio, 0.8 [95% CI, 0.6-0.9]; P=0.008), and implanted valve size (odds ratio, 0.8 [95% CI, 0.7-1.0]; P=0.025) were significant factors associated with native sinus thrombosis. In the in vitro experiments, CoreValve showed noticeable flow stasis compared with SAPIEN3. High-positioned SAPIEN3 was linked to reduced velocity within the native sinus of Valsalva. Coronary artery flow led to higher sinus velocity and improved particle washout, reducing sinus thrombosis risk.

CONCLUSIONS

This study provides insights into the relationship between transcatheter heart valve deployment and native sinus thrombosis, emphasizing the role of anatomic factors in relation to the risk of sinus thrombosis.

Long-Term Results Following Transcatheter Versus Surgical Aortic Valve Replacement in Low-Risk Patients With Severe Aortic Stenosis: A Systematic Review and Meta-Analysis of Randomized Trials

Transcatheter aortic valve replacement (TAVR) is a safe and effective treatment option for patients with severe aortic stenosis at intermediate or high surgical risk. Results after TAVR in low-risk patients are very encouraging at midterm follow-up, whereas limited long-term (≥3 year) data are available in this subset of patients. This meta-analysis aims to compare the long-term follow-up after TAVR versus surgical aortic valve replacement (SAVR) in low-risk patients. We searched databases up to July 7, 2024 for randomized clinical trials comparing TAVR versus SAVR in low-risk patients (defined as Society of Thoracic Surgeons Predicted Risk of Mortality score <4%) (PROSPERO ID: CRD42023480495). Primary outcome analyzed was all-cause death at a minimum of 3 years of follow-up. The secondary outcomes were cardiovascular death, disabling stroke, myocardial infarction, aortic valve reintervention, endocarditis, new-onset atrial fibrillation, permanent pacemaker implantation, and bioprosthetic valve failure. A total of 3 randomized clinical trials with 2,644 patients (TAVR n = 1,371 patients; SAVR n = 1,273 patients) were included. The follow-up time was 6 ± 2.9 years. TAVR resulted noninferior to SAVR for all-cause death (risk ratio [RR] 0.99, 95% confidence interval [CI] 0.84 to 1.17, p = 0.89, I2 = 28%), cardiovascular death (RR 0.94, 95% CI 0.76 to 1.15, p = 0.54, I2 = 0%), myocardial infarction (RR 1.06, 95% CI 0.71 to 1.57, p = 0.79, I2 = 61%), aortic valve reintervention, endocarditis, and bioprosthetic valve failure. New-onset atrial fibrillation was more common in the SAVR group, whereas permanent pacemaker implantation was more common in the TAVR group. In conclusion, our meta-analysis showed that TAVR is associated with similar long-term outcomes compared with SAVR in selected low-risk patients.

Successful management of acute left main coronary occlusion following transcatheter aortic valve implantation: a case report

BACKGROUND

Transcatheter aortic valve implantation is an established, highly effective procedure in selected patients with severe degenerative aortic valve stenosis at high risk for conventional surgery.

CASE PRESENTATION

We report a case of a 74-year-old Caucasian man who had an acute left main occlusion after transcatheter implantation of balloon-expandable valve prosthesis, followed by coronary intervention with successful recanalization.

CONCLUSIONS

Acute coronary occlusion is a rare life-threatening complication of transcatheter aortic valve implantation that is poorly predictable and requires immediate diagnosis and treatment.

Cardiology department versus intensive care unit admission after successful uncomplicated transcatheter aortic valve replacement (TAVR)

BACKGROUND

Most patients after transcatheter aortic valve replacement (TAVR) are admitted directly to the cardiac intensive care unit (CICU) despite low complication rates. Reducing unnecessary CICU hospitalization reduces healthcare costs. This study aimed to compare the outcomes between patients admitted directly to the cardiology department (CD) and those admitted to CICU based on prespecified protocols.

METHODS

Historical cohort study of all patients who underwent TAVR and were admitted directly to the CD according to a prespecified protocol (uncomplicated procedure, hemodynamically stable, without new conduction abnormalities) in 2017-2018, and the same number of patients meeting the same criteria who were admitted to the CICU in 2015-2016 before direct CD admission was initiated. Pacemaker implantation during the procedure was not considered a new conduction abnormality. In-hospital outcomes and 30-day post-discharge outcomes were compared.

RESULTS

Overall, 260 patients (130 CICU + 130 CD) were included in the study. There was no in-hospital mortality in either group, and the post-procedure length of stay was shorter for patients admitted to CD (median and IQR: 2, 2-4 vs. 4, 3-5 days, p <0.001). There was no significant difference in 30-day emergency department visits between groups (CICU:13.9% vs. CD:16.2%, p = 0.602), rehospitalization rate (9.3%) was the same in both groups, and one patient from the CICU group died. Similar results were observed in multivariable analysis and after matching.

CONCLUSION

Direct admission to the CD after TAVR, according to the proposed criteria, may be considered as a safe and less expensive alternative for stable patients after an uncomplicated TAVR procedure.

Anaesthetic and Procedural-Related Complications in Transcatheter Aortic Valve Implantation (TAVI) and Its Outcome: A Retrospective Observational Study

Background Transcatheter aortic valve implantation (TAVI) presents significant challenges in its management, not only due to the technical complexity of the procedure but also because it is primarily performed on elderly patients who often have multiple comorbidities, making perioperative care and post-procedural recovery more intricate and demanding. The study's objective is to discover the challenges faced during the TAVI procedure and the frequency of complications that occurred during and after the procedure. Methods This is a single-centre retrospective study. Patients with symptomatic severe aortic stenosis, considered at high risk for conventional surgical aortic valve replacement, were included, their medical records were extracted, and data were collected. Endpoints at one-year follow-up comprised one-year mortality, cause of death, and valve dysfunction. Procedural-related complications were also noted as procedural-related outcomes. Results The mean age and body mass index (BMI) of the patients were 73.9 years and 28.3 kg/m2, respectively. The main comorbidities were hypertension (n = 33, 84.6%), diabetes mellites (n = 21, 53.8%), ischemic heart disease (n = 6, 15.38%), and chronic obstructive pulmonary disease (COPD) (n = 5, 12.8%). The mean European System for Cardiac Operative Risk Evaluation (EuroSCORE) was 5.75% with a median of 2.38%. General anaesthesia was received (n = 27), whereas the rest of the cases were performed under monitored anaesthesia care (MAC). None of the patients developed surgical site hematoma or massive blood loss. Post-operative mechanical ventilation was required in three patients (10.2%), and two (5.12%) of them expired in the intensive care unit. One patient had on-table mortality. Conclusion A low rate of anaesthesia and procedural-related complications was observed. The TAVI procedures done in our centre are promising and parallel to the finest global centres' outcomes in terms of procedural triumph and complication rate.

A Three-Day Prehabilitation Program is Cost-Effective for Preventing Pulmonary Complications after Heart Valve Surgery: A Health Economic Analysis of a Randomized Trial

Background

While prehabilitation (pre surgical exercise) effectively prevents postoperative pulmonary complications (PPCs), its cost-effectiveness in valve heart disease (VHD) remains unexplored. This study aims to evaluate the cost-effectiveness of a three-day prehabilitation program for reducing PPCs and improving quality adjusted life years (QALYs) in Chinese VHD patients.

Methods

A cost-effectiveness analysis was conducted alongside a randomized controlled trial featuring concealed allocation, blinded evaluators, and an intention-to-treat analysis. In total, 165 patients scheduled for elective heart valve surgery at West China Hospital were randomized into intervention and control groups. The intervention group participated in a three-day prehabilitation exercise program supervised by a physiotherapist while the control group received only standard preoperative education. Postoperative hospital costs were audited through the Hospital Information System, and the EuroQol five-dimensional questionnaire was used to provide a 12-month estimation of QALY. Cost and effect differences were calculated through the bootstrapping method, with results presented in cost-effectiveness planes, alongside the associated cost-effectiveness acceptability curve (CEAC). All costs were denominated in Chinese Yuan (CNY) at an average exchange rate of 6.73 CNY per US dollar in 2022.

Results

There were no statistically significant differences in postoperative hospital costs (8484 versus 9615 CNY, 95% CI -2403 to 140) or in the estimated QALYs (0.909 versus 0.898, 95% CI -0.013 to 0.034) between the intervention and control groups. However, costs for antibiotics (339 versus 667 CNY, 95% CI -605 to -51), nursing (1021 versus 1200 CNY, 95% CI -330 to -28), and electrocardiograph monitoring (685 versus 929 CNY, 95% CI -421 to -67) were significantly lower in the intervention group than in the control group. The CEAC indicated that the prehabilitation program has a 92.6% and 93% probability of being cost-effective in preventing PPCs and improving QALYs without incurring additional costs.

Conclusions

While the three-day prehabilitation program did not significantly improve health-related quality of life, it led to a reduction in postoperative hospital resource utilization. Furthermore, it showed a high probability of being cost-effective in both preventing PPCs and improving QALYs in Chinese patients undergoing valve surgery.

Clinical Registration Number

This trial is registered in the Chinese Clinical Trial Registry (URL: https://www.chictr.org.cn/) with the registration identifier ChiCTR2000039671.

Transcatheter Aortic Valve Replacement in Low Surgical Risk Patients: An Updated Metanalysis of Extended Follow-Up Randomized Controlled Trials

The long-term safety and effectiveness of transcatheter aortic valve replacement (TAVR) compared with surgical aortic valve replacement (SAVR) in low surgical risk has not been evaluated in a pooled analysis. An electronic database search was conducted for randomized controlled trials with a maximal 5 years clinical and echocardiographic follow-up including low surgical risk patients who underwent TAVR or SAVR. We calculated odds ratio (OR) and 95% confidence intervals (CIs) using a random-effects model. Subgroups analysis was performed for permanent pacemaker implantation and paravalvular leaks. Three randomized controlled trials were included with a total of 2,611 low surgical risk patients (Society of Thoracic Surgeons score <4%). Compared with SAVR, the TAVR group had similar rates of all-cause mortality (OR 0.94,95% CI 0.65 to 1.37, p = 0.75) and disabling stroke (OR 0.84, 95% CI 0.52 to 1.36, p = 0.48). No significant differences were registered in the TAVR group in terms of major cardiovascular events (OR 0.96, 95% CI 0.67 to 1.38, p = 0.83), myocardial infarction (OR 0.69, 95% CI 0.34 to 1.40, p = 0.31), valve thrombosis (OR 3.11, 95% CI 0.29 to 33.47, p = 0.35), endocarditis (OR 0.71,95% CI 0.35 to 1.48, p = 0.36), aortic valve reintervention (OR 0.93, 95% CI 0.52 to 1.66, p = 0.80), and rehospitalization (OR 0.80, 95% CI 0.52 to 1.02, p = 0.07) compared with SAVR. However, TAVR patients had a higher risk of paravalvular leaks (OR 8.21, 95% CI 4.18 to 16.14, p <0.00001), but lower rates of new-onset atrial fibrillation (OR 0.27,95% CI 0.17 to 0.30, p <0.0001). The rates of permanent pacemaker implantation were comparable from 1 year up to a maximum of 5 years (OR 1.32, 95% CI 0.88 to 1.97, p = 0.18). Lastly, TAVR had a greater effective orifice area (0.10 cm2/m2, 95% CI 0.05 to 0.15, p = 0.0001), but similar transvalvular mean gradients (0.60, 95% CI 3.94 to 2.73, p = 0.72). In conclusion, TAVR patients had similar long-term outcomes compared with SAVR, except for an elevated risk of paravalvular leaks in the TAVR group and increased rates of atrial fibrillation in the SAVR cohort.

Examining lack of referrals to heart valve specialists as mechanisms of potential underutilization of aortic valve replacement

BACKGROUND

Recent studies suggest that aortic valve replacement (AVR) remains underutilized.

AIMS

Investigate the potential role of non-referral to heart valve specialists (HVS) on AVR utilization.

METHODS

Patients with severe aortic stenosis (AS) between 2015 and 2018, who met class I indication for intervention, were identified. Baseline data and process-related parameters were collected to analyze referral predictors and evaluate outcomes.

RESULTS

Among 981 patients meeting criteria AVR, 790 patients (80.5%) were assessed by HVS within six months of index TTE. Factors linked to reduced referral included increasing age (OR: 0.95; 95% CI: 0.94-0.97; P < .001), unmarried status (OR: 0.59; 95% CI: 0.43-0.83; P = .002) and inpatient TTE (OR: 0.27; 95% CI: 0.19-0.38; P < .001). Conversely, higher hematocrit (OR: 1.13; 95% CI: 1.09-1.16; P < .001) and eGFR (OR: 1.01; 95% CI: 1.00-1.02; P = .003), mean aortic valve gradient (OR: 1.03; 95% CI: 1.01-1.04; P < .001) and preserved LVEF (OR: 1.59; 95% CI: 1.02-2.48; P = .04), were associated with increased referral likelihood. Moreover, patients assessed by HVS referral as a time-dependent covariate had a significantly lower two-year mortality risk than those who were not (aHR: 0.30; 95% CI: 0.23-0.39; P < .001).

CONCLUSION

A substantial proportion of severe AS patients meeting indications for AVR are not evaluated by HVS and experience markedly increased mortality. Further research is warranted to assess the efficacy of care delivery mechanisms, such as e-consults, and telemedicine, to improve access to HVS expertise.

Impaired Gastrointestinal Motility and Worsening Heart Failure in Patients Receiving Trans-Catheter Aortic Valve Replacement

Background: Impaired gastric motility in the form of constipation may often occur in elderly patients with chronic heart failure. Candidates for trans-catheter aortic replacement (TAVR) are of old age and have multiple comorbidities, probably including constipation. However, the clinical implication of a history of constipation in patients receiving TAVR remains unknown. Methods: Patients who underwent TAVR at our large academic center between 2015 and 2022 were eligible. The prognostic impact of the prescribed laxative type and number, which was assumed as the severity of constipation, on the incidence of death or heart failure readmission two years after index discharge was investigated. Results: A total of 344 patients were included. Median age was 85 years, and 99 patients were men. Patients with any laxatives (N = 166) had higher systolic blood pressure, higher plasma B-type natriuretic peptide levels, and a lower prescription rate of renin-angiotensin system inhibitors at the time of index discharge after TAVR (p < 0.05 for all). The number of laxative types was independently associated with the composite primary outcome with an adjusted hazard ratio of 1.83 (95% confidence interval 1.27-2.63, p = 0.001) with a cutoff of one type of laxative used, which significantly stratified the 2-year cumulative incidence of the primary outcome (18% versus 7%, p = 0.001). Conclusions: The presence of constipation was associated with worse clinical outcomes following TAVR. The prognostic impact of an aggressive intervention for constipation remains a future concern in this cohort.

Novel Techniques and Technologies for Surgical Aortic Valve Replacement: A Large Retrospective Cohort Analysis

Background/Objectives: In an era of growing evidence for transaortic valve implantation (TAVI), our research topic was the evaluation of how surgical aortic valve replacements (SAVRs) are performing in terms of short- and long-term outcomes in different risk categories. Methods: This was a single centre, prospective, and observational cohort study of consecutive patients with aortic valve stenosis, undergoing isolated aortic valve replacement using a biological or mechanical prosthesis, Freestyle™ (Medtronic, Minneapolis, MN, USA) graft, homograft, or Ross procedure. The participant data were collected by review of an internal database. The primary endpoints were all-cause operative mortality (in hospital and at 30 days) and late mortality at the follow-up date. The secondary composite endpoint was the incidence of postoperative complications. Results: 1501 patients underwent SAVR; the mean age was 67 years (SD: 12.6). The in-hospital mortality was 1% (n = 16). At a median follow-up of 60 months, the survival rate was 98.7%. The main predictors for mortality were operative urgency and cardiogenic shock. The overall incidence of PPM was 2.3% (n = 34). Patients who underwent Ross procedure were younger (mean age: 20 years (SD: 1.7)), had a lower incidence of postoperative complications, and were all alive at follow-up. Conclusions: SAVR shows an excellent survival rate and a low rate of postoperative complications despite an increasing surgical risk. Recent advancements in technology, like sutureless/rapid deployment prostheses and minimally invasive techniques, are shown to have favourable effects on outcomes.

Single suture-mediated closure system after transfemoral transcatheter aortic valve implantation: A single-center real-world experience

BACKGROUND

Despite the use of two crossed Perclose ProGlide™ (Abbott Vascular Devices) is the most widespread technique to close the main arterial access in transfemoral transcatheter aortic valve implantation (TF-TAVI), the safest and most effective strategy still remains much debated.

AIMS

The aim of the present study was to evaluate the performance of a single Perclose ProGlide suture-mediated closure device to obtain femoral hemostasis after sheathless implantation of self-expanding transcatheter heart valves through their 14 F-equivalent fix delivery systems.

METHODS

This prospective observational study included 439 patients undergoing TF-TAVI at the "Montevergine" Clinic of Mercogliano, Italy. All patients underwent hemostasis of the large-bore access using a single Perclose ProGlide with preclose technique, after sheathless implantation of self-expanding transcatheter heart valves through 14 F-equivalent fix delivery systems. A multidetector computed tomography analysis of size, tortuosity, atherosclerotic, and calcification burdens of the ilio-femoral access route was made by a dedicated corelab. Vascular complications (VCs), percutaneous closure device (PCD) failure, and bleedings were adjudicated by a clinical events committee.

RESULTS

A total of 81 different VCs were observed in 60 patients (13.7%); among these, 41 (5% of patients) were categorized as major. PCD failure occurred in 14 patients (3.2%). At the logistic regression analysis, no predictors of PCD failure have been identified.

CONCLUSION

This registry suggests that the use of a single suture-mediated closure device could be considered a safe and efficient technique to achieve access site hemostasis in patients undergoing TF-TAVI through 14 F-equivalent fix delivery systems.

Multimodal preoperative imaging for transcatheter mitral valve replacement in the domestic sheep model

Preclinical in vivo evaluation is an essential step in the progression of new cardiac devices into patient use, with studies predominantly performed in the domestic sheep model. A growing area of interest in cardiac device development is transcatheter mitral valve replacement (TMVR). Clinically, multimodal imaging, or computed tomography (CT) and echocardiography (echo) are used extensively to preoperatively determine mitral valve morphology prior to an intervention, but there is no description on how these modalities can be implemented to support preclinical studies. The purpose of this study is to apply clinically relevant CT and echo acquisition and assessment techniques to a large group of naive research sheep in order to analyze and report modality-related effects on mitral valve dimensional reference intervals in the sheep model. To this end, fifty-five adult domestic sheep underwent preoperative CT and echo exams and resultant images were analyzed using a landmark-based multiplanar measurement protocol and compiled into a master dataset for statistical analysis. We found moderate agreement between CT and echo-derived measurements of the mitral valve in sheep and propose the first clinically-relevant dimensional indices for the sheep's naive mitral valve which can be used to guide future studies evaluating novel TMVR devices. This study is the first of its kind in proposing a reproducible method for detailed examination of the mitral valve in the sheep model using clinically-relevant multimodal imaging. As in patients, CT and echo can reveal accurate native mitral valve dimensions in the sheep prior to preclinical TMVR studies.

Role of aortic valve replacement in moderate aortic stenosis: a 10-year outcomes study

OBJECTIVE

Patients with moderate aortic stenosis (AS) exhibit high morbidity and mortality. Limited evidence exists on the role of aortic valve replacement (AVR) in this patient population. To investigate the benefit of AVR in moderate AS on survival and left ventricular function.

METHODS

In a retrospective cohort study, patients with moderate AS between 2008 and 2016 were selected from the Cleveland Clinic echocardiography database and followed until 2018. Patients were classified as receiving AVR or managed medically (clinical surveillance). All-cause and cardiovascular mortality were assessed by survival analyses. Temporal haemodynamic and structural changes were assessed with longitudinal analyses using linear mixed effects models.

RESULTS

We included 1421 patients (mean age, 75.3±5.4 years and 39.9% women) followed over a median duration of 6 years. Patients in the AVR group had lower risk of all-cause (adjusted HR (aHR)=0.51, 95% CI: 0.34 to 0.77; p=0.001) and cardiovascular mortality (aHR=0.50, 95% CI: 0.31 to 0.80; p=0.004) compared with those in the clinical surveillance group irrespective of sex, receipt of other open-heart surgeries and underlying malignancy. These findings were seen only in those with preserved left ventricular ejection fraction (LVEF) ≥50%. Further, patients in the AVR group had a significant trend towards an increase in LVEF and a decrease in right ventricular systolic pressure compared with those in the clinical surveillance group.

CONCLUSIONS

In patients with moderate AS, AVR was associated with favourable clinical outcomes and left ventricular remodelling.

Transcatheter aortic valve replacement in low-risk young population: A double edge sword?

Since the advent of transcatheter aortic valve replacement (TAVR) in 2002, it has now become the default interventional strategy for symptomatic patients presenting with severe aortic stenosis, particularly in intermediate to high-surgical risk patients. In 2019, the United States Food and Drug Administration approved TAVR in low-risk patients based on two randomized trials. However, these breakthrough trials excluded patients with certain unfavorable anatomies and odd profiles. While currently there is no randomized study of TAVR in young patients, it may be preferred by the young population given the benefits of early discharge, shorter hospital stay, and expedite recovery. Nonetheless, it is important to ruminate various factors including lifetime expectancy, risk of pacemaker implantation, and the need for future valve or coronary interventions in young cohorts before considering TAVR in these patients. Furthermore, the data on long-term durability (> 10 years) of TAVR is still unknown given most of the procedures were initially performed in the high or prohibitive surgical risk population. Thus, this editorial aims to highlight the importance of considering an individualized approach in young patients with consideration of various factors including lifetime expectancy while choosing TAVR against surgical aortic valve replacement.

Trends and Disparities in Valvular Heart Disease Mortality in the United States From 1999 to 2020

BACKGROUND

Percutaneous heart valve procedures have been increasingly performed over the past decade, yet real-world mortality data on valvular heart disease (VHD) in the United States remain limited.

METHODS AND RESULTS

We queried the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research database among patients ≥15 years old from 1999 to 2020. VHD and its subtypes were listed as the underlying cause of death. We calculated age-adjusted mortality rate (AAMR) per 100 000 individuals and determined overall trends by estimating the average annual percent change using the Joinpoint regression program. Subgroup analyses were performed based on demographic and geographic factors. In the 22-year study, there were 446 096 VHD deaths, accounting for 0.80% of all-cause mortality (56 014 102 people) and 2.38% of the total cardiovascular mortality (18 759 451 people). Aortic stenosis recorded the highest mortality of VHD-related death in both male (109 529, 61.74%) and female (166 930, 62.13%) populations. The AAMR of VHD has declined from 8.4 (95% CI, 8.2-8.5) to 6.6 (95% CI, 6.5-6.7) per 100 000 population. Similar decreasing AAMR trends were also seen for the VHD subtypes. Men recorded higher AAMR for aortic stenosis and aortic regurgitation, whereas women had higher AAMR for mitral stenosis and mitral regurgitation. Mitral regurgitation had the highest change in average annual percent change in AAMR.

CONCLUSIONS

The mortality rate of VHD among the US population has declined over the past 2 decades. This highlights the likely efficacy of increasing surveillance and advancement in the management of VHD, resulting in improved outcomes.

Predictors, clinical impact, and management strategies for conduction abnormalities after transcatheter aortic valve replacement: an updated review

Transcatheter aortic valve replacement (TAVR) has increasingly become a safe, feasible, and widely accepted alternative surgical treatment for patients with severe symptomatic aortic stenosis. However, the incidence of conduction abnormalities associated with TAVR, including left bundle branch block (LBBB) and high-degree atrioventricular block (HAVB), remains high and is often correlated with risk factors such as the severity of valvular calcification, preexisting conditions in patients, and procedural factors. The existing research results on the impact of post-TAVR conduction abnormalities and permanent pacemaker (PPM) requirements on prognosis, including all-cause mortality and rehospitalization, remain contradictory, with varied management strategies for post-TAVR conduction system diseases across different institutions. This review integrates the latest research in the field, offering a comprehensive discussion of the mechanisms, risk factors, consequences, and management of post-TAVR conduction abnormalities. This study provides insights into optimizing patient prognosis and explores the potential of novel strategies, such as conduction system pacing, to minimize the risk of adverse clinical outcomes.

Clinical Profiles and Outcomes of Prosthesis-Specific Infective Endocarditis Subsequent to Transcatheter Versus Surgical Aortic Valve Replacement: A Systematic Review and Meta-Analysis

Prosthetic valve endocarditis (PVE) is a rare but serious complication following aortic valve replacement using either a transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR). This study aims to review the profiles and outcomes of PVE after surgical versus transcatheter aortic valve replacement. Electronic searches were performed on Scopus, EMBASE, and PubMed to retrieve related articles. To be included, study designs had to be randomized controlled trials (RCT) or observational cohort studies (in English) with PVE patients that compared differences based on TAVI or SAVR. This review included data for 13,221 patients with PVE diagnoses. Of those, 2,109 patients had an initial SAVR, and 11,112 patients had an initial TAVI. There was no difference in the incidence of PVE in patients who had initial TAVI versus SAVR (1.05% versus 1.01% per person-year, p=0.98). However, the onset of early PVE was more frequently observed in the TAVI group (risk ratio (RR): 1.54, 95% confidence interval (CI) [1.14, 2.08], p=0.005). Patients in the TAVI group had a lower indication for surgery to treat PVE when compared to SAVR (RR: 0.55, 95%CI [0.44, 0.69], p<0.001). Staphylococcus aureus was more likely to be the source of PVE in patients who had previous TAVI (RR: 1.34, 95%CI [1.17, 1.54], p<0.001). Also, Enterococcus faecalis was more frequently observed as a cause of PVE in the TAVI group (RR: 1.49, 95%CI [1.21, 1.82], p<0.001). Patients who underwent SAVR and TAVI had similar incidences of PVE. However, patients who underwent SAVR had a greater indication for surgery to treat PVE, while those who underwent TAVI had higher comorbidities, a higher likelihood of early PVE, and a trend towards higher one-year mortality.

Minimally invasive, surgical, and transcatheter aortic valve replacement: A network meta-analysis

BACKGROUND

Transcatheter aortic valve replacement (TAVR) has evolved as an alternative to surgical aortic valve replacement (SAVR). In addition to full-sternotomy (FS), recent reports have shown successful minimally-invasive SAVR approaches, including mini-sternotomy (MS) and mini-thoracotomy (MT). This network-meta-analysis (NMA) seeks to provide an outcomes comparison based on these different modalities (MS, MT, TAVR) compared with FS as a reference arm for the management of aortic valve disease.

METHODS

A comprehensive literature search was performed to identify studies that compared minimally-invasive SAVR (MS/MT) to conventional FS-SAVR, and/or TAVR. Bayesian NMA was performed using the random effects model. Outcomes were pooled as risk ratios (RR) with their 95 % confidence intervals (CIs). Our primary outcomes included 30-day mortality, stroke, acute kidney injury (AKI), major bleeding, new permanent pacemaker (PPM), and paravalvular leak (PVL). We also assessed long-term mortality at the latest follow-up.

RESULTS

A total of 27,117 patients (56 studies) were included; 10,397 patients had FS SAVR, 9523 had MS, 5487 had MT, and 1710 had TAVR. Compared to FS, MS was associated with statistically-significantly lower rates of 30-day mortality (RR, 0.76, 95%CI 0.59-0.98), stroke (RR, 0.84, 95%CI 0.72-0.97), AKI (RR, 0.76, 95%CI 0.61-0.94), and long-term mortality (RR 0.84, 95%CI 0.72-0.97) at a weighted mean follow-up duration of 10.4 years, while MT showed statistically-significantly higher rates of 30-day PVL (RR, 3.76, 95%CI 1.31-10.85) and major bleeding (RR 1.45; 95%CI 1.08-1.94). TAVR had statistically significant lower rates of 30-day AKI (RR 0.49, 95%CI 0.31-0.77), but showed statistically-significantly higher PPM (RR 2.50; 95%CI 1.60-3.91) and 30-day PVL (RR 12.85, 95%CI 5.05-32.68) compared to FS.

CONCLUSIONS

MS was protective against 30-day mortality, stroke, AKI, and long-term mortality compared to FS; TAVR showed higher rates of 30-day PVL and PPM but was protective against AKI. Conversely, MT showed higher rates of 30-day PVL and major bleeding. With the emergence of TAVR, the appropriate benchmarks for SAVR comparison in future trials should be the minimally-invasive SAVR approaches to provide clinical equipoise.

Prognostic Implication of Intestinal Wall Edema in Patients with Aortic Stenosis Receiving Trans-Catheter Aortic Valve Replacement

BACKGROUND

A recently proposed mechanism, the intestinal-cardiovascular relationship, serves as a framework to elucidate the interplay between these two systems. In our investigation, we assessed the prognostic implications of colon wall thickness, a marker correlated with intestinal congestion and dysfunction, in patients diagnosed with severe aortic stenosis undergoing transcatheter aortic valve replacement (TAVR).

METHODS

Patients diagnosed with severe aortic stenosis who underwent TAVR at our institution during the period spanning 2015 to 2022 were retrospectively enrolled. As part of the institutional protocol, patients underwent abdominal computed tomography upon admission, preceding TAVR. Our analysis aimed to assess the influence of colon wall thickness on the occurrence of either all-cause mortality or readmission due to heart failure within a two-year period.

RESULTS

A total of 345 patients were included. The median age was 85 (82, 88) years, and 99 patients were male. Baseline colon wall thickness was distributed widely, with a median value of 2.2 (2.0, 2.5) mm. Patients with thicker colon walls tended to have lower pulmonary artery pulsatility index values, indicating more impaired right ventricular function and more advanced malnutrition. A thicker colon wall was independently associated with 2-year death or heart failure readmission with a hazard ratio of 2.02 (95% confidence interval 1.01-14.07), adjusted for hemoglobin, age, and plasma B-type natriuretic peptide levels (p = 0.049), and significantly stratified the primary endpoint at a cutoff of 2.7 mm (25% versus 10%, p = 0.005).

CONCLUSIONS

Our initial observation revealed that a thicker baseline colon wall correlated with increased rates of mid-term mortality and readmission due to heart failure subsequent to TAVR. Developing a comprehensive understanding of the underlying causality necessitates further in-depth investigations through subsequent studies.

Efficacy and Safety of Moderate-Intensity Continuous Training on the Improvement of Cardiopulmonary Function in Patients After Transcatheter Aortic Valve Replacement (ENERGY): A Randomized Controlled Trial

OBJECTIVES

To investigate the effect of moderate-intensity continuous training (MICT) on the improvement of cardiopulmonary function for patients undergoing transcatheter aortic valve replacement (TAVR).

DESIGN

Randomized controlled study.

SETTING AND PARTICIPANTS

Between August 20, 2021, and February 28, 2022, a total of 66 patients after TAVR were screened for inclusion and randomly divided into the MICT and control groups at a ratio of 1:1. MICT was scheduled 3 times per week for 3 months in the intervention group. Patients in the control group received one-time advice on physical activity according to the current guideline.

METHODS

The primary endpoint was the 3-month change in peak oxygen consumption (peak VO2) assessed by cardiopulmonary exercise testing. The secondary endpoints included the 3-month change in 6-minute walk test (6MWT), the 12-Item Short Form Health Survey (SF-12), New York Heart Association (NYHA) class, echocardiographic parameters, and laboratory parameters.

RESULTS

After 3 months, the change in peak VO2 was higher in the MICT group than that in the control group (1.63 mL/kg/min, 95% CI 0.58-2.67, P = .003). Change in 6MWT (21.55 m, 95% CI 0.38-42.71, P = .046) was higher in the MICT group compared with the control group. A significant change in favor of MICT was also observed for low-density lipoprotein cholesterol (-0.62 mmol/L, 95% CI -1.00 to -0.23, P = .002). However, there were no significant changes in other echocardiographic indices, laboratory parameters, and SF-12 between the 2 groups (all P > .05).

CONCLUSIONS AND IMPLICATIONS

MICT had a positive effect on the cardiopulmonary function and physical capacity of patients after TAVR.

Health-related quality of life following TAVI or cardiac surgery in patients at intermediate and low risk: a systematic review and meta-analysis

Recent randomised trials have shown that clinical outcomes with transcatheter aortic valve implantation (TAVI) are non-inferior to surgical aortic valve replacement (SAVR) in patients with symptomatic aortic stenosis at intermediate to low risk. Health-related quality of life (HrQoL) outcomes in these patient groups remain uncertain. A systematic search of the literature was conducted that included nine trials and 11,295 patients. Kansas City Cardiomyopathy Questionnaire (KCCQ), a heart-failure-specific measure and EuroQol-5D (EQ-5D) (a generic health status tool) changes were the primary outcomes. New York Heart Association (NYHA) classification was the secondary outcome. Improvement in KCCQ scores was greater with TAVI (mean difference (MD)=13.56, 95% confidence interval (CI) 11.67-15.46, p<0.001) at 1 month, as was the improvement in EQ-5D (MD=0.07, 95% CI 0.05-0.08, p<0.001). There was no difference in KCCQ (MD=1.05, 95% CI -0.11 to 2.21, p=0.08) or EQ-5D (MD=-0.01, 95% CI -0.03 to 0.01), p=0.37) at 12 months. NYHA functional class 3/4 was lower in patients undergoing TAVI at 1 month (MD=0.51, 95% CI 0.34-0.78, p=0.002), but there was no difference at 12 months (MD=1.10; 95% CI 0.87-1.38, p=0.43). Overall, TAVI offers early benefit in HRQoL outcomes compared with SAVR, but they are equivalent at 12 months.

Aspirin Versus Warfarin after Transcatheter Aortic Valve Replacement in Low-Risk Patients: 2-Year Follow-Up

Subclinical leaflet thrombosis occurs with transcatheter heart valves (THVs) and could be associated with structural valve deterioration. The current guidelines recommend the use of antiplatelet agents after transcatheter aortic valve replacement (TAVR) but not the routine use of oral anticoagulation. Our study examines the effects of short-term warfarin therapy on THV hemodynamics at 24 months after TAVR in low-risk patients. Low-risk patients who underwent TAVR were randomly allocated 1:1 to receive low-dose aspirin (n = 50) or low-dose aspirin plus warfarin (n = 44). After 30 days of treatment, ongoing medication regimens, including anticoagulation, were at the physicians' discretion. Follow-up after a period of 24 months was available for clinical and echocardiographic outcomes. At the 24-month mark, follow-up echocardiography of the randomly allocated patients revealed just 1 additional case of new structural valve deterioration in the aspirin group (compared with the occurrence within 30 days), based on the Valve Academic Research Consortium 3 definitions. There were also no differences in mean pressure gradients (11.5 ± 0.5 mm Hg vs 11.05 ± 4.0 mm Hg, p = 0.6) or peak velocity (2.2 ± 0.5 m/s vs 2.1 ± 0.4 m/s, p = 0.7) between the groups. A composite end point (mortality, stroke, and myocardial infarction) did not show any difference between the groups at long-term follow-up (p = 0.07). In conclusion, in low-risk patients who underwent TAVR, short-term anticoagulation with warfarin did not impact clinical outcomes or THV hemodynamics by echocardiography at 24 months.

The Relation Between Hospital Transcatheter Aortic Valve Replacement Volume and Transcatheter Edge-to-Edge Repair Outcomes: A Study Using the National Readmissions Database

Volume-outcome relations exist for transcatheter aortic valve replacement (TAVR) and mitral transcatheter edge-to-edge repair (TEER), but how the volume of one impacts the outcomes of the other has not been studied. We, therefore, examined the association between TAVR volume and TEER outcomes using patients who underwent TEER in the Nationwide Readmissions Database from 2016 to 2018. For each year, hospitals were categorized into quartiles (first = lowest volume, fourth = highest volume) by TAVR volume. The primary outcomes for TEER, including 30-day composite mortality and morbidity and 30-day readmissions, were compared between TAVR volume quartiles before and after adjustment. Overall, 16,156 patients who underwent TEER were included: 209 at hospitals in the first, 1,094 at hospitals in the second, 3,363 at hospitals in the third, and 11,490 at hospitals fourth quartile by TAVR volume. There were no significant differences in observed in the 30-day composite morbidity and mortality (41.0% vs 26.1% vs 28.2% vs 28.3%, p = 0.063) or 30-day readmissions (14.8% vs 14.1% vs 14.8% vs 15.0%, p = 0.920) across the first through fourth quartiles. The adjusted results revealed that TEER performed at hospitals in the second through fourth quartiles by TAVR volume had significantly lower odds of 30-day composite morbidity and mortality in 2016 (adjusted odds ratio 0.41 [019 to 0.85], 0.32 [0.18 to 0.57], and 0.35 [0.20 to 0.62]) and 2018 (adjusted odds ratio 0.55 [0.31 to 0.96], 0.53 [0.33 to 0.84], and 0.59 [0.38 to 0.91]) relative to TEER at hospitals in the lowest TAVR volume quartile (all p <0.05). In conclusion, the lowest volume TAVR centers are associated with increased morbidity and mortality after TEER. Therefore, a minimum TAVR volume cutoff may guide the designation of TEER centers and Valve Centers of Excellence.

Comparative Analysis of TAVR (Transcatheter Aortic Valve Replacement) and Surgical Valve Replacement for Low-Risk Patients

"Aortic stenosis" (AS) refers to a cardiac condition in which the aortic valve narrows, creating an obstruction that hinders the flow of blood from the left ventricle to the aorta. This contraction of the arteries influences normal blood circulation, leading to elevated pressure within the left ventricle and potentially culminating in heart failure. The management of AS typically involves two primary treatments, i.e. "surgical aortic valve replacement" (SAVR) and "transcatheter aortic valve replacement" (TAVR). In both cases, the goal is to replace a dysfunctional aortic valve with a functional substitute. Presently, TAVR has gained much preference over SAVR in clinical practice. However, there is a dearth of comprehensive research directly comparing the real-world outcomes of TAVR and SAVR. In recent years, TAVR has emerged as an attractive alternative to SAVR, yet studies that provide a detailed comparison of their real-world solutions are limited. This review article assesses the mortality of patients who underwent TAVR vis-a-vis patients who underwent SAVR.

Loss of Independent Living in Patients Undergoing Transcatheter or Surgical Aortic Valve Replacement: A Retrospective Cohort Study

BACKGROUND

The recommendation for transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) in patients 65 to 80 years of age is equivocal, leaving patients with a difficult decision. We evaluated whether TAVR compared to SAVR is associated with reduced odds for loss of independent living in patients ≤65, 66 to 79, and ≥80 years of age. Further, we explored mechanisms of the association of TAVR and adverse discharge.

METHODS

Adult patients undergoing TAVR or SAVR within a large academic medical system who lived independently before the procedure were included. A multivariable logistic regression model, adjusting for a priori defined confounders including patient demographics, preoperative comorbidities, and a risk score for adverse discharge after cardiac surgery, was used to assess the primary association. We tested the interaction of patient age with the association between aortic valve replacement (AVR) procedure and loss of independent living. We further assessed whether the primary association was mediated (ie, percentage of the association that can be attributed to the mediator) by the procedural duration as prespecified mediator.

RESULTS

A total of 1751 patients (age median [quartiles; min-max], 76 [67, 84; 23-100]; sex, 56% female) were included. A total of 27% (222/812) of these patients undergoing SAVR and 20% (188/939) undergoing TAVR lost the ability to live independently. In our cohort, TAVR was associated with reduced odds for loss of independent living compared to SAVR (adjusted odds ratio [OR adj ] 0.19 [95% confidence interval {CI}, 0.14-0.26]; P < .001). This association was attenuated in patients ≤65 years of age (OR adj 0.63 [0.26-1.56]; P = .32) and between 66 and 79 years of age (OR adj 0.23 [0.15-0.35]; P < .001), and magnified in patients ≥80 years of age (OR adj 0.16 [0.10-0.25]; P < .001; P -for-interaction = .004). Among those >65 years of age, a shorter procedural duration mediated 50% (95% CI, 28-76; P < .001) of the beneficial association of TAVR and independent living.

CONCLUSIONS

Patients >65 years of age undergoing TAVR compared to SAVR had reduced odds for loss of independent living. This association was partly mediated by shorter procedural duration. No association between AVR approach and the primary end point was found in patients ≤65 years of age.

Post-TAVR patients with atrial fibrillation: are NOACs better than VKAs?-A meta-analysis

Objective

This study aimed to compare the efficacy of novel oral anticoagulants (NOACs) with traditional anticoagulants vitamin K antagonists (VKAs) in patients with atrial fibrillation (AF) post transcatheter aortic valve replacement (TAVR).

Methods

Studies comparing the usage of NOACs and VKAs in AF patients with oral anticoagulant indication post-TAVR were retrieved from PubMed, EMBASE, Medline, and Cochrane databases from their building-up to Jan. 2023. The literature was screened in line of inclusion and exclusion criteria. Risk ratio (RR) or odds ratio (OR),95% confidence interval (CI) and number needed to treat (NNT) were calculated for four main indexes that composite endpoints composed mainly of any clinically relevant risk events, stroke, major bleeding, and all-cause mortality. Subsequently, a meta-analysis was performed using the RevMan5.3 and Stata 16.0 software.

Results

In the aggregate of thirteen studies, contained 30388 post-TAVR patients with AF, were included in this meta-analysis. Our results indicated that there was no significant difference in stroke between the NOACs group and the VKAs group, and the NOACs group had a numerically but non-significantly higher number of composite endpoint events compared with the other group. Nevertheless, the incidence of major bleeding [11.29% vs. 13.89%, RR 0.82, 95%CI (0.77,0.88), P < 0.00001, I² = 69%, NNT = 38] and all-cause mortality [14.18% vs. 17.61%, RR 0.83, 95%CI (0.79,0.88), p < 0.00001, I² = 82%, NNT = 29] were significantly lower in the NOACs group than another group.

Conclusion

Taken together, our data indicated that the usage of NOACs reduced the incidence of major bleeding and all-cause mortality compared to VKAs in post-TAVR patients with AF.

Prognostic Impact of Modified H2FPEF Score in Patients Receiving Trans-Catheter Aortic Valve Replacement

BACKGROUND

H2FPEF is a recently introduced score for the diagnosis of heart failure with preserved ejection fraction (HFpEF). Many patients with severe aortic stenosis have clinical/subclinical HFpEF and have worsening heart failure even after trans-catheter aortic valve replacement (TAVR). We investigated the prognostic impact of the H2FPEF score in TAVR candidates.

METHODS

Patients undergoing TAVR procedures at a single academic center between 2015 and 2022 were included. The H2FPEF score was calculated using baseline characteristics before TAVR. The prognostic impact of the score on the post-TAVR composite endpoint, consisting of all-cause death and heart failure readmissions during the 2-year observation period, was evaluated.

RESULTS

A total of 244 patients (median age 86 years, 70 males) were included. The median value of H2FPEF score was 3 (2, 4). The score was significantly associated with the primary outcome with a hazard ratio of 1.33 (95% confidence interval 1.02-1.74, p = 0.036). We constructed a modified H2FPEF score by adjusting cutoffs of several items for better prognostic stratification (i.e., age and body mass index). A modified score had a higher area under the curve than the original one (0.65 vs. 0.59, p = 0.028) and was independently associated with the primary outcome with an adjusted hazard ratio of 1.22 (95% confidence interval 1.01-1.49, p = 0.047).

CONCLUSIONS

A modified H2FPEF score, which was originally developed to diagnose the presence of HFpEF, could be used to risk-stratify elderly patients receiving TAVR. The clinical utility of this score should be validated in future studies.

Swimming With Sharks: Left Main Coronary Obstruction Following Transcatheter Aortic Valve Implantation

Delayed coronary obstruction (DCO) occurs when there is obstruction of the coronary ostia following a transcatheter aortic valvular implantation (TAVI). It is an uncommon but serious complication that often leads to death, usually presents as severe hypotension after TAVI, and should be suspected if migration of the valve occurs. We report the case of a 70-year-old female patient with severe aortic stenosis who underwent TAVI using a 26-mm CoreValve Evolut Pro (Medtronic, Dublin, Ireland). Although the valve was implanted successfully, she experienced hypotension with intermittent ST elevations and had a cardiac arrest shortly after, requiring Advanced Cardiovascular Life Support (ACLS). An aortogram showed sealing of the sinotubular junction (STJ) by CoreValve, without coronary flow. CoreValve was then snared and repositioned in the ascending aorta recovering coronary flow and cardiac pulsatility. A second TAVI was performed and an Edwards 20 mm Sapiens 3 valve (Edwards Lifesciences, Irvine, CA, USA) was implanted as standard procedure.

Negative Prognostic Impact of Mineralocorticoid Receptor Antagonist in Elderly Patients Receiving TAVR

Background: Morbidity and mortality following trans-catheter aortic valve replacement (TAVR) remain high. Renin-angiotensin system inhibitors improve clinical outcomes in the cohort studied in this work. However, post-TAVR prognostic impact of mineralocorticoid receptor antagonist (MRA), another neuro-hormonal blocker, remains uncertain. Here, we hypothesized that MRA was associated with improved clinical outcomes in elderly patients with severe aortic stenosis receiving TAVR.

METHODS

Consecutive patients who received TAVR at our institute between 2015 and 2022 were considered for inclusion. Propensity score matching analysis was performed to match pre-procedural baseline characteristics between those with and without MRA. The prognostic impact of MRA use on the composite primary endpoint consisting of all-cause death and heart failure during the 2-year observational period following index discharge was evaluated.

RESULTS

Among 352 patients who received TAVR, 112 patients (median 86 years, 31 men) were included, consisting of baseline-matched 56 patients with MRA and 56 patients without MRA. Following TAVR, patients with MRA had more impaired renal function compared with no MRA group. Following index discharge, serum potassium tended to increase, and renal function tended to decline in patients with MRA. Patients with MRA had a higher cumulative incidence of the primary endpoints during a two-year observational period (30% versus 8%, p = 0.022).

CONCLUSIONS

Routine prescription of MRA might not be recommended in elderly patients with severe aortic stenosis receiving TAVR, given its negative prognostic impact. Optimal patient selection for MRA administration in this cohort needs further study.

Assessment of TVT and STS Risk Score Performances in Patients Undergoing Transcatheter Aortic Valve Replacement

Background

The Society of Thoracic Surgeons (STS) score has been used to risk stratify patients undergoing transcatheter aortic valve replacement (TAVR). The Transcatheter Valve Therapy (TVT) score was developed to predict in-hospital mortality in high/prohibitive-risk patients. Its performance in low and intermediate-risk patients is unknown. We sought to compare TVT and STS scores' ability to predict clinical outcomes in all-surgical-risk patients undergoing TAVR.

Methods

Consecutive patients undergoing TAVR from 2012-2020 within a large health care system were retrospectively reviewed and stratified by STS risk score. Predictive abilities of TVT and STS scores were compared using observed-to-expected mortality ratios (O:E) and area under the receiver operating characteristics curves (AUCs) for 30-day and 1-year mortality.

Results

We assessed a total of 3270 patients (mean age 79 ± 9 years, 45% female), including 191 (5.8%) low-risk, 1093 (33.4%) intermediate-risk, 1584 (48.4%) high-risk, and 402 (5.8%) inoperable. Mean TVT and STS scores were 3.5% ± 2.0% and 6.1% ± 4.3%, respectively. Observed 30-day and 1-year mortality were 2.8% (92/3270; O:E TVT 0.8 ± 0.16 vs STS 0.46 ± 0.09), and 13.2% (432/3270), respectively. In the all-comers population, both TVT and STS risk scores showed poor prediction of 30-day (AUC: TVT 0.68 [0.62-0.74] vs STS 0.64 [0.58-0.70]), and 1-year (AUC: TVT 0.65 [0.62-0.58] vs STS 0.65 [0.62-0.58]) mortality. After stratifying by surgical risk, discrimination of the TVT and STS scores remained poor in all categories at 30 days and 1 year.

Conclusions

An updated TAVR risk score with improved predictive ability across all-surgical-risk categories should be developed based on a larger national registry.

Mortality in patients with chronic obstructive pulmonary disorder undergoing transcatheter aortic valve replacement: The importance of chronic obstructive pulmonary disease exacerbation

BACKGROUND

Severe chronic obstructive pulmonary disease (COPD) has been associated with futile outcome after transcatheter aortic valve replacement (TAVR). Data on outcomes according to COPD severity are warranted to aid identification of patients who may not benefit from TAVR. We aimed to examine the association between risk of COPD exacerbation and 1-year mortality after TAVR.

METHODS

Using Danish nationwide registries we identified patients undergoing first-time TAVR during 2008-2021 by COPD status. COPD severity levels were defined as low or high risk of acute exacerbation of COPD (AE-COPD) and treatment intensity levels (none or short-term, mono/dual, triple therapy, or home oxygen). Kaplan-Meier functions and adjusted Cox regression models were used to assess 1-year mortality comparing COPD severity groups with patients without COPD.

RESULTS

We identified 7,047 patients with TAVR of whom 644 had a history of COPD (low risk of AE-COPD: 439, high risk of AE-COPD: 205). The median age of the TAVR cohort was 81.4 years (IQR: 76.8-85.1) and 55.8% were males. One-year mortality for TAVR patients without COPD was 8.5% (95% CI: 7.8-9.2) and 15.4% (95% CI: 12.5-18.2) for those with COPD (adjusted HR: 1.63 [95% CI: 1.28-2.07]). Patients with low or high risk of AE-COPD had 1-year mortality of 13.1% (95% CI: 9.8-16.3) and 20.2% (95% CI: 14.6-25.8) corresponding to adjusted HRs of 1.31 (95% CI: 0.97-1.78) and 2.44 (95% CI: 1.70-3.50) compared with patients without COPD. Patients with high risk of AE-COPD and no/short term therapy or use of home oxygen represented the subgroups of patients with the highest 1-year mortality (31.6% [95% CI: 14.5-48.7] and 30.9% [95% CI: 10.3-51.6]).

CONCLUSION

Among patients undergoing TAVR, increasing risk of exacerbation with COPD was associated with increasing 1-year mortality compared with non-COPD patients. Patients with a high risk of exacerbation with COPD not using any guideline recommended COPD medication and those using home oxygen had the highest 1-year mortality.

Outcomes in Patients With Early Menopause Who Underwent Transcatheter Aortic Valve Implantation

Early menopause is associated with an increased risk of cardiovascular diseases, including aortic stenosis (AS). We sought to investigate the prevalence and impact of early menopause on clinical outcomes in patients who underwent transcatheter aortic valve implantation (TAVI) for severe symptomatic AS. Women's International TAVI is a multinational, prospective, observational registry of women who underwent TAVI for severe symptomatic AS (n = 1,019). Patients were divided into 2 groups based on age of menopause: early menopause (age ≤45 years) and regular menopause (age >45 years). The primary outcome of interest was Valve Academic Research Consortium 2 efficacy end point, a composite of mortality, stroke, myocardial infarction, hospitalization for valve-related symptoms, or heart failure or valve-related dysfunction at 1-year follow-up. Of 732 patients with available data on menopause age, 173 (23.6%) were classified as having early menopause. These patients presented for TAVI at a younger age (81.6 ± 6.9 vs 82.7 ± 5.9, p = 0.05) and had a significantly lower Society of Thoracic Surgeons score (6.6 ± 4.8 vs 8.2 ± 7.1, p = 0.03) than those with regular menopause. However, the total valve calcium volume was smaller among patients with early versus regular menopause (731.8 ± 850.9 mm³ vs 807.6 ± 633.8 mm^3, p = 0.002). Other co-morbidities were similar between the 2 groups. At 1-year follow-up, there were no significant differences in clinical outcomes between patients with early versus regular menopause (hazard ratio 1.00, 95% confidence interval 0.61 to 1.63, p = 1.00). In conclusion, despite presenting for TAVI at a younger age, patients with early menopause had a similar risk of adverse events as patients with regular menopause at 1 year after TAVI.

TAVR in 2023: Who Should Not Get It?

Since the first transcatheter delivery of an aortic valve prosthesis was performed by Cribier et al in 2002, the picture of aortic stenosis (AS) therapeutics has changed dramatically. Initiated from an indication of inoperable to high surgical risk, extending to intermediate and low risk, transcatheter aortic valve replacement (TAVR) is now an approved treatment for patients with severe, symptomatic AS across all the risk categories. The current evidence supports TAVR as a frontline therapy for treating severe AS. The crucial question remains concerning the subset of patients who still are not ideal candidates for TAVR because of certain inherent anatomic, nonmodifiable, and procedure-specific factors. Therefore, in this study, we focus on these scenarios and reasons for referring selected patients for surgical aortic valve replacement in 2023.

In-hospital outcomes following percutaneous versus surgical intervention in the treatment of aortic stenosis and concomitant coronary artery disease

INTRODUCTION AND OBJECTIVES

Concomitant coronary artery disease (CAD) is prevalent among aortic stenosis patients; however the optimal therapeutic strategy remains debated. We investigated periprocedural outcomes among patients undergoing transcatheter aortic valve implantation with percutaneous coronary intervention (TAVI/PCI) vs surgical aortic valve replacement with coronary artery bypass grafting (SAVR/CABG) for aortic stenosis with CAD.

METHODS

Using discharge data from the Spanish National Health System, we identified 6194 patients (5217 SAVR/CABG and 977 TAVI/PCI) between 2016 and 2019. Propensity score matching was adjusted for baseline characteristics. The primary outcome was in-hospital all-cause mortality. Secondary outcomes were in-hospital complications and 30-day cardiovascular readmission.

RESULTS

Matching resulted in 774 pairs. In-hospital all-cause mortality was more common in the SAVR/CABG group (3.4% vs 9.4%, P <.001) as was periprocedural stroke (0.9% vs 2.2%; P=.004), acute kidney injury (4.3% vs 16.0%, P <.001), blood transfusion (9.6% vs 21.1%, P <.001), and hospital-acquired pneumonia (0.1% vs 1.7%, P=.001). Permanent pacemaker implantation was higher for matched TAVI/PCI (12.0% vs 5.7%, P <.001). Lower volume centers (< 130 procedures/y) had higher in-hospital all-cause mortality for both procedures: TAVI/PCI (3.6% vs 2.9%, P <.001) and SAVR/CABG (8.3 vs 6.8%, P <.001). Thirty-day cardiovascular readmission did not differ between groups.

CONCLUSIONS

In this large contemporary nationwide study, percutaneous management of aortic stenosis and CAD with TAVI/PCI had lower in-hospital mortality and morbidity than surgical intervention. Higher volume centers had less in-hospital mortality in both groups. Dedicated national high-volume heart centers warrant further investigation.

Early acute kidney injury after transcatheter aortic valve implantation: predictive value of currently available risk scores

BACKGROUND

Acute kidney injury (AKI) after transcatheter aortic valve implantation (TAVI) is a frequent complication associated with adverse outcomes and mortality. Various scores have been developed to predict this complication in the coronary setting. However, none have ever been tested in a large TAVI population. This study aimed to evaluate the power of four different scores in predicting AKI after TAVI.

METHODS

Overall, 1535 consecutive TAVI patients from the observational multicentric "Magna Graecia" TAVI registry were included in the analysis. Of the study population, 235 (15.31%) developed AKI early. The Mehran, William Beaumont Hospital, CR₄EATME₃AD₃, and ACEF scores were calculated retrospectively.

RESULTS

The patients who developed TAVI-related AKI had significantly higher absolute values of all risk scores than those who did not. The receiver-operating characteristic analysis also showed a significant correlation between these four scores and AKI, but without a significant difference among all of them (p value = 0.176). Nevertheless, based on their area under the curve values (≤0.604 for all), none had adequate diagnostic accuracy in predicting TAVI-related AKI. Importantly, multivariate analysis identified myocardial revascularization close to the TAVI procedure and implantation of self-expanding prostheses, as well as atrial fibrillation, low-osmolar contrast media administration, corrected contrast medium volume, and any transfusion (p value < 0.05 for all) as independent risk factors for AKI.

CONCLUSIONS

Although high values of current AKI risk scores are significantly associated with the development of this complication, these are not sufficiently accurate. Further studies are needed so that a TAVI-dedicated AKI risk score may be created.

Transcatheter Aortic Valve Replacement vs. Surgical Aortic Valve Replacement for Long-Term Mortality Due to Stroke and Myocardial Infarction: A Meta-Analysis during the COVID-19 Pandemic

Background and objectives: One of the leading causes of mortality and morbidity in people over the age of 50 is stroke. The acceptance of transcatheter aortic valve replacement (TAVR) as a treatment option for severe symptomatic aortic stenosis (AS) has increased as a result of numerous randomized clinical trials comparing surgical aortic valve replacement (SAVR) and TAVR in high- and intermediate-risk patients, showing comparable clinical outcomes and valve hemodynamics. Materials and Methods: An electronic search of Medline, Google Scholar and Cochrane Central was carried out from their inception to 28 September 2022 without any language restrictions. Results: Our meta-analysis demonstrated that, as compared with SAVR, TAVR was not linked with a lower stroke ratio or stroke mortality. It is clear from this that the SAVR intervention techniques applied in the six studies were successful in reducing cardiogenic consequences over time. Conclusions: A significantly decreased rate of mortality from cardiogenic causes was associated with SAVR. Additionally, when TAVR and SAVR were compared for stroke mortality, the results were nonsignificant with a p value of 0.57, indicating that none of these procedures could decrease stroke-related mortality.

Antithrombotic strategies after transcatheter aortic valve implantation: A systematic review and network meta-analysis of randomized controlled trials

AIMS

Meta-analyses comparing different antithrombotic strategies were conducted to determine the optimal therapeutic regimen post transcatheter aortic valve implantation (TAVI). However, there were restricted high-quality direct comparisons across the different antithrombotic therapeutic regimens. We sought to explore the safety and efficacy of different antithrombotic therapy strategies after TAVI using network meta-analyses of randomized controlled trials (RCTs).

METHODS

We searched CENTRAL, PubMed, Embase and Medline through August 2021 for RCTs that directly compared different antithrombotic schemes in adults who had undergone TAVI. We conducted a pairwise and network meta-analysis measuring all-cause mortality, stroke, myocardial infarction, all bleeding and life-threatening or major bleeding events. The surface under the cumulative ranking (SUCRA) curve was estimated to rank the therapies. We evaluated the risk of bias and graded the quality of the evidence using established methods.

RESULTS

Six RCTs of 2824 patients who underwent TAVI were analysed. The risk of all bleeding [relative risk (RR) 1.88 (1.34-2.64)] and life-threatening or major bleeding [RR 2.03 (1.27-3.24)] was significantly higher for dual antiplatelet therapy (DAPT) than single antiplatelet therapy (SAPT), whereas there was no significant difference in the risk of all-cause mortality [RR 1.01 (0.61-1.68)] between DAPT and SAPT. Oral anticoagulant (OAC) + SAPT (OACSAPT) had significantly higher rates of all bleeding and life-threatening or major bleeding events compared with SAPT ([RR 3.46 (2.23-5.36)], [RR 2.86 (1.50-5.45)]). The risk of all-cause mortality [RR 1.72 (1.14-2.59)] and all bleeding [RR 1.84 (1.38-2.44)] were significantly higher for OACSAPT than DAPT, whereas there was no significant difference in the risk of life-threatening or major bleeding events [RR 1.41 (0.89-2.23)] between DAPT and OACSAPT. There was no significant difference in stroke or myocardial infarction among the different antithrombotic strategies (SAPT, DAPT and OACSAPT). Additionally, patients receiving OACSAPT had the highest risks for all-cause mortality (SUCRA 3.5%) and life-threatening or major bleeding (SUCRA 2.3%). SAPT seemed to be superior to DAPT in terms of all-cause mortality (SUCRA SAPT: 76.7%, DAPT: 69.8%) and stroke (SUCRA 69.6%, 59.7%).

CONCLUSIONS

Except for OACSAPT having a higher all-cause mortality than DAPT, patients who underwent TAVI had similar all-cause mortality, stroke and myocardial infarction rates among different antithrombotic regimens. Patients on SAPT had a significantly lower bleeding risk than those on DAPT and OACSAPT. Our study indicates that SAPT is the preferred therapeutic strategy when there is no indication for OAC or DAPT. Furthermore, the application of OACSAPT was ranked the worst among all antithrombotic regimens and should be averted due to an increased risk of all-cause mortality and all bleeding.

Prognostic value of ventricular longitudinal strain in patients undergoing transcatheter aortic valve replacement: A systematic review and meta-analysis

Introduction

Strain obtained by speckle tracking echocardiography (STE) can detect subclinical myocardial impairment due to myocardial fibrosis (MF) and is considered a prognostic marker. Aortic stenosis (AS) is not only a valve disease, but also a cardiomyopathy characterized by MF. The purpose of this study was to systematically review and analyze ventricular strain as a predictor of adverse outcomes in patients with AS undergoing transcatheter aortic valve replacement (TAVR).

Methods

PubMed, Embase, and the Cochrane library were searched for studies that investigated the prognostic value of impaired ventricular strain on patients with AS undergoing TAVR with all-cause mortality (ACM) and major adverse cardiovascular events (MACE). Pooled odds ratios (ORs), hazard ratios (HRs), and 95% confidence intervals (CIs) were calculated to assess the role of left (LVLS) and right (RVLS) ventricular longitudinal strain in the prognostic prediction of patients with AS undergoing TAVR. Sensitivity and subgroup analysis was performed to assess heterogeneity.

Results

Twelve studies were retrieved from 571 citations for analysis. In total, 1,489 patients with a mean age of 82 years and follow-up periods varying between 1 year and 8.5 years were included. Meta-analysis showed the impaired LVLS from eight studies was associated with an increased risk for combined ACM and MACE (OR: 1.08, 95% CI: 1–1.16; p = 0.037), and ACM alone (HR: 1.08, 95% CI: 1.01–1.16; p = 0.032). Impaired RVLS from four studies was associated with an increased risk of combined ACM and MACE (OR: 1.08, 95% CI: 1.02–1.14; p < 0.01), and ACM alone (HR: 1.07, 95% CI: 1.02–1.12; p < 0.01).

Conclusions

This meta-analysis demonstrated that ventricular strain, including LVLS and RVLS, had a substantial prognostic value in ACM or combined ACM and MACE, which could be used as a valid marker for risk stratification in patients with AS undergoing TAVR.

Bleeding risk differences after TAVR according to the ARC-HBR criteria: insights from SCOPE 2

BACKGROUND

The Academic Research Consortium - High Bleeding Risk (ARC-HBR) initiative defined conditions associated with percutaneous coronary intervention (PCI)-related bleeding.

AIMS

We sought to further explore these HBR conditions in the setting of transcatheter aortic valve replacement (TAVR).

METHODS

Patients from the SCOPE 2 trial were stratified by their bleeding risk status based on the ARC-HBR definitions. Baseline and procedural characteristics, as well as key clinical outcomes including Bleeding Academic Research Consortium (BARC) 3-5 bleeding, were compared in ARC-HBR positive (HBR+) and ARC-HBR negative (HBR-) patients.

RESULTS

Of 787 patients randomised in SCOPE 2 and included in this study, 633 were HBR+ (80.4%). Compared with HBR- patients, those HBR+ were older and more frequently presented with diabetes, a history of coronary artery disease, atrial fibrillation, prior cerebrovascular accident, and a Society of Thoracic Surgeons predicted risk of 30-day mortality (STS-PROM) (4.9±2.9% vs 3.3%±2.1%; p<0.0001). In addition, HBR+ patients were more frequently on oral anticoagulation therapy. At 1 year, HBR+ patients had higher rates of all-cause death (12.4% vs 4.3%, respectively, risk difference 8.09%; 95% confidence interval [CI]: 3.76-12.41; p=0.0002); the rates of BARC 3-5 type bleeding were relatively high but not statistically different compared with HBR- patients (7.7% vs 6.1%, risk difference 1.67%; 95% CI: -2.72 to 6.06; p=0.46). Subgroup analyses for bleeding events showed no significant interaction in terms of STS-PROM score, age, or medications.

CONCLUSIONS

The ARC-HBR criteria failed to isolate a subgroup of patients at higher bleeding risk in TAVR patients from a randomised trial. These findings have potential implications, especially for the selection of post-TAVR antithrombotic regimens based on individual bleeding-risk profiles. Specific HBR criteria should be defined for TAVR patients.

Comparison of cusp-overlap projection and standard three-cusp coplanar view during self-expanding transcatheter aortic valve replacement: A systematic review and meta-analysis

Objective

Permanent pacemaker implantation (PPI) is a common complication after transcatheter aortic valve replacement (TAVR). Recently, the cusp-overlap projection (COP) technique was thought to be a feasible method to reduce PPI risk. However, the evidence is still relatively scarce. Therefore, this meta-analysis was performed to compare COP and standard three-cusp coplanar (TCC) projection technique.

Methods

PubMed and EMBASE databases were systematically searched for relevant literature published from the inception (EMBASE from 1974 and PubMed from 1966) to 16 April 2022, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The primary outcome of interest was post-operative (including in-hospital and 30-day) PPI.

Results

Total of 3,647 subjects from 11 studies were included in this meta-analysis. Of those, 1,453 underwent self-expanding TAVR using COP and 2,194 using TCC technique. In a pooled analysis, the cumulative PPI incidence was 9.3% [95% confidence interval (CI): 6.9-11.7%] and 18.9% (95% CI: 15.5-22.3%) in the COP group and TCC group, respectively. The application of the COP technique was associated with a significant PPI risk reduction (I2 = 40.3% and heterogeneity Chi-square p = 0.070, random-effects OR: 0.49, 95% CI: 0.36-0.66, p < 0.001). A higher implantation depth was achieved in the COP group compared with the TCC group [standardized mean difference (SMD) = -0.324, 95% CI: (-0.469, -0.180)]. There was no significant difference between the two groups in second valve implantation, prosthesis pop-out, fluoroscopic time, post-operative left bundle branch block, mortality, stroke, moderate/severe paravalvular leakage, mean gradient, and length of hospital stay. However, radiation doses were higher in the COP group [SMD = 0.394, 95% CI: (0.216, 0.572), p < 0.001].

Conclusion

In self-expanding TAVR, the application of the cusp overlap projection technique was associated with a lower risk of PPI compared with the standard TCC technique.

Systematic review registration

[https://inplasy.com/inplasy-2022-4-0092/], identifier [INPLASY202240092].

Trends, Predictors, and Outcomes of 30-Day Readmission With Heart Failure After Transcatheter Aortic Valve Replacement: Insights From the US Nationwide Readmission Database

BACKGROUND

Data on trends, predictors, and outcomes of heart failure (HF) readmissions after transcatheter aortic valve replacement (TAVR) remain limited. Moreover, the relationship between hospital TAVR discharge volume and HF readmission outcomes has not been established.

METHODS AND RESULTS

The Nationwide Readmission Database was used to identify 30‐day readmissions for HF after TAVR from October 1, 2015, to November 30, 2018, using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD‐10‐CM) codes. A total of 167 345 weighted discharges following TAVR were identified. The all‐cause readmission rate within 30 days of discharge was 11.4% (19 016). Of all the causes of 30‐day rehospitalizations, HF comprised 31.4% (5962) of all causes. The 30‐day readmission rate for HF did not show a significant decline during the study period (P_trend=0.06); however, all‐cause readmission rates decreased significantly (P_trend=0.03). HF readmissions were comparable between high‐ and low‐volume TAVR centers. Charlson Comorbidity Index >8, length of stay >4 days during the index hospitalization, chronic obstructive pulmonary disease, atrial fibrillation, chronic HF, preexisting pacemaker, complete heart block during index hospitalization, paravalvular regurgitation, chronic kidney disease, and end‐stage renal disease were independent predictors of 30‐day HF readmission after TAVR. HF readmissions were associated with higher mortality rates when compared with non‐HF readmissions (4.9% versus 3.3%; P<0.01). Each HF readmission within 30 days was associated with an average increased cost of $13 000 more than for each non‐HF readmission.

CONCLUSIONS

During the study period from 2015 to 2018, 30‐day HF readmissions after TAVR remained steady despite all‐cause readmissions decreasing significantly. All‐cause readmission mortality and HF readmission mortality also showed a nonsignificant downtrend. HF readmissions were comparable across low‐, medium‐, and high‐volume TAVR centers. HF readmission was associated with increased mortality and resource use attributed to the increased costs of care compared with non‐HF readmission. Further studies are needed to identify strategies to decrease the burden of HF readmissions and related mortality after TAVR.

Transition to Parenthood and Marital Satisfaction: A Meta-Analysis

The transition to parenthood is a major life event characterized by profound changes for a considerable number of people. Previous meta-analyses summarized the results obtained by various researchers in the first year and, respectively, in the first 2 years postpartum, globally. The current studyadds to the literature by testing the changes from 12 to 24 months, the cross-partner associations and the analysis of different moderators. The aims of thispresent meta-analysis are to investigate the decrease in marital satisfaction during the first and second year postpartum, to examine cross-partner associations of the decline in postpartum marital satisfaction, and to investigate the potential moderating variables of this decrease. Forty-nine studies (97 samples of parents and 9 samples of non-parents) that fit our criteria are included in the meta-analysis. The data analysis was performed using meta-analytic techniques. Marital satisfaction has a medium decrease between pregnancy and 12 months postpartum, and a small decline between 12 and 24 months postpartum for both genders. In a similar period with first year postpartum, non-parents present a small decline in marital satisfaction. Moreover, the analysis of the dyadic studies data shows cross-partner associations, confirming that one partner's satisfaction has a steeper decline when the other partner's satisfaction presents a steep decrease. The decrease in marital satisfaction does not stop after the first postpartum year, and the coss-partners associations are present. Theoretical and therapeutic implications are also discussed.

30-Day Outcomes after Surgical or Transapical Aortic Valve Replacement in Symptomatic Aortic Regurgitation

Background: We aimed to analyze the short-term clinical outcomes of transapical aortic valve replacement (TA-TAVR) compared with surgical aortic valve replacement (SAVR) in symptomatic aortic regurgitation (AR) patients to draw preliminary conclusions about the advantages and disadvantages of TA-TAVR compared with SAVR and to provide evidence for future use of TA-TAVR in AR patients. Method: From September 2016 to September 2021, 69 patients undergoing TA-TAVR with J-valve implantation and 42 patients undergoing SAVR at the Second Hospital of Zhejiang University School of Medicine were analyzed for clinical data and 30-day follow-up outcomes to analyze and compare the differences in clinical endpoints between the two procedures. Results: At 30-day follow-up, there were no significant differences in mortality or neurological events between the two groups before and after the PSM. In secondary endpoints there were significant differences between the pre-match TAVR and SAVR groups, such as the incidence of paravalvular leaks (33.8% vs. 4.8%, p < 0.05), which also remained after the PSM (37.5% vs. 0, p < 0.05). In addition, the incidence of major bleeding was 7.4% in the TAVR group and 26.2% in the SAVR group before matching (p < 0.05). After matching, the statistical difference still remained. In longitudinal comparison, significant improvements in postoperative cardiac ultrasound indices and NYHA classification occurred in both groups. Conclusion: The TA-TAVR approach is safe and reliable, with similar clinical efficacy to SAVR, and has advantages in bleeding rate and speed of recovery.

Early versus late discharge after transcatheter aortic valve replacement and readmissions for permanent pacemaker implantation

OBJECTIVE

To examine the rate of readmission for permanent pacemaker (PPM) implantation with early versus late discharge after transcatheter aortic valve replacement (TAVR).

BACKGROUND

There is a current trend toward early discharge after TAVR. However, paucity of data exists on the impact of such practice on readmissions for PPM implantation.

METHODS

The Nationwide Readmission Database 2016-2018 was queried for all hospitalizations where patients underwent TAVR. Hospitalizations were stratified into early (Days 0 and 1) versus late (≥Day 2) discharge groups. Observations in which PPM was required in the index admission were excluded. Multivariable regression analyses involving patient- and hospital-related variables were utilized. The primary outcome was 90-day readmission for PPM implantation.

RESULTS

The final analysis included 68,482 TAVR hospitalizations, 20,261 (29.6%) with early versus 48,221 (70.4%) with late discharge. Early discharge after TAVR increased over the study period (16.2% in 2016 vs. 37.9% in 2018, P_trend  < 0.01). Nevertheless, 90-day readmission for PPM implantation remained stable (1.8% in 2016 vs. 2.0% in 2018, P_trend  = 0.32). The 90-day readmission rate for PPM implantation (2.0% vs. 1.8%; adjusted odds ratio: 1.15; 95% confidence interval: 0.95-1.39; p = 0.15) and median time-to-readmission (5 days [interquartile range, IQR 3-9] vs. 5 days [IQR 3-14], p = 0.92) were similar with early versus late discharge. Similar rates were observed regardless of whether readmission was elective versus not. Early discharge was associated with lower hospitalization cost ($39,990 ± $13,681 vs. $46,750 ± $18,218, p < 0.01) compared with late discharge.

CONCLUSION

In patients who did not require PPM during the index TAVR hospitalization, the rate of readmission for PPM implantation was similar with early versus late discharge.

Prognostic Outcome of New-Onset Left Bundle Branch Block After Transcatheter Aortic Valve Replacement in Patients With Aortic Stenosis: A Systematic Review and Meta-Analysis

Background

Left bundle branch block (LBBB) is a common complication of the transcatheter aortic valve replacement (TAVR), and its impact on prognosis is controversial.

Methods

A comprehensive electronic search was conducted in databases (PubMed, Embase, Cochrane Library, and The Web of Science), from the date of database establishment till March 2021, to screen for studies on new-onset LBBB after TAVR. We next performed a meta-analysis to evaluate the effect of new-onset LBBB after TAVR on patient prognosis, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

Results

A total of 17 studies, including 9205 patients, were eligible for our analysis. Patients with new-onset LBBB had elevated all-cause mortality risk verses patients without new-onset LBBB, during all follow ups. The relevant data are as follows: 30-day (RR:1.71; 95%CI:1.27–2.29; P &lt; 0.001), 1-year (RR:1.31; 95%CI:1.12–1.52; P &lt; 0.001), and 2-year (RR:1.31; 95%CI:1.09–1.56; P = 0.003) follow ups. Likewise, new-onset LBBB patients also experienced increased cardiovascular mortality, compared to non-new-onset LBBB patients, but only in the 1-year follow up (RR:1.49; 95%CI:1.23–1.82; P &lt; 0.001). Hospitalization for heart failure was dramatically elevated in patients with new-onset LBBB verses non-new-onset LBBB, in all follow ups. The relevant data are as follows: 30-day (RR:1.56; 95%CI:1.13–2.12; P = 0.007), 1-year (RR:1.35; 95%CI:1.08–1.68; P = 0.007), and 2-year (RR:1.49; 95%CI:1.21–1.84; P &lt; 0.001). Similarly, new-onset LBBB patients had higher PPI risk than non-new-onset LBBB patients, in all follow ups. The relevant data are as follows: 30-day (RR:3.05; 95%CI:1.49–6.22; P = 0.002), 1-year (RR:2.15; 95%CI:1.52–3.03; P &lt; 0.001), and 2-year (RR:2.52; 95%CI:1.68–3.78; P &lt; 0.001).

Conclusion

Patients with new-onset LBBB have worse prognosis after TAVR than those without new-onset LBBB. Recognition of the adverse effects of post-TAVR new-onset LBBB can lead to the development of new strategies that enhance clinical outcomes.

Systematic Trial Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=197224, identifier: 19722.

Relation of Subacute Kidney Injury to Mortality After Transcatheter Aortic Valve Implantation

Acute kidney injury after transcatheter aortic valve implantation (TAVI) has been associated with adverse outcomes; however, data are limited on the subacute changes in renal function that occur after discharge and their impact on clinical outcomes. This study investigates the relation between subacute changes in kidney function at 30 days after TAVI and survival. Patients from 2 centers who underwent TAVI and survived beyond 30 days with baseline, in-hospital, and 30-day measures of renal function were retrospectively analyzed. Patients were stratified based on change in estimated glomerular filtration rate (eGFR) from baseline to 30 days as follows: improved (≥15% higher than baseline), worsened (≤15% lower), or unchanged (values in between). Univariable and multivariable models were constructed to identify predictors of subacute changes in renal function and of 2-year mortality. Of the 492 patients who met inclusion criteria, eGFR worsened in 102 (22%), improved in 110 (22%), and was unchanged in 280 (56%). AKI occurred in 90 patients (18%) and in only 27% of patients with worsened eGFR at 30 days. After statistical adjustment, worsened eGFR at 30 days (hazard ratio vs unchanged eGFR 2.09, 95% CI 1.37 to 3.19, p <0.001) was associated with worse survival, whereas improvement in renal function was not associated with survival (hazard ratio vs unchanged eGFR 1.30, 95% CI 0.79 to 2.11, p = 0.30). Worsened renal function at 30 days after TAVI is associated with increased mortality after TAVI. In conclusion, monitoring renal function after discharge may identify patients at high risk of adverse outcomes.

Apical versus subclavian transcatheter aortic valve implantation: An 8-year United Kingdom analysis

OBJECTIVES

Subclavian (SC) and transapical (TA) approaches are the main alternatives to the default femoral delivery for transcatheter aortic valve implantation (TAVI). The aim of this study was to compare complications and morbidity/mortality associated with SC and TA in a long-term time frame.

METHODS

From January 2007 to July 2015, 1506 patients underwent TAVI surgery in 36 United Kingdom TAVI centers. Primary outcomes were complications according to VARC-2 criteria. The secondary outcome was long-term survival.

RESULTS

The enrolled patients were distributed as follows: 1216 in the TA group and 290 in the SC group. There were no differences in the rates of acute myocardial infarction, emergency valve-in-valve, paravalvular leak, balloon post dilatation, cardiac tamponade, stroke, renal replacement therapy, vascular injuries, and 30-day mortality among the groups. Conversely, the rate of permanent pacemaker implantation (p = .02), the procedural time duration (p = .04), and the 12-month mortality (p = .03) was higher in SC than in TA, while in-hospital length of stay was reduced in SC than in TA (p = .01). Up to 8 years, the long-term mortality was not different among groups (p = .77), and no difference in long-term survival between self- versus balloon-expandable devices was found (p = .26).

CONCLUSIONS

According to our results, TA provided the best 12-month survival compared to SC, while the long-term survival up to 2900 days is not significantly different between groups, so SC and TA may both represent a safe non-femoral access if femoral is precluded.

Frailty as a Predictor of Postoperative Outcomes in Invasive Cardiac Surgery: A Systematic Review of Literature

OBJECTIVES

Frailty is a syndrome characterized by increased vulnerability and reduced ability to maintain homeostasis after stressful events that results in an increased risk for poor outcomes. Frailty screening could potentially be valuable in cardiac surgery risk assessment. The purpose of this review is to evaluate the current literature linking multicomponent frailty assessment and invasive cardiac surgery outcomes.

METHODS

We searched PubMed, EMBASE, and CINAHL; 1887 articles met the search criteria, and each was independently reviewed by 2 reviewers.

RESULTS

The 19 eligible studies assessed 52 291 subjects using 17 different frailty measurements. The most commonly used instruments were the Fried Frailty Phenotype and the Clinical Frailty Scale. Between 9% and 61% of participants were found to be frail in each study. All 19 studies included mortality as an outcome, 12 included surgical complications, 12 included hospital length of stay, 3 included quality of life, and 2 included functional status. Nine found statistically significant differences in survival between frail and nonfrail patients, 6 of 12 found that frail patients had a longer length of stay, 4 of 12 found that frail patients were more likely to experience major complications, and 2 of 2 found that frail patients were more likely to have a decrease in functional status.

CONCLUSION

Although some studies lacked power, the majority confirmed that frail patients are more likely to experience poor outcomes. Further research is needed to determine which frailty measure provides the best predictive validity and to identify interventions to mitigate the risks that major cardiac surgery poses to frail patients.