Aortic Valve Replacement In Patients Research Articles

Transcatheter aortic valve replacement for aortic regurgitation: a systematic review and meta-analysis.

The efficacy and safety of new-generation devices (NGDs) for severe aortic regurgitation (AR) have mostly been based on single-arm studies with limited sample sizes. Our goal was to summarize the current evidence on NGDs and compare the safety and efficacy of 'off-label' and 'on-label' devices in NGDs. We searched MEDLINE, Embase, Cochrane Library, and Scopus for articles on transcatheter aortic valve replacement in patients with AR. A total of 31 studies that included 1851 patients were identified through April 2023. Among these, 1067 (57.6%) patients received treatment with 'on-label' devices (JenaValve and J-Valve). For NGDs, the total device success rate at 30days was 94.5% (on-label: 97.8%, off-label: 89.9%; P<0.001), the all-cause mortality was 4.2% (on-label: 2.6%, off-label: 5.1%; P=0.006), permanent pacemaker implantation (PPI) was 8.8% (on-label: 6.9%, off-label: 18.4%; P<0.001), and the rate of greater-than-mild paravalvular leak (PVL) was 1.2% (on-label: 0.9%, off-label: 3.8%; P=0.003). On-label devices showed significantly better safety and efficacy in terms of the success rate, PPI, greater-than-mild PVL, and 30day mortality than off-label devices.

Medical treatment of heart failure with RAS inhibitors and beta blockers in aortic stenosis – association to long-term outcome after aortic valve replacement

Abstract Background There is a lack of robust data on optimal medical treatment of heart failure in patients with severe aortic stenosis, with no randomized controlled trials guiding treatment. Objective To study the association between exposure to renin-angiotensin-aldosterone system (RAS) inhibitors or beta-blockers and outcome after aortic valve replacement in patients with aortic stenosis and heart failure. Methods and results The study included all patients with heart failure undergoing aortic valve replacement for aortic stenosis in Sweden between 2008-2016 (n = 4668 patients). Exposure to treatment was assessed by continuous tracking of drug dispensations and outcome events were all-cause mortality and hospitalization for heart failure collected from national patient registries. After adjustment for age, sex, atrial fibrillation, hypertension, diabetes mellitus and prior myocardial infarction Cox regression analysis showed that RAS inhibition was associated with a lower risk of all-cause mortality in patients with reduced LV-EF (HR 0.58, 95% CI 0.51 - 0.65) and preserved LV-EF (HR 0.69, 95% CI 0.56 - 0.85). Beta-blockade was associated with a lower risk of all-cause mortality in patients with reduced LV-EF (HR 0.81, 95% CI 0.71–0.92), but not in preserved LV-EF (HR 0.87, 95% CI 0.69 - 1.10). There was no association between RAS inhibition or beta-blockade and the risk of hospitalization for heart failure. Conclusions RAS inhibition was associated with lower all-cause mortality after valve replacement in patients with both reduced and preserved LV-EF. Beta-blockade was associated with lower all-cause mortality only in patients with reduced LV-EF.

OR7-6 | The Outcomes of Transcatheter Versus Surgical Aortic Valve Replacement in Patients With Pure Aortic Regurgitation: A Systematic Review and Meta-analysis

OR7-6 | The Outcomes of Transcatheter Versus Surgical Aortic Valve Replacement in Patients With Pure Aortic Regurgitation: A Systematic Review and Meta-analysis

E-40 | Transcatheter Aortic Valve Replacement versus Surgical Aortic Valve Replacement in Patients with Bicuspid Aortic Stenosis: A Propensity Score Matching Analysis

E-40 | Transcatheter Aortic Valve Replacement versus Surgical Aortic Valve Replacement in Patients with Bicuspid Aortic Stenosis: A Propensity Score Matching Analysis

E-31 | In-Hospital Complications and Outcomes of Transcatheter Aortic Valve Replacement in Patients with End-Stage Renal Disease

E-31 | In-Hospital Complications and Outcomes of Transcatheter Aortic Valve Replacement in Patients with End-Stage Renal Disease

E-22 | Transcatheter Versus Surgical Aortic Valve Replacement in Patients With Aortic Stenosis and Cardiogenic Shock

E-22 | Transcatheter Versus Surgical Aortic Valve Replacement in Patients With Aortic Stenosis and Cardiogenic Shock

Stroke risk after transcatheter aortic valve replacement in patients with carotid stenosis: A systematic review and meta-analysis

BackgroundStroke is a feared complication of transcatheter aortic valve replacement (TAVR). Patients undergoing TAVR typically have multiple comorbidities, such as carotid artery stenosis (CAS). We conducted the present meta-analysis to determine the risk of stroke and mortality following TAVR in patients with CAS. MethodsWe searched PubMed/Medline, Scopus, ScienceDirect, and Cochrane Clinical Trials databases for clinical studies that compared CAS ≥50% and CAS ≥70% versus non-CAS TAVR population. The endpoints included the 30-day incidence of stroke or transient ischemic attack (TIA) and 30-day all-cause of mortality. ResultsWe identified seven studies that included 12,418 patients in the CAS group and 102,316 in the control group. CAS ≥50% was not associated with an increased risk of 30-day stroke or TIA after TAVR [risk ratio (RR): 1.38; 95% confidence interval (95% CI): 0.95–2.02; p = 0.09]. However, patients with CAS ≥70% had an increased risk of stroke or TIA (RR: 1.43; 95% CI: 1.02–2.01; p = 0.04). No difference in 30-day all-cause mortality was observed between CAS ≥50% or CAS ≥70% and control groups (RR: 1.09; 95% CI: 0.79–1.52; p = 0.59 and RR: 1.11; 95% CI: 0.85–1.45; p = 0.43, respectively). ConclusionsCAS ≥70% was associated with an increased risk of stroke or TIA following TAVR compared with patients without CAS.

LB-9 | Self-Expanding Versus Balloon-Expandable Transcatheter Aortic Valve Replacement in Patients with Small Aortic Annuli: Additional Outcomes from the SMART Trial

LB-9 | Self-Expanding Versus Balloon-Expandable Transcatheter Aortic Valve Replacement in Patients with Small Aortic Annuli: Additional Outcomes from the SMART Trial

E-30 | Valve-in-Valve Transcatheter Aortic Valve Replacement in Patients with Previous Aortic Homograft/stentless bioprosthetic valve

E-30 | Valve-in-Valve Transcatheter Aortic Valve Replacement in Patients with Previous Aortic Homograft/stentless bioprosthetic valve

Outcomes of Different Mitral Valve Approaches Combined with Aortic Valve Replacement in Patients with Degenerative Valve Disease

Introduction: The objective of this cohort study was to analyze the long-term relative survival of degenerative valve disease (DVD) patients who underwent mitral valve repair (MVP) or replacement and aortic valve replacement (AVR). Methods: A total of 146 patients underwent double valve replacement (DVR) or MVP+AVR at four institutions between 2016 and 2022. Kaplan–Meier method was applied to analyze survival rate. The potential predictors of mortality were investigated by Cox regression. Results: Of 146 patients, 62 underwent MVP+AVR, and 84 underwent DVR. The thirty-day mortality rate was 4.76% in the DVR cohort and 1.61% in the MVP+AVR cohort. At baseline, there were differences in age (63.39 ± 8.01 vs. 58.46 ± 9.92, p = 0.012), proportions of male patients (51.61% vs. 72.62, p = 0.014), smoking history (45.16% vs. 28.57%, p = 0.039). More biological valves were applied in the MVP+AVR cohort (77.42% vs. 47.62%, p &lt; 0.001). There was no significant difference in mortality between the cohorts (1339.5 [Interquartile range (IQR), 1021.25–1876.75] vs. 1026.00 [IQR, 679.50–1674.00], p = 0.252). The overall mortality rate was 16.67% for DVR and 6.45% for MVP+AVR. Mechanical valve replacement (hazard ratio (HR) = 3.7, 95% confidence interval (CI): 1.0–12.0, p = 0.029) was increased the risk of postoperative mortality. Conclusion: Although the superiority of MVP+AVR was not verified with statistical significance in our cohort, we believe that MVP+AVR should be the preferred strategy for treating most DVD patient because it is associated with higher survival rates during follow-up.

On-X aortic valve replacement patients treated with low dose warfarin and low dose aspirin.

To assess if warfarin targeted to INR 1.8 (range 1.5-2.0) is safe for all patients with an On-X aortic mechanical valve. This prospective, observational registry follows patients receiving warfarin targeted at an INR of 1.8 (range 1.5-2.0) plus daily aspirin (75-100 mg) after On-X aortic valve replacement. The primary end-point is a composite of thromboembolism, valve thrombosis, and major bleeding. Secondary end-points include the individual rates of thromboembolism, valve thrombosis, and major bleeding, as well as the composite in subgroups of home or clinic-monitored INR and risk categorization for thromboembolism. The control was the patient group randomized to standard-dose warfarin (INR 2.0-3.0) plus daily aspirin 81 mg from the PROACT trial. A total of 510 patients were enrolled at 23 centers in the UK, United States, and Canada. Currently, the median follow-up duration is 3.4 years, and median achieved INR is 1.9. The primary composite end-point rate in the low INR patients is 2.31% vs 5.39% (95% confidence interval 4.12%-6.93%) per patient-year in the PROACT control group, constituting a 57% reduction. Results are consistent in subgroups of home or clinic-monitored, and high-risk patients, with reductions of 56%, 57%, and 57%, respectively. Major and total bleeding are decreased by 85% and 73%, respectively, with similar rates of thromboembolic events. No valve thrombosis occurred. Interim results suggest that warfarin targeted at an INR of 1.8 (range 1.5-2.0) plus aspirin is safe and effective in patients with an On-X aortic mechanical valve with or without home INR monitoring.

Vascular complications and outcomes following transcatheter aortic valve replacement in patients on chronic steroid therapy: a meta-analysis.

Chronic steroid (CS) therapy was reportedly linked to increased vascular complications following percutaneous coronary intervention. However, its association with vascular complications after transcatheter aortic valve replacement (TAVR) remained uncertain, with conflicting results being reported. The authors aimed to compare the rate of vascular complications and outcomes between patients with and without CS use after TAVR. The authors conducted a comprehensive literature search in PubMed, Embase, and Cochrane databases from their inception until 18th April 2022 for relevant studies. Endpoints were described according to Valve Academic Research Consortium-2 definitions. Effect sizes were pooled using DerSimonian and Laird random-effects model as risk ratio (RR) with 95% CI. Five studies with 6136 patients undergoing TAVR were included in the analysis. The included studies were published between 2015 and 2022. The mean ages of patients in both study groups were similar, with the CS group averaging 80 years and the nonsteroid group averaging 82 years. Notably, a higher proportion of patients in the CS group were female (56%) compared to the nonsteroid group (54%). CS use was associated with a significantly higher risk of major vascular complications (12.5 vs. 6.7%, RR 2.32, 95% CI: 1.73-3.11, P <0.001), major bleeding (16.8 vs. 13.1%, RR 1.61, 95% CI: 1.27-2.05, P <0.001), and aortic annulus rupture (2.3 vs. 0.6%, RR 4.66, 95% CI: 1.67-13.01, P <0.001). There was no significant difference in terms of minor vascular complications (RR 1.43, 95% CI: 1.00-2.04, P =0.05), in-hospital mortality (2.3 vs. 1.4%, RR 1.86, 95% CI: 0.74-4.70, P =0.19), and 30-day mortality (2.9 vs. 3.1%, RR 1.14, 95% CI: 0.53-2.46, P =0.74) between both groups. Our study showed that CS therapy is associated with increased major vascular complications, major bleeding, and annulus rupture following TAVR. Further large multicenter studies or randomized controlled trials are warranted to validate these findings.

Extracellular Volume Fraction by Computed Tomography Predicts Prognosis After Transcatheter Aortic Valve Replacement.

Extracellular volume fraction (ECV) on magnetic resonance imaging can predict prognosis after aortic valve replacement in patients with aortic stenosis (AS). However, the usefulness of ECV on computed tomography (CT) for patients who have undergone transcatheter aortic valve replacement (TAVR) is unclear, so we investigated whether ECV analysis on CT is associated with clinical outcomes in TAVR candidates.Methods and Results: We analyzed 127 patients with severe AS who underwent preoperative CT for TAVR. We evaluated the utility of ECV analysis on single-energy CT for predicting patient prognosis after TAVR. The primary outcome was a composite of all-cause death and hospitalization due to heart failure (HF) after TAVR. 15 patients (12%) had composite outcomes: 4 deaths and 11 hospitalizations due to HF. In multivariate survival analysis using the Cox proportional hazard model, atrial fibrillation (AF) (hazard ratio (HR), 7.86; 95% confidence interval (CI), 2.57-24.03; P<0.001), history of congestive HF (HR, 4.91; 95% CI, 1.49-16.2; P=0.009) and ECV ≥32.6% on CT (HR, 6.96; 95% CI, 1.92-25.12; P=0.003) were independent predictors of composite outcomes. On Kaplan-Meier analysis, the higher ECV group (≥32.6%) had a significantly greater number of composite outcomes than the lower ECV group (P<0.001). ECV on CT is an independent predictor of prognosis after TAVR.

Transcatheter aortic valve replacement in patients with severe aortic stenosis reduced the frequency of intradialytic hypotension.

Intradialytic hypotension (IDH) is a common complication during hemodialysis that increases cardiovascular morbidity and mortality. Aortic stenosis (AS) is a cause of IDH. Transcatheter aortic valve replacement (TAVR) has become an established treatment for patients with severe AS. However, whether TAVR reduce the frequency of IDH has not been investigated. This study aims to verify the efficacy of TAVR for reduction of the frequency of IDH. Consecutive hemodialysis patients who underwent TAVR at Sendai Kosei Hospital from February 2021 to November 2021 with available records 1month before and 3months after TAVR were included in the study. IDH was defined as a decrease in systolic blood pressure by 20mmHg or a decrease in the mean blood pressure by 10mmHg associated with hypotensive symptoms or requiring intervention. Patients with ≥ 3 episodes of IDH in ten hemodialysis sessions comprised the IDH group. Overall, 18/41 (43.9%) patients were classified into the IDH group. In ten hemodialysis sessions, IDH events were observed 2.1, 4.3, and 0.4 times in the overall cohort, IDH group, and non-IDH group, respectively. After TAVR, the incidence of IDH decreased from 43.2 to 10.3% (p < 0.0001) and IDH improved significantly in 15 patients in the IDH group. The result suggested that severe AS was the major cause of IDH in this cohort, and TAVR may be an effective treatment option for reduction of the frequency of IDH in patients with severe AS.

Mechanical versus Bioprosthetic Aortic Valve Replacement in Patients Aged 50 to 70 Years.

This study compared the outcomes of surgical aortic valve replacement (AVR) in patients aged 50 to 70 years based on the type of prosthetic valve used. We compared patients who underwent mechanical AVR to those who underwent bioprosthetic AVR at our institution between January 2000 and March 2019. Competing risk analysis and the inverse probability of treatment weighting (IPTW) method based on propensity score were employed for comparisons. A total of 1,580 patients (984 patients with mechanical AVR; 596 patients with bioprosthetic AVR) were enrolled. There was no significant difference in early mortality between the mechanical AVR and bioprosthetic AVR groups (0.9% vs. 1.7%, p=0.177). After IPTW adjustment, the risk of all-cause mortality was significantly higher in the bioprosthetic AVR group than in the mechanical AVR group (hazard ratio [HR], 1.39; 95% confidence interval [CI], 1.07-1.80; p=0.014). Competing risk analysis revealed lower risks of stroke (sub-distributional hazard ratio [sHR], 0.44; 95% CI, 0.28-0.67; p<0.001) and anticoagulation- related bleeding (sHR, 0.35; 95% CI, 0.23-0.53; p<0.001) in the bioprosthetic AVR group. Conversely, the risk of aortic valve (AV) reintervention was higher in the bioprosthetic AVR group (sHR, 6.14; 95% CI, 3.17-11.93; p<0.001). Among patients aged 50 to 70 years who underwent surgical AVR, those receiving mechanical valves showed better survival than those with bioprosthetic valves. The mechanical AVR group exhibited a higher risk of stroke and anticoagulation-related bleeding, while the bioprosthetic AVR group showed a higher risk of AV reintervention.

Diastolic dysfunction and clinical outcomes after transcatheter or surgical aortic valve replacement in patients with atypical aortic valve stenosis.

Diastolic dysfunction is a predictor of poor outcomes in many cardiovascular conditions. At present, it is unclear whether diastolic dysfunction predicts adverse outcomes in patients with atypical aortic stenosis who undergo aortic valve replacement (AVR). Five hundred and twenty-three patients who underwent transcatheter AVR (TAVR) (n = 303) and surgical AVR (SAVR) (n = 220) at a single institution were included in our analysis. Baseline left and right heart invasive hemodynamics were assessed. Baseline transthoracic echocardiograms were reviewed to determine aortic stenosis subtype and parameters of diastolic dysfunction. Aortic stenosis subtype was categorized as typical (normal flow, high-gradient) aortic stenosis, classical, low-flow, low-gradient (cLFLG) aortic stenosis, and paradoxical, low-flow, low-gradient (pLFLG) aortic stenosis. Cox proportional hazard models were utilized to examine the relation between invasive hemodynamic or echocardiographic variables of diastolic dysfunction, aortic stenosis subtype, and all-cause mortality. Propensity-score analysis was performed to study the relation between aortic stenosis subtype and the composite outcome [death/cerebrovascular accident (CVA)]. The median STS risk was 5.3 and 2.5% for TAVR and SAVR patients, respectively. Relative to patients with typical aortic stenosis, patients with atypical (cLFLG and pLFLG) aortic stenosis displayed a significantly higher prevalence of diastolic dysfunction (LVEDP ≥ 20mmHg, PCWP ≥ 20mmHg, echo grade II or III diastolic dysfunction, and echo-PCWP ≥ 20mmHg) and, independently of AVR treatment modality, had a significantly increased risk of death. In propensity-score analysis, patients with atypical aortic stenosis had higher rates of death/CVA than typical aortic stenosis patients, independently of diastolic dysfunction and AVR treatment modality. We demonstrate the novel observation that compared with patients with typical aortic stenosis, patients with atypical aortic stenosis have a higher burden of diastolic dysfunction. We corroborate the worse outcomes previously reported in atypical versus typical aortic stenosis and demonstrate, for the first time, that this observation is independent of AVR treatment modality. Furthermore, the presence of diastolic dysfunction does not independently predict outcome in atypical aortic stenosis regardless of treatment type, suggesting that other factors are responsible for adverse clinical outcomes in this higher risk cohort.

Prediction of symptom development and aortic valve replacement in patients with low-gradient severe aortic stenosis.

Current evidence on the prognostic value of exercise stress echocardiography (ESE) in asymptomatic patients with low-gradient severe aortic stenosis (AS) is limited. Therefore, this study aimed to elucidate its prognostic implications for patients with low-gradient severe AS and determine the added value of ESE in risk stratification for this population. This retrospective observational study included 122 consecutive asymptomatic patients with either moderate [mean pressure gradient (MPG) < 40 mmHg and aortic valve area (AVA) 1.0-1.5 cm2] or low-gradient severe (MPG < 40 mmHg and AVA < 1.0 cm2) AS and preserved left ventricular ejection fraction (≥50%) who underwent ESE. All patients were followed up for AS-related events. Of 143 patients, 21 who met any exclusion criteria, including early interventions, were excluded, and 122 conservatively managed patients [76.5 (71.0-80.3) years; 48.3% male] were included in this study. During a median follow-up period of 989 (578-1571) days, 64 patients experienced AS-related events. Patients with low-gradient severe AS had significantly lower event-free survival rates than those with moderate AS (log-rank test, P < 0.001). Multivariable Cox regression analysis showed that the mitral E/e' ratio during exercise was independently associated with AS-related events (hazard ratio = 1.075, P < 0.001) in patients with low-gradient severe AS. This study suggests that asymptomatic patients with low-gradient severe AS have worse prognoses than those with moderate AS. Additionally, the mitral E/e' ratio during exercise is a useful parameter for risk stratification in patients with low-gradient severe AS.

Application of echocardiography in transcatheter aortic valve replacement in patients with severe aortic regurgitation and correlation analysis of postprocedural complications.

Transcatheter aortic valve replacement (TAVR) is gradually becoming an alternative therapy for patients who cannot adapt to surgical treatment or have contraindications. The purpose of this study was to investigate the value of echocardiography in the evaluation of severe AR patients treated with TAVR and to analyze the correlations with postprocedural complications to improve the evaluation and screening of patients. We retrospectively analyzed clinical and echocardiographic data of 70 patients with severe AR. Periaortic valve structures were carefully measured by esophageal echocardiography (TEE) and compared with the multilayer slice computed tomography (MSCT) findings. Real-time three-dimensional esophageal echocardiography (RT-3D TEE) was monitored during the operation, and a 30-day postprocedural follow-up was performed. The relationship between postprocedural complications and patients' clinical data or periaortic valve structures was analyzed by multifactorial analysis to identify relevant predictors of complications. The TEE measurements of periaortic valve structures were in good agreement with the MSCT measurements. Among the patients who underwent successful operations, both left atrial (LA) and left ventricular (LV) diameters were reduced, and the left ventricular ejection fraction (LVEF) was improved 30 days after TAVR compared with the preprocedural period (P<.05). Permanent pacemakers were implanted in 15 patients. The presence of preprocedural right bundle branch block (RBBB) (OR: 2.93; 95% CI: 1.18-12.70; P=.01) was an independent factor for permanent pacemaker implantation after TAVR. Echocardiography plays an extremely important role in TAVR procedures. The presence of preprocedural RBBB can be an independent predictor of postprocedural pacemaker implantation.

Clinical benefits of surgical ablation during isolated aortic valve replacement: a nationwide study.

To compare the early- and long-term clinical outcomes of concomitant surgical ablation (SA) for atrial fibrillation (AF) during isolated aortic valve replacement (AVR) using data from the Korean National Health Insurance Service Database. Of 23,332 adult patients who underwent AVR between 2003 and 2019, those with underlying AF with or without concomitant SA were extracted, and propensity score matching analysis was performed. Overall, 1,741 patients with underlying AF with (n = 445, group A) or without (n = 1,296, group N) concomitant SA during isolated AVR were enrolled, from whom 435 pairs were matched in a 1:1 ratio using propensity score matching analysis. The operative mortality and early postoperative morbidities, including bleeding reoperation, stroke, permanent pacemaker implantation and acute kidney injury were comparable between the groups. The overall survival showed no differences between the groups. However, the cumulative incidence of new-onset late ischaemic stroke was significantly lower in group A than group N in propensity score-matched patients [2.3 vs 3.5 per 100 patient-years, adjusted hazard ratio (95% confidence interval) 0.64 (0.43-0.96), Group A versus Group N, respectively]. The cumulative incidence of other morbidities such as reoperation, permanent pacemaker implantation and progression to chronic renal failure showed no difference between groups. The incidence of late ischaemic stroke was significantly lower when concomitant SA was performed during isolated AVR in patients with underlying AF. Therefore, concomitant SA should be actively considered in patients with underlying AF undergoing isolated AVR to prevent the occurrence of late ischaemic stroke.

Feasibility of Goal-Directed Fluid Therapy in Patients with Transcatheter Aortic Valve Replacement - An Ambispective Analysis.

Goal-directed fluid therapy (GDFT) has been shown to reduce postoperative complications. The feasibility of GDFT in transcatheter aortic valve replacement (TAVR) patients under general anesthesia has not yet been demonstrated. We examined whether GDFT could be applied in patients undergoing TAVR in general anesthesia and its impact on outcomes. Forty consecutive TAVR patients in the prospective intervention group with GDFT were compared to 40 retrospective TAVR patients without GDFT. Inclusion criteria were age ≥ 18 years, elective TAVR in general anesthesia, no participation in another interventional study. Exclusion criteria were lack of ability to consent study participation, pregnant or nursing patients, emergency procedures, preinterventional decubitus, tissue and/or extremity ischemia, peripheral arterial occlusive disease grade IV, atrial fibrillation or other severe heart rhythm disorder, necessity of usage of intra-aortic balloon pump. Stroke volume and stroke volume variation were determined with uncalibrated pulse contour analysis and optimized according to a predefined algorithm using 250 ml of hydroxyethyl starch. Stroke volume could be increased by applying GDFT. The intervention group received more colloids and fewer crystalloids than control group. Total volume replacement did not differ. The incidence of overall complications as well as intensive care unit and hospital length of stay were comparable between both groups. GDFT was associated with a reduced incidence of delirium. Duration of anesthesia was shorter in the intervention group. Duration of the interventional procedure did not differ. GDFT in the intervention group was associated with a reduced incidence of postinterventional delirium.