Management Of Aortic Stenosis Research Articles

Transcatheter aortic valve implantation: A review article

Aortic stenosis is a valvular heart disease commonly found in developed and developing countries. The frequency of aortic valve sclerosis is about 25% in people over 65 years of age. In contrast to developing countries, infectious diseases, such as endocarditis or rheumatic fever, contribute greatly to aortic stenosis. Severe aortic stenosis without valve replacement has a poor prognosis and some patients are at high risk for surgery. Transcatheter aortic valve implantation (TAVI) is emerging as an alternative in patients with aortic stenosis who cannot or are at high risk for surgery. TAVI has revolutionized the management of aortic stenosis. This procedure continues to improve yearly and exceeds surgical aortic valve replacement in 2019. Initially, TAVI generated skepticism and criticism, but with many clinical trials and evidence-based investigations, TAVI is now widely accepted. Until now, the development of TAVI continues, starting with better technology, approaches, and new implantation strategies; TAVI is becoming safer for patients. This literature review will discuss more deeply about TAVI and its development.

Regional Variation in the Use and Outcomes of Transcatheter Aortic Valve Replacement in California

BackgroundTranscatheter aortic valve replacement (TAVR) has been widely adopted for management of aortic stenosis. The purpose of this study was to examine regional access to and outcomes following TAVR in California. MethodsPatients undergoing TAVR or isolated surgical aortic valve replacement (SAVR) from 2008 to 2019 in California were identified in the Office of Statewide Health Planning and Development database. California was divided into seven regions: Northern California, San Francisco Bay Area, Central California, Los Angeles, Inland Empire, Orange, and San Diego. Regional TAVR volumes were normalized to Medicare beneficiaries or isolated SAVR volume. Outcomes included risk-adjusted 30-day mortality and major adverse cardiovascular and cerebral events (MACCE). Trends were studied using non-parametric tests, and regional outcomes using logistic regression. ResultsTAVR volume increased annually since 2011, with 7148 cases performed in California in 2019. After normalization, variation in utilization of TAVR was evident, with the least performed in Central California. TAVR to SAVR ratios in 2019 were greatest in Northern California, Los Angeles, and San Diego, and least in the Inland Empire. After risk adjustment, there were no significant regional differences in 30-day mortality, but lower 30-day MACCE in the San Francisco Bay Area. ConclusionsRegional differences in TAVR utilization exist, with limited access in Central California and the Inland Empire, but risk-adjusted outcomes are similar. Efforts to reach underserved areas through existing program expansion or regional referrals may distribute transcatheter technology more equitably across California.

Live longer and better without aortic valve stenosis

Live longer and better without aortic valve stenosis

Challenges in the management of aortic stenosis, multiple valve disease, culture-negative endocarditis, and cardiac surgery during pregnancy.

Challenges in the management of aortic stenosis, multiple valve disease, culture-negative endocarditis, and cardiac surgery during pregnancy.

Impact of Managing Provider Type on Severe Aortic Stenosis Management and Mortality.

BackgroundMany patients with symptomatic severe aortic stenosis do not undergo aortic valve replacement (AVR) despite clinical guidelines. This study analyzed the association of managing provider type with cardiac specialist follow‐up, AVR, and mortality for patients with newly diagnosed severe aortic stenosis (sAS).Methods and ResultsWe identified adults with newly diagnosed sAS per echocardiography performed between January 2017 and March 2019 using Optum electronic health record data. We then selected from those meeting all eligibility criteria patients managed by a primary care provider (n=1707 [25%]) or cardiac specialist (n=5039 [75%]). We evaluated the association of managing provider type with cardiac specialist follow‐up, AVR, and mortality, as well as the independent association of cardiac specialist follow‐up and AVR with mortality, within 1 year of echocardiography detecting sAS. A subgroup analysis was limited to patients with symptomatic sAS. Patient characteristics and comorbidities at baseline were used for covariate‐adjusted cause‐specific and multivariable Cox proportional hazard models assessing group differences in outcomes by managing provider type. An adjusted Cox proportional hazard model with additional time‐dependent covariates for follow‐up and AVR was used to assess these practices' association with mortality. Within 1 year of echocardiography detecting sAS, data revealed that primary care provider management was associated with lower rates of cardiac specialist follow‐up (hazard ratio [HR], 0.47 [95% CI, 0.43–0.50], P<0.0001) and AVR (HR, 0.58 [95% CI, 0.53–0.64], P<0.0001) and with higher 1‐year mortality (HR, 1.45 [95% CI, 1.26–1.66], P<0.0001). Cardiac specialist follow‐up and AVR were independently associated with lower mortality (follow‐up: HR, 0.55 [95% CI, 0.48–0.63], P<0.0001; AVR: HR, 0.70 [95% CI, 0.60–0.83], P<0.0001). Results were similar for patients with symptomatic sAS. All analyses were adjusted for baseline patient characteristics and comorbidities.ConclusionsFor patients newly diagnosed with sAS, we observed differences in rates of cardiac specialist follow‐up and AVR and risk of mortality between primary care provider‐ versus cardiologist‐managed patients with sAS. In addition, a lower likelihood of receiving follow‐up and AVR was independently associated with higher mortality.

Comparison of In-Hospital Mortality and Clinical Outcomes Between Patients Aged More Than and Less Than 80 Years Undergoing Transcatheter Aortic Valve Replacement.

BackgroundThe transcatheter aortic valve replacement (TAVR) procedure has been increasingly utilized in the management of aortic stenosis among the elderly. In this study, we sought to assess the hospital outcomes and major adverse events (MAEs) associated with TAVR in patients aged ≥80 years compared to those aged <80 years.MethodologyWe performed a retrospective observational study using the National Inpatient Sample in 2018. We divided TAVR patients into two cohorts based on age, namely, ≥80 years old and <80 years old. The primary outcomes included the comparison of in-hospital mortality and MAEs in the two cohorts.ResultsWe identified 63,630 patients who underwent TAVR from January 1 to December 31, 2018. Among them, 35,115 (55%) were ≥80 years and 28,515 (45%) were <80 years of age. There was a higher rate of post-procedural in-hospital mortality in patients ≥80 years old (1.6% vs. 1.1%, adjusted odds ratio (aOR) = 1.56, [confidence interval (CI) = 1.13-2.16], p = 0.006). They also had higher rates of pacemaker insertion compared to those <80 years old (7.4% vs. 6.5%, aOR = 1.17 [CI = 1-1.35], p = 0.03). On subgroup analysis, the rates of MAEs were not different between the two cohorts (23.8% vs. 23.4%, p = 0.09); however, patients aged ≥80 years who experienced MAEs had higher in-hospital mortality (5.7% vs. 4.3%, aOR = 1.58 [CI = 1.08-2.32], p = 0.01) and shorter length of hospital stay (7.2 vs. 8.7 days, p = 0.03) compared to those aged <80 years. Anemia, liver disease, chronic kidney disease, and previous stroke were associated with higher odds of in-hospital MAEs in both groups.ConclusionsThe results of our study show that patients older than 80 years of age undergoing TAVR had higher rates of in-hospital mortality and pacemaker insertion compared to those less than 80 years of age. The rates of MAEs were not significantly different between the two groups.

On the Modeling of Transcatheter Therapies for the Aortic and Mitral Valves: A Review

Transcatheter aortic valve replacement (TAVR) has become a milestone for the management of aortic stenosis in a growing number of patients who are unfavorable candidates for surgery. With the new generation of transcatheter heart valves (THV), the feasibility of transcatheter mitral valve replacement (TMVR) for degenerated mitral bioprostheses and failed annuloplasty rings has been demonstrated. In this setting, computational simulations are modernizing the preoperative planning of transcatheter heart valve interventions by predicting the outcome of the bioprosthesis interaction with the human host in a patient-specific fashion. However, computational modeling needs to carry out increasingly challenging levels including the verification and validation to obtain accurate and realistic predictions. This review aims to provide an overall assessment of the recent advances in computational modeling for TAVR and TMVR as well as gaps in the knowledge limiting model credibility and reliability.

Single Centre Retrospective Analysis of TAVI for Native Aortic Regurgitation Versus Severe Aortic Stenosis With New Generation Transcatheter Heart Valves

TAVI is approved for the management of aortic stenosis (AS); however, the indications are expanding to include non-calcified aortic regurgitation (NAVR) for surgically ineligible patients. Left untreated, the annual mortality risk for aortic regurgitation is 20%.

Aortic stenosis management in 2021: better teaming up than fighting between specialties

Management of severe symptomatic aortic stenosis over the decades. Left upper panel: 1980–1990. Valve replacement reverses the dismal outcome of severe symptomatic AS (adapted from Horstkotte and Loogen3). Right upper panel: 1990–2000. Many patients do not receive AVR because of older age and comorbidities (graph based on data from Charlson et al.,5 Iung et al.,6 and Bouma et al.7). Left lower panel: 2000–2010. TAVI evolves as an alternative to SAVR, RCTs demonstrate non-inferiority (adapted from Jorgensen et al.13 and Makkar et al.14). Right lower panel: 2010–2020. The number of AVRs more than doubles and in-hospital mortality decreases for SAVR and TAVI. AS, aortic stenosis; AVR, aortic valve replacement; RCT, randomized controlled trial; TAVI, transcatheter aortic valve implantation; TAVR, transcatheter aortic valve replacement.

Cost comparison between transcatheter aortic valve implantation and surgical valve replacement using individual data in a Spanish public hospital

BackgroundTranscatheter aortic valve implantation has revolutionized the management of aortic stenosis and is currently an alternative to surgical aortic valve replacement. Some studies have found costs of percutaneous procedure to be greater than those of surgical replacement. However, these published studies are based on pooled data from clinical registries. The objective of the present study was to compare costs of both treatments during the hospital phase in a Spanish public hospital. MethodsA hospital phase cost study consisted of patients diagnosed and treated with aortic stenosis in a Spanish tertiary hospital between 1st January 2019 and 29th February 2020. An individual analysis was conducted in relation to real costs pertaining to materials, staffing and hospital stay. Several baseline characteristics were controlled for. ResultsMean costs per patient from procedure through to discharge were 26,684.1 € in the percutaneous group and 14,939.5 € in the surgical group (p<0.001). Independent of comorbidities, the cost of transcatheter aortic valve implantation was, on average, 8636.6 € greater than that of surgical aortic valve replacement (95% CI 6086.3–11,186.9; p < 0.001). ConclusionsAortic stenosis treatment costs in hospital phase were greater when percutaneous option was used in comparison to surgery.

Gender disparities in the treatment of aortic stenosis – an analysis of the united states national inpatient sample (2009–2018)

Abstract Introduction Gender disparity in the management of a variety of cardiovascular disorders has been well established. Studies have shown that women are less likely to undergo surgical aortic valve replacement (SAVR), and have higher mortality and health care cost in the management of aortic stenosis (AS). The impact of transcatheter aortic valve replacement (TAVR) on this gender disparity has not been well established. Purpose We sought to examine the impact of gender on outcomes following aortic valve replacement for AS in the era of routine transcatheter valve replacement. Methods We used the National Inpatient Sample (2009–18), a representative probability sample of the United States, to study visits for all aortic valve replacements and in-hospital outcomes as a function of gender. Survey estimation commands were used to provide national estimates. Results There were an estimated 431,344 SAVR and 189,137 TAVR inpatient visits during the periods of 2009–18 and 2011–18, respectively with a higher representation of women in the TAVR cohort (46.4% [95% CI, 45.9%-46.9%]) than SAVR (36.8% [95% CI, 36.4%-37.2%]). Women were slightly older with higher prevalence of uncomplicated hypertension (HTN) and pulmonary circulation disorders. However, women exhibited a lower prevalence of complicated HTN, complicated diabetes mellitus, prior percutaneous coronary intervention, prior coronary artery bypass grafting, peripheral vascular disease and renal failure. In-hospital mortality was higher in women after SAVR (3.8%±0.1 vs 2.7%±0.07, p&amp;lt;0.001) and TAVR (2.4%±0.1 vs 1.7%±0.1, p&amp;lt;0.001) compared to men. Female SAVR patients had higher rates of permanent pacemaker (PPM) implantation, stroke and significant bleeding (5.9%±0.1 vs 5%±0.1, 2.8%±0.1 vs 2.3%±0.07, and 37.8%±0.8 vs 29.8%±0.6; p&amp;lt;0.001, respectively) but lower rates of acute kidney injury (AKI) (16.4%±0.3 vs 20.3%±0.3, p&amp;lt;0.001). In addition, women undergoing TAVR had higher rates of stroke and significant bleeding (2.4%±0.1 vs 1.6%±0.09 and 28.7%±0.6 vs 22%±0.5; p&amp;lt;0.001 respectively) but lower rates of PPM and AKI (9.5%±0.3 vs 10.7%±0.2 and 11.3%±0.3 vs 13.4%±0.3; p&amp;lt;0.001, respectively). There was a reduction in mortality, compared to the early TAVR era, for all groups during the study period, particularly in female TAVR patients (from approximately 5.2% to 1.7%). In-hospital mortality for women was lower after TAVR than SAVR, both after multivariable adjustment (OR = 0.33, 95% CI 0.24–0.45) and propensity matching (mean difference 1.28%±0.49). Conclusions TAVR appears to have narrowed the gender disparity in the management of AS. Although women continue to have a higher in-hospital mortality following both TAVR and SAVR compared to men, TAVR is associated with a lower inpatient mortality in women compared to SAVR. Thus, TAVR may represent a bridge for the gender gap in aortic valve replacement. Funding Acknowledgement Type of funding sources: None.

Late Clinical and Hemodynamic Outcomes in patients with degenerated bioprosthetic aortic valves undergoing transcatheter valve-in-valve implantation

Abstract Background Clinical studies have shown promising early outcomes for valve-in-valve transcatheter aortic valve implantation (ViV-TAVI); however, the late outcomes of this procedure remain under-investigated. Purpose We performed the present analysis to assess the late clinical and hemodynamic outcomes of ViV-TAVI in patients with degenerated bioprosthetic aortic valves. Methods A comprehensive chart review was performed for eligible patients to retrieve data on procedural characteristics, admission details following the procedure, and echocardiographic parameters. Clinical outcomes included all-cause mortality, heart failure hospitalization and structural valve deterioration (SVD), as defined by VARC-II criteria, up to 5 years of follow-up. To assess the trends in mean and peak transvalvular gradients, data from the follow-up echocardiographic reports were analyzed using Syngo Dynamics imaging software. Results A total of 188 patients were included with a mean age of 75.8±10.4 years. Balloon- and self-expandable valves were used in 155 (82.4%) and 33 (17.6%) patients, respectively. At 30 days, 3 (1.6%) patients died and 8 (4.2%) required hospitalization for heart failure, while at 5 years, both events were recorded in 29 (15.4%) and 37 (19.7) patients, respectively. Kaplan-Meier survival analysis showed that patients with smaller surgical valves (internal diameter ≤21 mm) had a significantly higher mortality rate (log-rank p=0.021) than those with larger valves; however, no significant difference (log-rank p=0.59) was detected between different transcatheter valves (self vs. balloon-expandable). Three patients underwent re-intervention, performed via a transcatheter approach. Further, assessment of follow-up echocardiographic reports revealed 9 (4.8%) cases of SVD, as well as stable mean (16.3±6.9 at discharge and 16.9±11.3) and peak (30.3±12.1 at discharge and 30.7±18.4 at 5 years) transvalvular gradients. No difference (p&amp;gt;0.05) was observed based on transcatheter valve type or surgical valve internal diameter in terms of mean and peak transvalvular gradients throughout the follow-up period. Conclusion The present study showed good clinical outcomes among patients undergoing VIV-TAVI, with stable VIV performance over a five-year period. Future long-term studies are warranted to analyze the predictors of outcomes following ViV-TAVI and explore the role of this treatment option in the life-long management of aortic stenosis. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Jennifer and Robert McNeil Donation to the Heart, Thoracic, and Vascular Institute at Cleveland Clinic. Figure 1

Current and future transcatheter aortic valve replacement valves.

This review analyzes currently available commercial transcatheter aortic valve replacement (TAVR) valves as well as valves in investigational status and those in preclinical testing. The design features and clinical outcomes of the Edwards SAPIEN S3 and Medtronic Evolut PRO+ are described and compared with highlight clinical circumstances where one may be favoured over the other. Multiple randomized and nonrandomized trials have compared commercial and investigational TAVR valves. The results of these are summarized and discussed within this review with a focus on how the SAPIEN S3 and Evolut PRO+ both compare to each other as well as various valves in different investigational stages. TAVR is an innovative and ground-breaking technology that will forever have revolutionized the management of aortic stenosis. Though the technology and valves themselves have come a long way, further developments are necessary if we are to continue to expand its indications and achieve a safer perioperative experience with more durable valves.

BUDGET IMPACT ANALYSIS OF TRANSCATHETER AORTIC VALVE REPLACEMENT COMPARED TO SURGICAL AORTIC VALVE REPLACEMENT IN LOW-RISK AORTIC STENOSIS PATIENTS: A CANADIAN PERSPECTIVE

<h3>BACKGROUND</h3> In patients with severe symptomatic aortic stenosis (AS), transcatheter aortic valve replacement (TAVR) is approved for use across the entire spectrum of risk, including low surgical risk patients. TAVR has been shown to provide rapid improvement in quality-of-life while being less invasive than surgical aortic valve replacement (SAVR). In Canada, TAVR funding is limited, and the perceived higher cost of TAVR may be a barrier to expanding the therapy to low-risk patients. While TAVR has been shown to be cost-effective, the affordability of implementing TAVR for low-risk AS patients from the hospital's payers' perspective is not known. <h3>METHODS AND RESULTS</h3> A budget impact analysis was conducted using a one-year time horizon to quantify the total cost of healthcare resource utilization to initially treat low-risk AS patients and the subsequent management of adverse events (AEs). Micro-costing was performed for both self-expandable TAVR and SAVR based on resource utilization (operating room time, supplies, intensive care unit (ICU) and total length of stay (LOS)) and complication event rates (heart failure (HF) hospitalization, pacemaker implantation, stroke, acute kidney injury) from the recently published Evolut Low-Risk CoreValve trial. Overall differences in cost between TAVR and SAVR were calculated for 100 patients for various scenarios of TAVR uptake (0% to 70%) in low-risk AS patients. Costs were obtained from provincial datasets and the published literature (reported in 2021 Canadian dollars). The mean procedural cost of SAVR and TAVR per patient was $41,405 and $44,061, respectively. The one-year cost of managing AEs for SAVR and TAVR were $4,883 and $4,398, respectively (difference = $485). Overall, the incremental difference in cost was $2,172 higher with TAVR at one year per patient. The total cost of care for a hypothetical cohort of 100 low-risk AS patients in the base-case scenario (10% TAVR, 90% SAVR) was $4,650,357. The proportion of TAVR/SAVR was increased incrementally to a final scenario (70% TAVR, 30% SAVR) where the total cost of care was $4,780,612 representing a 2.8% increase in cost. One-way sensitivity analysis on key variables showed that the main contributors to the cost difference were the ICU LOS (difference in cost: -3.1% to 3.2%) and HF hospitalization rates (2.8% to 3.9%). <h3>CONCLUSION</h3> Despite the higher upfront procedure cost, the incremental cost of implementing TAVR in low-risk severe symptomatic aortic stenosis patients was small due to relatively lower adverse events rates at one year. In severe aortic stenosis management, a shift from SAVR to TAVR is likely affordable.

Surgical Explantation After TAVR Failure: Mid-Term Outcomes From the EXPLANT-TAVR InternationalRegistry.

The aim of this study was to evaluate clinical characteristics, mechanisms of failure, and outcomes of transcatheter aortic valve replacement (TAVR) explantation. Surgical explantation following TAVR may be required for structural valve degeneration, paravalvular leak, infection, or other reasons. However, in-depth data on indications and outcomes are lacking. Data from a multicenter, international registry (EXPLANT-TAVR) of patients who underwent TAVR explantation were reviewed retrospectively. Explantations performed during the same admission as initial TAVR were excluded. Clinical and echocardiographic outcomes were evaluated. Median follow-up duration was 6.7months (interquartile range [IQR]: 1.0-18.8months) after TAVR explantation and was 97.7% complete at 30days and 86.1% complete at 1 year. From November 2009 to September 2020, 269 patients across 42 centers with a mean age of 72.7 ± 10.4 years underwent TAVR explantation. About one quarter (25.9%) were deemed low surgical risk at index TAVR, and median Society of Thoracic Surgeons risk at TAVR explantation was 5.6% (IQR: 3.2%-9.6%). The median time to explantation was 11.5months (IQR: 4.0-32.4months). Balloon-expandable and self-expanding or mechanically expandable valves accounted for 50.9% and 49.1%, respectively. Indications for explantation included endocarditis (43.1%), structural valve degeneration (20.1%), paravalvular leak (18.2%), and prosthesis-patient mismatch (10.8%). Redo TAVR was not feasible because of unfavorable anatomy in 26.8% of patients. Urgent or emergency cases were performed in 53.1% of patients, aortic root replacement in 13.4%, and 54.6% had concomitant cardiac procedures. Overall survival at last follow-up was 76.1%. In-hospital, 30-day, and 1-year mortality rates were 11.9%, 13.1%, and 28.5%, respectively, and stroke rates were 5.9%, 8.6%, and 18.7%, respectively. The EXPLANT-TAVR registry reveals that surgical risks associated with TAVR explantation are not negligible and should be taken into consideration in the lifetime management of aortic stenosis.

Critical aortic stenosis in neonates: Balloon valvuloplasty versus surgical valvotomy

Congenital aortic valvular stenosis in neonates is a life-threatening condition requiring urgent management. Therapeutic strategy remains controversial between balloon valvuloplasty (BV) and surgical valvulotomy (SV). We reviewed our long-term single-center experience of neonatal aortic stenosis management and compared aortic valve outcomes regarding BV versus SV. Between 1990 and 2020, 137 patients underwent aortic stenosis treatment (SV [ n = 83] and BV [ n = 54]) with a median age of 5.5 days (range: 0 to 30 days) and a median weight of 3 kg (range: 1.8 to 4.8 kg). Procedure strategy was decided according to the surgeon availability especially at the beginning of the study. Additionally, there was a traditional local protocol favoring balloon in case of left ventricular dysfunction like in many centers. The median follow-up was 6.7 years (up to 28y, 88% complete). We did not report any operative death but the intra-hospital mortality was notably greater for patients after balloon procedure (20.3%) versus SV group (8.4%). The one-year and ten-year patient survival was respectively 90 and 89% in SV group versus 75 and 69% in BV group ( P < 0.005). In our cohort, 77 patients underwent reoperation for persistent aortic stenosis. Most of the patients after BV ( n = 38, 70%) required a reintervention. The median age for reintervention was 2.9 years in the SV group versus 0.3 years for patients in the BV group. Associated intracardiac lesions and the initial valvuloplasty procedure were significantly associated with the risk of reoperation independently of the maximal gradient and the aortic annulus size. Ten-year freedom from reintervention for SV and BV group were respectively 53% and 35% ( P < 0.005, Fig. 1 ). Long-term survival and freedom from reintervention are excellent after surgical valvotomy. However, poor results are obtained when patients had initial left ventricular dysfunction or multiple left ventricular outflow lesions.

Perioperative Management of Aortic Stenosis and Cerebral Aneurysm in a Patient with Chronic Thromboembolic Pulmonary Hypertension Based on Left Ventricular Filling Pressure

Perioperative Management of Aortic Stenosis and Cerebral Aneurysm in a Patient with Chronic Thromboembolic Pulmonary Hypertension Based on Left Ventricular Filling Pressure

Role of Balloon Aortic Valvuloplasty in the Management of Aortic Stenosis

Balloon aortic valvuloplasty (BAV) provides an excellent alternative to surgical intervention and has become the preferred intervention for initial palliation for aortic stenosis in neonates, infants, children, adolescents, and young adults. The elderly patients with calcific aortic stenosis do not benefit from BAV. With the exception of neonates, most patients can be discharged home within 24-hours of the procedure. Although there is definitive evidence for pressure gradient relief immediately after as well as at follow-up and postponement of surgical intervention following BAV, the progression of aortic insufficiency at late follow up remain a major concern. In the neonatal population, severe aortic insufficiency may develop requiring surgical intervention. Despite these limitations, balloon aortic valvuloplasty is currently considered as therapeutic procedure of choice in the management of congenital aortic stenosis in the pediatric and young adult population. Careful follow-up to detect recurrence of stenosis and development of significant aortic insufficiency is recommended.

Evolution of Technology in Replacement of Heart Valves: Transcatheter Aortic Valves, a Revolution for Management of Valvular Heart Diseases

Objectives: The goal of this study is to analyze the evolution of technology in artificial heart valves for solving the problem of aortic stenosis (a narrowing of the aortic valve opening) that is one of the most common valvular heart diseases in society. In particular, this study explains the technological evolution of the new technology of transcatheter aortic valve implantation (TAVI) compared to surgical aortic valve replacement (SAVR). Methods: Data of Scopus (2020) based scientific products and patents that have in title, abstract or keywords the following terms: “transcatheter aortic valve implantation (TAVI)” or “surgical aortic valve replacement (SAVR)”. The evolution of technology is analyzed with a model, which shows how TAVI technique is substituting established technique of SAVR in cardiology. The relationships are investigated with loglinear models using ordinary least squares method for estimating the unknown parameters in relationships under study. Statistical analyses are performed with the Statistics Software SPSS 26. Results: Statistical analyses reveal that TAVI, with its growing scientific and technological production, is expected to be a dominant technology in the not too distant future for the treatment of aortic stenosis in society. In fact, the scientific production of TAVI has a coefficient of growth in function of time equal to 0.40(P<.001) compared to a coefficient for SAVR that is 0.10(P<.001). Statistical analyses with patent production confirm these results. Findings hint at general properties of the evolutionary behavior of this medical technology: 1) TAVI has a disproportionate growth in scientific products and patents compared to SAVR; 2) TAVI has a growing scientific and technological production driven by major and minor technological advances to solve consequential problems to treat valvular heart diseases; 3) learning via diffusion and diffusion by learning are driving forces underlying the development and adoption of TAVI in cardiology. Conclusions: TAVI, introduced in 2002, is growing in terms of scientific production and innovative activity to revolutionize the management of aortic stenosis in cardiology with important implications of health management based on improved cost-effectiveness of this new technology and better efficiency in healthcare of people.

Evaluation and Management of Aortic Stenosis in Chronic Kidney Disease: A Scientific Statement From the American Heart Association.

Aortic stenosis with concomitant chronic kidney disease (CKD) represents a clinical challenge. Aortic stenosis is more prevalent and progresses more rapidly and unpredictably in CKD, and the presence of CKD is associated with worse short-term and long-term outcomes after aortic valve replacement. Because patients with advanced CKD and end-stage kidney disease have been excluded from randomized trials, clinicians need to make complex management decisions in this population that are based on retrospective and observational evidence. This statement summarizes the epidemiological and pathophysiological characteristics of aortic stenosis in the context of CKD, evaluates the nuances and prognostic information provided by noninvasive cardiovascular imaging with echocardiography and advanced imaging techniques, and outlines the special risks in this population. Furthermore, this statement provides a critical review of the existing literature pertaining to clinical outcomes of surgical versus transcatheter aortic valve replacement in this high-risk population to help guide clinical decision making in the choice of aortic valve replacement and specific prosthesis. Finally, this statement provides an approach to the perioperative management of these patients, with special attention to a multidisciplinary heart-kidney collaborative team-based approach.