Prohibitive Operative Risk Research Articles

The Tendyne transcatheter mitral valve replacement system for the treatment of mitral regurgitation.

Mitral valve regurgitation (MR) is the most prevalent valvular disorder among the growing elderly population, occurring in over 6% of those aged>65. Unfortunately, many individuals with severe MR (particularly those with systolic dysfunction or secondary MR) will not be candidates for surgical valve repair or replacement due to high or prohibitive operative risk. For such patients, transcatheter mitral valve replacement represents a viable option. The TendyneTM valve (Abbott Vascular, CA, USA) is one of the most well-studied system to date, with a good safety and efficacy profile.

Transcatheter Edge-to-edge Repair of Severe Tricuspid Regurgitation

Despite the increasing knowledge of the long-term adverse consequence of severe tricuspid regurgitation (TR), most patients with moderate- to-severe TR are still treated conservatively because of the high risk of surgery. Percutaneous procedures have emerged as an attractive alternative treatment. Transcatheter edge-to-edge repair is a validated technique to treat mitral regurgitation. In recent years, the same concept has been applied to patients with TR and prohibitive operative risk. Early trials have shown feasibility and safety. More clinical experiences and long-term results are still being gathered. In this article, we provide an overview of transcatheter edge-to-edge repair and look at the current evidence and clinical results regarding procedure.

Transcatheter aortic valve implantation in Germany.

Over the past years, there has been a tremendous evolution of transcatheter aortic valve implantation (TAVI) that turned a novel revolutionary approach to a mature concept. Peri-procedural complications and mortality rates have markedly decreased; hence, TAVI became an integral component of the treatment strategy for patients with severe aortic stenosis and now is the preferred therapy in elderly patients with moderate to high or prohibitive operative risk. This successful development would not have been possible without the joint efforts of clinicians, scientists, engineers, and many others from around the world. In this context, Germany has been one of the forerunners in implanting transcatheter heart valves, as evidenced not only by the high numbers of procedures, but in particular by some individual pioneering achievements. Here, we picture German contributions in the field of TAVI that had impact on clinical practice, including first-in-man experience, CE mark trials, randomized studies, large registries, and other procedurally relevant aspects.

Outcomes after carotid artery stenting in hemodialysis patients

Patients who require hemodialysis are historically excluded from randomized studies of carotid artery stenting (CAS) due to perceived poor outcomes. Observational studies of outcomes after CAS in hemodialysis patients are mostly limited to small, single-institution series. This study evaluated long-term outcomes after CAS in a large nationally representative cohort of hemodialysis patients. We studied all patients who underwent CAS in the United States Renal Disease System database between January 2006 and December 2011. Patient outcomes were determined by matching with the Medicare database. Univariable and multivariable logistic and Cox regression were used to compare perioperative (stroke, death, myocardial infarction) and long-term (stroke, death) outcomes after CAS. The cohort included 1109 patients who underwent CAS. Median follow-up was 2.5years (interquartile range, 1.30-3.71; maximum, 4.97years). Mean age was 67 (standard deviation, 9.9) years, and 61% of patients were male, 75% were white, and 83% were asymptomatic. Overall, 30-day perioperative stroke, myocardial infarction, and death rates were 5.5%, 5.5%, and 3.1%, respectively. Long-term freedom from stroke was 90% at 1year, 85% at 2years, and 76% at 4years. Patient survival was 73% at 1year and 29% at 4years. Symptomatic status was the only significant predictor of stroke in a long-term period of 4years (hazard ratio, 1.92; 95% confidence interval, 1.12-3.29; P< .05). This study, which is the largest population-based study of outcomes after CAS in hemodialysis patients, demonstrates relatively poor long-term survival and prohibitive operative stroke and death risk. We recommend avoidance of CAS in asymptomatic dialysis patients and cautious consideration when planning CAS in symptomatic patients.

Bariatric Surgery in Patients with Dialysis-Dependent Renal Failure.

Laparoscopic procedures for the treatment of morbid obesity are commonly offered to patients with comorbidities previously thought to carry prohibitive operative risk. In this study, we reviewed characteristics and perioperative outcomes of patients with dialysis-dependent renal failure (DDRF) who underwent laparoscopic bariatric procedures. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2006 to 2011 was reviewed. Preoperative characteristics and 30-day outcome data of patients who underwent three common laparoscopic procedures were analyzed using ANOVA and Pearson chi-squared tests. One hundred thirty-eight patients (52.5 % female) with DDRF and a median body mass index (BMI) of 45.5 kg/m(2) were identified; 33.8 % (n = 47) underwent laparoscopic banding (LAGB), 48.9 % (n = 68) laparoscopic Roux-en-Y gastric bypass (RYGB), and 16.5 % (n = 23) laparoscopic sleeve gastrectomy (LSG). No differences were found among groups in age, prevalence of American Society of Anesthesiology IV classification, BMI, weight, gender, prevalence of diabetes, and vascular or neurologic comorbidities. Total operation time and length of hospital stay were significantly different between groups. Mortality was 0.7 %, and overall morbidity was 5.8 %. The case mix reflected a decrease in LAGB procedures from 45.5 to 23.3 % from 2006-2009 to 2010-2011 and an increase in LSG procedures from 9.1 to 24.7 % (p < 0.006). When performed in selected DDRF patients, bariatric surgery is safe. An increase in LSG with a concurrent decline in LAGB procedures was demonstrated over the period of the study.

Journal of Rare Cardiovascular Diseases: “One finger cannot lift a pebble” – cooperation as the only way to move forward

Dear Readers, Gaining more experience and exchange of knowledge in one thing is the only way to advance the field of rare cardiovascular diseases (RCD). Taking care of RCD patients on a daily basis quickly leads to realization that working to gether in multidisciplinary teams is the only way to deliver the best possible management to the patients. The cases presented in this issue of the Journal are perfect examples that such cooperation is more than recommended – it is often mandatory in RCD patients. What possibly could we have achieved without eye specialists or rheumatologists in Marfan syndrome or without hematologists in amyloidosis or without vigilant obstetricians in poor female with peripartutm cardiomyopathy? Our recitations are endless. Please stop for a second to reflect how often we simply forget to ask for a second opinion from a college who is only few meters away… The 10th (another anniversary!) issue of the Journal starts with the educational Review on the contemporary therapies in pulmonary hypertension, putting the special strength on chronic thrombo-embolic pulmonary hypertension (CTEPH). Dr Barbara Widlinska under the leadership of dr Grzegorz Kopec elaborate not only on pharmaco-therapy but also on novel invasive treatment of CTEPH which is balloon pulmonary angioplasty (BPA). Importantly, our Center is one of the few places in Poland where actually such treatment can be offered to the patients who are disqualified from surgical pulmonary endatherectomy due to prohibitive operative risk. The true “salt” of the Journal are clinical cases. The first, authored by Dr Pawel Rubis and colleagues, concerns peripartum cardiomyopathy. This is a very rare condition that affects pregnant women at the end of third trimester or as it was in this case few months after uneventful delivery of twins. Thanks to the vigilant obstetrician, who could have also easily dismissed the patient, she was promptly send to our Department where appropriate treatment including Bromocriptine was initiated. Fortunately, all ended well and the patient was discharged home in good clinical status to take care of her babies. The second case, reported by Dr Monika Komar and co-workers, concerns the middle-age patient with very rough course of cryptogenic patent foramen ovale (PFO) and related complications. After few cardiac interventions, including primary angioplasty for acute myocardial infarction and percutaneous closure of PFO and diagnosis of thrombophilia(mutation of Leiden V factor) the patient was eventually discharged home with life-long oral anticoagulation. Next case comes from our Partners from Chrzanow and is about the patient with multiple myeloma and systemic amyloidosis as a long-term complications. The case is enriched with a well-written discussion which gives an overview on amyloidosis and cardiac amyloidosis in particular. The forth case is from Katowice and once again touches the problem of mediastinal masses. After exhaustive diagnostic work-up it turned out the observed mediastinal pathology is probably result of allergic alveolitis or ectopic thymus tissue. Despite its close proximity to the cardiac tissue, the joint decision has been made to monitor the tumor and do not rush with hasty intervention. The last case, authored by dr Natalia Dluzniewska, is about coronary anomaly – Bland-White-Garland syndrome mimicking myocardial infarction. The authors discuss the problem of coronary anomalies in detail and surly this is a piece to read as paradoxically it is not so rare to encounter coronary anomaly during routine coronary angiography. The final part of this issue is a report, prepared by Dr Lidia Tomkiewicz-Pająk, on the recent Congress on Congenital Heart Diseases in Adults that was organized under the auspices of Polish Cardiac Societywitha significant participation from the Krakow CRCD Center. Such meetings are very important as most of those diseases are truly unique and require high level of expertise and experience. Therefore, opportunity to exchange thoughts and opinions is of utmost importance. The Editors hope that the current issue of the Journal will, again, serve its main purpose which is to raise awareness on the complexity of rare disease that may occasionally require multi-disciplinary to truly help our patients. Piotr Podolec Editor-in-Chief Journal of Rare Cardiovascular Diseases

Diagnosis and management of valvular aortic stenosis.

Valvular aortic stenosis (AS) is a progressive disease that affects 2% of the population aged 65 years or older. The major cause of valvular AS in adults is calcification and fibrosis of a previously normal tricuspid valve or a congenital bicuspid valve, with rheumatic AS being rare in the United States. Once established, the rate of progression of valvular AS is quite variable and impossible to predict for any particular patient. Symptoms of AS are generally insidious at onset, though development of any of the three cardinal symptoms of angina, syncope, or heart failure portends a poor prognosis. Management of symptomatic AS remains primarily surgical, though transcatheter aortic valve replacement (TAVR) is becoming an accepted alternative to surgical aortic valve replacement (SAVR) for patients at high or prohibitive operative risk.

Aortic balloon valvuloplasty prior to orthotopic liver transplantation: a novel approach to aortic stenosis and end-stage liver disease.

The combination of severe aortic stenosis and end-stage liver disease increases the morbidity and mortality of surgical aortic valve replacement or orthotopic liver transplantation resulting in a prohibitive operative risk. We propose a staged approach of balloon aortic valvuloplasty prior to orthotopic liver transplantation as a bridge to definitive aortic valve replacement. Between 2010 and 2012, four patients with severe aortic stenosis and end-stage liver disease underwent staged balloon aortic valvuloplasty followed by orthotopic liver transplantation. All patients had been deemed to be inappropriate candidates for liver transplantation or aortic valve surgery due to their comorbidity. One patient died of complications from a perivalvular abscess. Three patients went on to successful graft implantation and function and surgical recovery. Two of the three patients proceeded to definitive surgical aortic valve replacement with the remainder currently undergoing evaluation. In this case series, we present a novel approach of balloon aortic valvuloplasty prior to liver transplantation as a potential bridge to definitive treatment of severe aortic stenosis in the end-stage liver patient.

Circulation Editors’ Picks

<i>Circulation</i> Editors’ Picks

Outcomes of Esophagectomy for Esophageal Achalasia in the United States

BackgroundWhile the outcomes after Heller myotomy have been extensively reported, little is known about patients with esophageal achalasia who are treated with esophagectomy. MethodsThis was a retrospective analysis using the Nationwide Inpatient Sample over an 11-year period (2000–2010). Patients admitted with a primary diagnosis of achalasia who underwent esophagectomy (group 1) were compared to patients with esophageal cancer who underwent esophagectomy (group 2) during the same time period. Primary outcome was in-hospital mortality. Secondary outcomes included length of stay, postoperative complications, and total hospital charges. A propensity-matched analysis was conducted comparing the same outcomes between group 1 and well-matched controls in group 2. ResultsNine hundred sixty-three patients with achalasia and 18,003 patients with esophageal cancer underwent esophagectomy. The propensity matched analysis showed a trend toward a higher mortality in group 2 (7.8 vs. 2.9 %, p = 0.08). Postoperative length of stay and complications were similar in both groups. Total hospital charges were higher for the achalasia group ($115,087 vs. $99, 654.2, p = 0.006). ConclusionThis is the largest study to date examining outcomes after esophagectomy in patients with achalasia. Based on our findings, esophagectomy can be considered a safe option, and surgeons should not be hindered by a perceived notion of prohibitive operative risk in this patient population.

The role of local excision in invasive adenocarcinoma of the ampulla of Vater.

The role of local excision in invasive adenocarcinoma of the ampulla of Vater.

Early outcomes of antireflux surgery for United States lung transplant recipients

This study aimed to evaluate early outcomes after antireflux surgery for lung transplant (LTx) recipients in the United States. Adult patients undergoing elective antireflux surgery between 2003 and 2008 were identified in the Nationwide Inpatient Sample. A propensity-matched analysis compared early outcomes between prior LTx recipients and well-matched control subjects consisting of non-LTx patients undergoing elective antireflux surgery during the same era. The primary outcome was inpatient mortality, and the secondary outcomes were hospital length of stay (LOS), perioperative complications, and hospital costs. During the study period, 401 LTx recipients underwent elective antireflux surgery. These patients were well matched with 401 control patients in terms of age, sex, individual and overall comorbidity burden, hospital teaching status, hospital location, hospital antireflux volume, and open versus laparoscopic approach. The overall operative mortality rate was 1.4 %, with no difference between the groups. The overall and individual morbidity rates also were similar. The LOS and hospital costs were significantly greater in the LTx group. Multivariable logistic regression analysis confirmed that prior LTx did not confer an increased risk of inpatient mortality after antireflux surgery. To date, this is the largest study to examine outcomes of antireflux surgery for LTx recipients. Operative mortality and morbidity appear to be comparable with those of the general population, although resource utilization is greater. Based on these data, trials to evaluate the role of antireflux surgery in preserving allograft function after LTx should not be hindered by a perceived notion of prohibitive operative risk in this patient population.

Identification of very high risk octogenarians undergoing coronary artery bypass surgery: results of a multicenter study

Excellent late survival is expected after coronary artery bypass (CABG) in patients aged ≥80years, but immediate postoperative mortality can be rather high. This study was planned to identify variables associated with very high operative risk in these fragile patients. This is a multicenter study including 2,246 patients aged ≥80years who underwent isolated CABG at 68 Italian hospitals. The proportion of patients aged ≥80years varied from 1.7 to 13.6% (overall 5.6%, p<0.0001) in different institutions. The median logistic EuroSCORE varied from 6.2 to 31.7% (overall median 11.3%, p=<0.0001) in different institutions. Thirty-day mortality in patients aged ≥80years correlated with that of patients aged <80years (rho: 0.310, p=0.027). The overall 30-day mortality rate was 6.5%. Both logistic regression and CART showed that emergency procedure, low left ventricular ejection fraction, unstable hemodynamics, and use of nitrates infusion at arrival in the operating room were independent predictors of 30-day mortality. CART analysis showed that 30-day mortality among patients undergoing emergency CABG with unstable hemodynamic conditions was 32.60% and it was 20.0% in patients undergoing non-emergency operation with nitrates infusion at arrival in the operating room and left ventricular ejection fraction <30%. The proportion and operative risk of patients aged ≥80years and undergoing CABG significantly varied among institutions. Patients requiring emergency surgery, with unstable hemodynamic conditions, requiring nitrates infusion, and low ejection fraction have a prohibitive operative risk. This small proportion of patients may benefit from percutaneous coronary intervention in order to stabilize their preoperative conditions.

Circulation: Clinical Summaries

Circulation: Clinical Summaries

Response to Letters Regarding Article, “Comparison Between Transcatheter and Surgical Prosthetic Valve Implantation in Patients With Severe Aortic Stenosis and Reduced Left Ventricular Ejection Fraction”

We thank Subramanian et al and Ranucci et al for their insightful comments with regard to our study.1 In response to the comments of Ranucci et al, we provide the following statements. 1. The important variability in the 30-day mortality rates (8% to 33%) reported in previous studies is essentially related to the differences in the cutoff values used for the left ventricular ejection fraction (LVEF), but also, and more importantly, it is related to the differences in the baseline risk profile of the study populations. The fact that the mortality (12%) observed in our surgical aortic valve replacement (SAVR) series is higher than that (8% to 10%) of some previous series is essentially related to the worse-risk profile of the patients included in this series. 2. The assessment of SAVR operative risk was based on a comprehensive analysis of the factors included in the risk scores, and those (eg, frailty) not included in these scores, as well. All patients included in the transcatheter aortic valve implantation (TAVI) series had been refused for SAVR by at least 2 cardiac surgeons. 3. We agree that the presence of reduced LVEF should not be used as the sole argument to recommend TAVI rather than SAVR in patients with severe aortic stenosis. SAVR remains the standard of care in the vast majority of patients with reduced LVEF and high …

Prevalence and prognostic implications of baseline anaemia in patients undergoing transcatheter aortic valve implantation

TAVI is a minimally invasive alternative to surgical aortic valve replacement or medical therapy in patients with a high or prohibitive operative risk. The clinical significance of baseline anemia and prognostic implications in this patient cohort are unknown. We sought to evaluate the prevalence and prognostic implications of baseline anaemia in patients undergoing transcatheter aortic valve implantation (TAVI) at our institution. One hundred and eighteen consecutive patients who underwent TAVI with the Medtronic Corevalve System (Medtronic Corp., Minneapolis, MN, USA) were included in the analysis. Clinical and biochemical data were prospectively collected before, during and after the procedure. Clinical follow-up was set at one month, one year and yearly thereafter. Anaemia was defined as a haemoglobin level <13 g/dL in men and <12 g/dL in women. Mortality was confirmed by consultation of the civil registry. The prevalence of baseline anaemia was 49%. Anaemic patients undergoing TAVI required more RBC transfusions (3.3 ± 3.1 versus 1.5 ± 2.3; p<0.001) and more frequently experienced a prolonged index hospitalisation exceeding two weeks. For patients with at least 1-year follow up (N=74), mortality at 30 days was no different; however 1-year mortality was significantly higher in the anaemic cohort (44 versus 15%, p=0.006). In a multivariable analysis, baseline anaemia emerged as an independent predictor of 1- year mortality (HR 2.10 [1.06-4.18]). In our series, baseline anaemia is common in patients undergoing TAVI, forecasts a need for more red blood cell transfusions and is associated with increased 1-year mortality.

A Case of Glomus Vagale Tumor with the Complaint of Hoarseness

Dear Editor, Vagal paragangliomas are uncommon tumors of the parapharyngeal space, approximately 200 cases having been reported.[1] They arise from tissue of the extra adrenal sympathetic nervous system.[2] They mostly manifest as a painless neck mass near the angle of the mandible usually between the skull base and the hyoid bone.[3] The other manifestations are hoarseness and less commonly dysphagia, palatal weakness and tongue hemi-atrophy.[1][4] Pressure on the cervical sympathetic chain causes horner syndrome. Ultrasonography, CT scan, MRI and angiography are diagnostic modalities been used, but combining conventional MR imaging with CE-MRA has dramatic diagnostic value for the assessment of head and neck paragangliomas.[5] Surgical resection is the treatment for carotid body tumors, and the procedure should be undertaken unless the patient has a prohibitive operative risk.[4] Here we present a rare glomus vagale case presented with hoarseness and show his management. A 37 years old farmer presented with hoarseness and left cervical mass beyond mandible angle. He did not claim of another symptom, on physical examination a firm mobile 2x2 cm mass was moving horizontally. Before treatment planning, we found left vocal cords paralyzed and CT scan demonstrated a heterogenous lesion next to the carotid bifurcation (Figure 1). Planning resection, he underwent surgery and we found two masses, one in 1.5x1.5 over bifurcation and the other just in bifurcation area extending toward skull through vagal foramen, we could resect these highly vascular masses while saving carotid branches but sacrificing involved vagal nerve. Pathologist confirmed these paragangliomas. Fig. 1 CT scan shows left neck mass. The normal carotid body is a small mass of neurovascular tissue located bilaterally in the medial valley of the carotid artery bifurcation. Although the term has historically been assigned to these masses, they are not carcinomas, and the neoplastic process is actually hypertrophy of the carotid body tissue.[6] The four main locations of glomus tissue within the head and neck are: (a) The carotid bifurcation (carotid body tumor), (b) The inferior ganglion region (ganglion nodosum) and cervical portion of the vagus nerve (glomus vagale or vagal paraganglioma), (c) The jugular bulb region (glomus jugulare) and (d) The middle ear cavity (glomus tympanicum).[3] Paragangliomas originate in the head and neck from the brachiomeric family of paraganglia, neuroendocrine tissue which lies along the carotid artery, the aorta, the glossopharyngeal nerve, and the middle ear.[7] Preoperative planning requires a selective carotid arteriogram to clarify arterial anatomy and the relation of the carotid body tumor to the carotid bifurcation. Embolization of the tumor may also be achieved through these branch vessels, particularly in cases in which the lesion extends over a considerable distance and may approach the base of the skull. Challenging options about surgical versus radiation treatment continues, advocating radiation for small lesions,[8][9] and surgery in younger patients and tumors causing bony destruction.[10] Morbidity associated with vagal paraganglioma surgery is significantly higher than that of carotid body tumor surgery. Plans for intraoperative blood cell salvage are appropriate, as significant blood loss is routine in the dissection of these lesions.[6] Therapeutic embolization reduces the size of the tumor and limits intraoperative blood loss but may rarely be considered as definitive treatment.[11] Radiation therapy is an alternative to surgery and may be effective in arresting the growth, but it can lead to neurologic sequelae and rarely can destroy the tumor. Irradiation is generally used in elderly patients as well as in large and unresectable tumors [1] and gathering data upon clinical examination and imaging, we prepared our client to surgery. Under general anesthesia via standard cervical approach, tumor dissected off the carotid branches but found left vagus nerve involved, extending toward skull base through cranial nerve foramen, so had to sacrify it.

Percutaneous Balloon-Expandable Aortic Valve Implantation: Transfemoral

While surgical aortic valve replacement has been an extraordinarily effective treatment for symptomatic aortic stenosis, it has been estimated that over 40% of patients with this condition go untreated. 1 Many of these face prohibitive operative risk, due to a number of factors such as porcelain aorta, cirrhosis, severe emphysema, and other comorbidities. Recently, transfemoral transcatheter aortic valve implantation (TAVI) has demonstrated clinical benefit in a patient population at prohibitively high risk for complications following traditional surgical valve implantation. 2 The initial application of this technology in human patients utilized an antegrade approach via the femoral vein, a transseptal puncture, and guidance of the prosthesis across the mitral valve and out through the left ventricular outflow tract. 3 Although this approach avoids the complications associated with large-bore access of the iliofemoral arterial system, it proved cumbersome for most operators and was associated with a high risk of other major complications, includingcardiacperforationandmajorstructuraldamageto the mitral valve. In recent years, TAVI procedures with a balloon-expandable system have been performed retrograde either through a transfemoral arterial approach (TF) or through a transapical approach involving a limited left thoracotomy and exposure of the apex of the heart. For the purposes of this article, we focusontheTFtechniqueusingtheEdwardsSapienballoonexpandable platform (Fig. 1; Edwards Lifesciences, Irvine, CA). This device is not currently approved for marketing in the United States and is limited to investigational use; it is currently the only device in clinical trial in the United States, although it has been Conformite European (CE) mark approved for use in Europe since September 2007. Another transcatheter aortic valve device, the Medtronic Corevalve (Medtronic, Inc, Minneapolis, MN), has impending clinical trials in the United States and has also received CE mark approval. A number of other innovative transcatheter valve devices are in various stages of preclinical and clinical testing internationally. Because our experience has been solely with the Edwards Sapien device, we limit our discussion to this system. The preoperative steps of this procedure, other than general patient selection, include proper evaluation of iliofemoral and aortic access for retrograde device deployment and accurate annulus sizing. The critical procedural steps include the following: reassessment of annular size, vascular access, accurate valve positioning, reliable rapid ventricular pacing, valve deployment, valve assessment, and control of vascular access and closure. The procedural steps of retrograde valve positioning and deployment have been well described 4 and we focus much of this discussion on our technique for total percutaneous device placement. These techniques can also prove useful for other largebore arterial access systems, such as endovascular aortic stent-graft placement.

Off-pump trans-apical trans-catheter aortic valve implantation: first successful case report in India

Trans-catheter aortic valve implantation has emerged as an alternative to conventional aortic valve replacement for patients with symptomatic severe aortic stenosis considered to be at very high or prohibitive operative risk. We report the first successful Off-pump trans-apical trans-catheter aortic valve implantation in India for a case of severe calcific aortic stenosis with a Logistic Euroscore of 18.82%.

Comparison Between Transcatheter and Surgical Prosthetic Valve Implantation in Patients With Severe Aortic Stenosis and Reduced Left Ventricular Ejection Fraction

Patients with severe aortic stenosis and reduced left ventricular ejection fraction (LVEF) have a poor prognosis with conservative therapy but a high operative mortality when treated surgically. Recently, transcatheter aortic valve implantation (TAVI) has emerged as an alternative to surgical aortic valve replacement (SAVR) for patients considered at high or prohibitive operative risk. The objective of this study was to compare TAVI and SAVR with respect to postoperative recovery of LVEF in patients with severe aortic stenosis and reduced LV systolic function. Echocardiographic data were prospectively collected before and after the procedure in 200 patients undergoing SAVR and 83 patients undergoing TAVI for severe aortic stenosis (aortic valve area ≤1 cm(2)) with reduced LV systolic function (LVEF ≤50%). TAVI patients were significantly older (81±8 versus 70±10 years; P<0.0001) and had more comorbidities compared with SAVR patients. Despite similar baseline LVEF (34±11% versus 34±10%), TAVI patients had better recovery of LVEF compared with SAVR patients (ΔLVEF, 14±15% versus 7±11%; P=0.005). At the 1-year follow-up, 58% of TAVI patients had a normalization of LVEF (>50%) as opposed to 20% in the SAVR group. On multivariable analysis, female gender (P=0.004), lower LVEF at baseline (P=0.005), absence of atrial fibrillation (P=0.01), TAVI (P=0.007), and larger increase in aortic valve area after the procedure (P=0.01) were independently associated with better recovery of LVEF. In patients with severe aortic stenosis and depressed LV systolic function, TAVI is associated with better LVEF recovery compared with SAVR. TAVI may provide an interesting alternative to SAVR in patients with depressed LV systolic function considered at high surgical risk.