Severe Symptomatic Aortic Stenosis In Patients Research Articles

Transcatheter aortic valve replacement and the value of increasing treatment for severe symptomatic aortic stenosis: a plain language summary

Plain Language Summary What is this summary about? This article summarizes an economic evaluation of transcatheter aortic valve replacement (TAVR), a treatment for severe symptomatic aortic stenosis (SSAS). SSAS occurs when the aortic valve, which allows blood to leave the heart, becomes very narrow. This reduces blood flow to the body, causing symptoms like tiredness, chest pain, dizziness, or fainting. Treating SSAS requires replacing the valve. Untreated SSAS results in heart failure and death. Before TAVR, SSAS patients had two options, medical management and surgical aortic valve replacement (SAVR). Medical management helps with symptoms but does not replace the valve, leading patients to eventually die from SSAS. SAVR replaces the valve through open-heart surgery, which is invasive, involving making a large cut through the chest bone. Concerns about this invasiveness led many patients to avoid SAVR, leaving their SSAS untreated. TAVR was introduced in 2010. It is less invasive than SAVR, involving inserting a new valve through a small cut in the leg. TAVR has become popular and twice as many patients now undergo TAVR compared to SAVR. We measure TAVR’s net benefits as the value of its health benefits minus its healthcare costs. We measure these net benefits in three patient groups aged 65 and above in the United States. Group 1 patients are ineligible for SAVR, so TAVR is their only treatment option. Group 2 patients would have received SAVR if TAVR were not available. Group 3 patients are eligible for SAVR but concerned about its invasiveness, and so would have stayed untreated without TAVR. Economic evaluation: A type of study that measures the benefits and costs of a treatment like TAVR and judges whether the benefits are sufficiently large to justify the costs (or put another way, whether the technology represents good value-for-money). Transcatheter aortic valve replacement (TAVR): Replacement of the aortic valve in SSAS patients using a thin tube called a catheter that enters the body through a small cut near the leg and delivers and installs a valve replacement. New treatment option for SSAS from 2010 onwards. A minimally invasive treatment. Aortic stenosis (AS): A heart condition where a heart valve called the aortic valve becomes very narrow, forcing the heart to work harder and limiting blood flow to the rest of the body. Severe Symptomatic Aortic Stenosis (SSAS): Severe form of AS when the narrowing of the aortic valve is significant and accompanied by symptoms like fatigue, chest pain, shortness of breath, dizziness, or fainting. What were the key takeaways? Net benefits per patient are significant in all groups, roughly equal in groups 1 and 2, and over six times larger in group 3. When net benefits are added up across patients, group 3’s total net benefit is 30 times larger than that of groups 1 and 2 combined. What are the main conclusions? Past studies ignored TAVR’s value in helping treat patients who might go untreated because of concerns over SAVR’s invasiveness. But this is TAVR’s largest value to SSAS patients. Our findings support continuing and increasing access to TAVR among SSAS patients, especially those who may go untreated because of concerns about invasive treatment. Aortic valve: One of the four heart valves. It connects the left side of the heart with the aorta, which is the large artery carrying oxygen-rich blood to the body. The aortic valve controls blood flow into the aorta, ensuring it moves in one direction. Medical management (MM): Involves medication and monitoring of SSAS patients but no treatment in the form of valve replacement. Associated with high risk of death. Surgical aortic valve replacement (SAVR): Replacement of the aortic valve in SSAS patients through open heart surgery. The sole treatment option for SSAS before 2010. A highly invasive treatment given its use of open-heart surgery. This is an abstract of the Plain Language Summary of Publication article. View the full Plain Language Summary PDF of this article to read the full-text Link to original article here

Outcomes of Transcatheter Aortic Valve Implantation in Patients with and without Diabetes Mellitus.

Diabetes mellitus (DM) in patients undergoing cardiac transcatheter or surgical interventions usually is correlated with poor outcomes. Transcatheter aortic valve implantation (TAVI) has been developed as a therapy choice for inoperable, high-, or intermediate-risk surgical patients with severe aortic stenosis (AS). To evaluate the impact of DM and hemoglobin A1c (HbA1c) on outcomes and survival after TAVI. Five hundred and fifty-two symptomatic severe AS patients who underwent TAVI, of whom 164 (29.7%) had DM, were included in this retrospective study. Follow-up was performed after 30 days, six months, and annually. The device success and risks of procedural-related complications were similar between patients with and without DM, except for acute kidney injury, which was more frequent in the DM group (2.4% vs. 0%, P=0.021). In-hospital and first-year mortality were similar between the groups (4.9% vs. 3.6%, P=0.490 and 15.0% vs. 11.2%, P=0.282, respectively). There was a statistical difference between HbA1c ≥ 6.5 and HbA1c ≤ 6.49 groups in total mortality (34.4% vs. 15.8%, P<0.001, respectively). The only independent predictors were Society of Thoracic Surgeons score (hazard ratio [HR] 1.28, 95% confidence interval [CI] 1.09-1.51; P=0.003) and HbA1c level ≥ 6.5 (HR 10.78, 95% CI 2.58-21.50; P=0.003) in multivariable logistic regression analysis. In this study, we conclude that DM was not correlated with an increased mortality risk or complication rates after TAVI. Also, it was shown that mortality was higher in patients with HbA1c ≥ 6.5, and it was an independent predictor for long-term mortality.

Transcatheter aortic valve implantation in severe aortic stenosis does not necessarily reverse left ventricular myocardial damage: data of long-term follow-up.

Aortic stenosis (AS) is causing myocardial damage and replacement is mainly indicated based on symptoms. Non-invasive estimation of myocardial work (MW) provides a less afterload-dependent too for assessing myocardial function. We sought to look at the impact of transcatheter aortic valve implantation (TAVI) on the myocardium at long-term follow-up and according to current indications. We conducted an observational, cross-sectional, single-centre study. Patients were selected based on the validated indication for a TAVI. Standardized echocardiographies were repeated. A total of 102 patients were included. The mean age was 85 years, 45% were female, 68% had high blood pressure, and 52% had a coronary disease. One-fifth was suffering from low-flow-low-gradient AS. A follow-up was performed at 22 ± 9.5 months after the TAVI. No TAVI dysfunction was observed. Left ventricular (LV) ejection fraction was stable (62 ± 8%), and global longitudinal strain had improved (-14.0 ± 3.7 vs. -16.0 ± 3.6%, P < 0.0001). No improvement of the MW parameters was noticed (LV global work index 2099 ± 692 vs. 2066 ± 706 mmHg%, P = 0.8, LV global constructive 2463 ± 736 vs. 2463 ± 676 mmHg%, P = 0.8). Global wasted work increased [214 (149; 357) vs. 247 (177; 394) mmHg%, P = 0.0008]. In a population of severe symptomatic AS patients who had undergone a TAVI, the non-invasive myocardial indices that assess the LV performance at long-term follow-up did not improve. These results are questioning the timing of the intervention and the need for more attention in the pharmacological management of these AS patients.

Relative longitudinal strain apical sparing pattern and low albumin as detrimental factors of cardiovascular outcome after transcatheter aortic valve replacement

Abstract Background Relative apical sparing pattern (RASP) of longitudinal strain (LS), a typical echocardiographic feature of cardiac amyloidosis, is associated with cardiac death or heart failure admission in severe aortic stenosis (AS) patients, and associated with all-cause death among elderly patients with severe AS undergoing transcatheter aortic valve replacement (TAVR). Purpose Present study aimed to explore clinical and echocardiographic determinants of short-term and long-term CV outcome (including CV death and CV hospitalization) in symptomatic severe AS patients after TAVR, and to assess the independent and incremental prognostic value of RASP on CV outcome in TAVR patients. Methods This retrospective study comprised 598 consecutive AS patients underwent TAVR (mean age 81.7±5.7 years, 48.7% male). Pre-operative clinical and echocardiography data, including 2D speckle tracking imaging indexes, were analyzed. Clinical outcomes included CV death and procedure related complications at 30 days, 1 year, and at 2 years after TAVR. Results Relative apical sparing pattern (RASP) of longitudinal strain (LS) was defined as ≥3 LV wall segments with the apical-basal LS ratio &amp;gt;3.0. The prevalence of RASP was 19.2%. Compared with patients without RASP, patients with RASP were associated with higher risk of acute kidney injury (AKI, 10.4% vs. 3.3%, P=0.001) and new-onset left bundle branch block (LBBB) after TAVR (17.4% vs. 6.8%, P&amp;lt;0.001) and higher 2-year CV mortality (22.6% vs. 9.9%, P&amp;lt;0.001, Figure 1) after TAVR. Lower pre-procedural albumin level and RASP were identified as independent determinants of increased 2-year CV mortality (RASP: HR=2.178, P=0.002; albumin&amp;lt;4.0g/dl: HR= 2.548, P&amp;lt;0.001), regardless of TAVR approach and EuroSCORE II. After adjustment, the addition of RASP significantly improved prognostic power of a model including clinical variables and low albumin level for predicting 2-year CV death (χ2 from 28.179 to 40.699, P=0.001, Figure 2). Conclusion RASP is a significant determinant of AKI and new-onset LBBB after TAVR. RASP together with low pre-procedural albumin level serve as the strongest determinants of increased risk of 2-year CV mortality after TAVR.Figure 1Figure 2

TCT-347 Mapping Out the Journey to TAVR in a Large Integrated Health System: Rates and Clinical Consequences of Delays in Referral of Severe Symptomatic Aortic Stenosis Patients to the Structural Heart Team Stratified by Gender, Ethnicity, and Socioeconomic Status

TCT-347 Mapping Out the Journey to TAVR in a Large Integrated Health System: Rates and Clinical Consequences of Delays in Referral of Severe Symptomatic Aortic Stenosis Patients to the Structural Heart Team Stratified by Gender, Ethnicity, and Socioeconomic Status

A Narrative Review on Periprocedural Stroke and Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) has become the treatment option for symptomatic severe aortic stenosis patients across all risk profiles. Despite remarkable advancements in technology and operator experience, the occurrence of periprocedural stroke remains a significant concern, predominantly attributed to thromboembolic events in the immediate postprocedural period. To optimize patient outcomes, various strategies have been developed to minimize the risk of stroke, encompassing comprehensive preprocedural planning, effective management of comorbidities, utilization of cerebral embolic protection devices, and tailored medical therapy. This comprehensive review summarizes the currently available strategies for mitigating periprocedural stroke post-TAVR and provides insights into future directions.

Left ventricular reverse remodeling in post operative aortic stenosis patients: prevalence and predictor(s)

Abstract Background In patients with severe aortic stenosis (AS), left ventricular (LV) remodeling is believed to be a compensatory adaptive process which should reverse after aortic valve intervention. However, this is not always the rule and remodeling persistence may negatively impact post-procedural outcomes and survival. Aim To assess the prevalence and predictors of morphological LV reverse remodeling in severe symptomatic AS patients after surgical aortic valve replacement (AVR). Methods We prospectively studied 75 patients (72y [68–77y], 45% male) with severe symptomatic AS - mean gradient (AVM): 61±17mmHg; mean indexed aortic valve area (AVAi) 0.41±0.10 cm2/m2 with no previous history of ischemic cardiomyopathy, all with high gradient, 4 with low-flow, 81% with hypertension, 27% with type 2 diabetes mellitus and 35% patients with stage 3 chronic kidney disease: median MDR creat clearance: 70.4mL/min [40–102]. All patients performed pre-operative cardiac magnetic resonance (CMR) at a mean period of 3.4 months (0–17 months) before AVR and at the 3–6th months after AVR, for LV reverse remodeling assessment. It was defined as at least the occurrence of one of the following: &amp;gt;15% reduction in LVEDVi; &amp;gt;15% reduction in LVMi by CMR; &amp;gt;10% reduction in geometric remodeling ratio. Clinical, AV severity data, preoperative functional LV and tissue characterization data were analyzed at multivariate regression to predict the occurrence of LV reverse remodeling. Results Overall, at pre-operative CMR: mean LV indexed mass (LVMi): 82±28.9 g/m2; mean end-diastolic LV indexed volume (LVEDVi): 87.4±26.6 mL/m2; mean geometric remodeling (LV mass/end-diastolic volume): 0.92±0.2 g/mL. After AVR, at echocardiographic evaluation, no patient had prosthetic obstruction or prosthetic patient mismatch: median LV-Ao gradient 12mmHg [9.1–14 mmHg]; 5 of them had mild paravalvular regurgitation. LV reverse remodeling occurred in 65 patients (88%) (Figure 1A) and these were younger, had significantly smaller preoperative AVAi and higher valvular gradients (Figure 1B). At multivariate analysis, only preoperative AVAi remained an independent predictor (odds ratio 0.85, 95% CI 0.735–0.984, p=0.029). Conclusions In this prospective cohort of patients LV reverse remodeling after surgical AVR was highly frequent, occurring in almost nine out of every ten patients. Funding Acknowledgement Type of funding sources: None.

The Role of Transcatheter Aortic Valve Replacement in Asymptomatic Aortic Stenosis: A Feasibility Analysis.

Surgical aortic valve replacement (SAVR) is the current treatment of choice for good surgical candidates with moderate to severe symptomatic aortic stenosis (AS). As transcatheter aortic valvular replacement (TAVR) has shown an improved one and two-year all-cause mortality, it has been chosen for moderately symptomatic severe AS patients. The purpose of this review was to perform a clinical comparison of TAVR vs. SAVR and to analyze the Health Index Factor (HIF) that makes TAVR a treatment of choice in asymptomatic AS patients. An extensive literature search of PubMed, Cochrane, and Embase databases was performed using the keywords “Aortic stenosis”, “SAVR”, “TAVR”, and “Asymptomatic”. A total of 45 prospective randomized clinical trials in the English language that were published from the year 2000 onwards were included in the final analysis. It has been found that 59.3% of asymptomatic AS patients are likely to die in the next five years without proactive treatment. Multiple studies have proven that early intervention with aortic valve replacement is superior to conservative treatment in severe asymptomatic AS; however, the choice between SAVR and TAVR is not well established. The NOTION Trial, SURTAVI Trail, and PARTNER 3 study have shown the non-inferiority of TAVR over SAVR, during one-year follow-up for low surgical risk patients. Evolut Low-Risk study and Early TAVR are the only two prospective studies performed to date that have enrolled patients with asymptomatic severe AS. The Evolut Trial demonstrated no difference in all-cause mortality at 30 days (1.3% vs. 4.8%. p=0.23), and 12 days (1.3% vs. 6.5%, p=0.11). Additionally, TAVR also decreases the risk of post-procedural atrial fibrillation, acute kidney injury (AKI), and rehospitalization, and leads to significant improvement in the mean trans-aortic pressure gradient. TAVR also showed marked improvement in the 30-day Quality of Life (QOL) index, where SAVR did not report any significant change in the QOL index. However, the official recommendations of Early TAVR are still awaited. TAVR has consistently shown a statistically non-significant difference in case mortality, risk of stroke, and rehospitalization with moderate to high surgical risk patients whereby recent initial trials have shown significant improvement in the QOL index and hemodynamic index for patients with asymptomatic disease. More extensive studies are required to prove the risk stratifications, long-term outcomes, and clinical characteristics that would make TAVR a preferred intervention in asymptomatic patients.

Cost-utility and cost-benefit analysis of TAVR availability in the US severe symptomatic aortic stenosis patient population

Aims We evaluated the availability of transcatheter aortic valve replacement (TAVR) to determine its value across all severe symptomatic aortic stenosis (SSAS) patients, especially those untreated because of concerns regarding invasive surgical AVR (SAVR) and its impact on active aging. Methods We performed payer perspective cost-utility analysis (CUA) and societal perspective cost-benefit analysis (CBA). The CBA’s benefit measure is active time: salaried labor, unpaid work, and active leisure. The study population is a cohort of US elderly SSAS patients. We compared a “TAVR available” scenario in which SSAS patients distribute themselves across TAVR, SAVR, and medical management (MM); and a “TAVR not available” scenario with only SAVR and MM. We structured each scenario with a decision-tree model of SSAS patient treatment allocation. We measured the association between health and active time in the US Health and Retirement Study and used this association to impute active time to SSAS patients given their health. Results The incremental cost-effectiveness ratio (ICER) and rate of return (RoR) of TAVR availability were $8,533 and 395%, respectively. CUA net monetary benefits (NMB) were $212,199 per patient and $43.4 billion population-wide. CBA NMB were $50,530 per patient and $10.3 billion population-wide. Limitations Among study limitations were scarcity of evidence regarding key parameters and the lack of long-term survival, health utility, and treatment cost data. Our analysis did not account for TAVR durability, retreatments, and valve-in-valve treatments. Conclusion Across risk-, age-, and treatment-eligibility groups, TAVR is the economically optimal treatment choice. It represents strong value-for-money per patient and population-wide. The vast majority of TAVR value involves raising treatment uptake among the untreated.

Elderly aortic stenosis patients' perspectives on treatment goals in transcatheter aortic valvular replacement

AimsTranscatheter aortic valvular replacement (TAVR) is increasingly being performed for elderly patients with aortic stenosis (AS), and current guidelines acknowledge the importance of shared decision‐making in their management. This study aimed to evaluate elderly symptomatic severe AS patients' perspectives on their treatment goals and identify factors that influence their treatment choice.Methods and ResultsWe performed a pre‐procedural cross‐sectional survey using a questionnaire at a single university hospital. The questionnaire included three primary domains: (i) symptom burden, (ii) goals and important factors related to treatment, and (iii) preferred place of residence after treatment. We investigated 98 symptomatic severe AS patients who underwent TAVR (median age 86 years, 26% men). None of the patients died during hospitalization, and most of them (94%) were discharged home. Prior to TAVR, the three most common symptom burdens were poor mobility (52%), shortness of breath (52%), and weakness (44%). The reported preferred treatment goals were symptom burden reduction (78%), independence maintenance (68%), ability to perform a specific activity/hobby (62%), and improvement in prognosis (58%). In total, 54% of the patients rated ‘in alignment with my values’ as the factor that affected their decision to undergo TAVR. Nearly all patients (95%) stated that they preferred to live at home after TAVR.ConclusionsAmong elderly AS patients with varying symptoms who underwent TAVR, symptom burden reduction was the most cited patient‐reported goal. Nearly all the patients preferred to live at home after the procedure. Encouraging patients to define their specific goals may improve the quality of shared decision‐making in such settings.

Transcatheter Aortic Valve Implantation: First Case in Nepal.

Surgical aortic valve replacement has remained the gold standard therapy for symptomatic severe aortic stenosis patients for decades. However, in past decade transcatheter aortic valve implantation has been an alternative to surgical aortic valve replacement in patients with symptomatic severe aortic stenosis who are not suitable for open heart surgery. We report first case of transcatheter aortic valve implantation in Nepal in an 80-year-old female with symptomatic severe AS who was successfully treated and had good functional and hemodynamic results at one-months follow-up.

Characteristics and clinical outcomes in patients with prior chest radiation undergoing TAVR: Observations from PARTNER-2.

The purpose of this study is to investigate the viability of transcatheter aortic valve replacement (TAVR) for severe symptomatic aortic stenosis (AS) in patients with prior chest radiation therapy (cXRT). Since patients with prior cXRT perform poorly with surgical aortic valve replacement, TAVR can be a viable alternative. However, clinical outcomes after TAVR in this patient population have not been well studied. From the pooled registry of the placement of aortic transcatheter valvesII trial, we identified patients with and without prior cXRT who underwent TAVR (n = 64 and 3923, respectively). The primary outcome was a composite of all-cause death and any stroke at 2 years. Time to event analyses were shown as Kaplan-Meier event rates and compared by log-rank testing. Hazard ratios (HRs) were estimated and compared by Cox proportional hazards regression model. There was no significant difference in the primary outcome between the patients with and without prior cXRT (30.7% vs. 27.0%; p = 0.75; HR, 1.08; 95% confidence interval, 0.66-1.77). Rates of myocardial infarction, vascular complications, acute kidney injury, or new pacemaker implant after TAVR were not statistically different between the two groups. The rate of immediate reintervention with a second valve for aortic regurgitation after TAVR was higher among the patients with prior cXRT. However, no further difference was observed during 2 years follow-up after discharge from the index-procedure hospitalization. TAVR is a viable alternative for severe symptomatic AS in patients who had cXRT in the past.

The prognostic value of left ventricular dimensions at the time of transcatheter aortic valve replacement: A propensity‐matched analysis

In the clinical practice a noteworthy proportion of severe symptomatic aortic stenosis patients presents with low-flow low-gradients features, these having reported a less favorable prognosis even when surgically or transcatheter treated. We retrospectively analyzed the prospectively collected data on 1051 consecutive patients undergone balloon-expandable transcatheter aortic valve replacement at our Institution from January 2008 to January 2020. We divided the population according with a mean aortic gradient (MAG) < or ≥40 mmHg and we performed a propensity-matched analysis based on the Society of Thoracic Surgery Score and age, obtaining two homogeneous groups of 314 patients each (Groups A and B, respectively). We then analyzed the outcomes of the two groups by implementing adjusted Cox models adjusted for significant clinical differences between the two groups, such as sex, ejection fraction, comorbidities and other variables not included in the propensity-matched analysis. The only variable associated with both cardiovascular and all-cause events was an ejection fraction ≤35%. Finally, a sensitivity analysis found that an ejection fraction ≤35% was associated with an increase cardiovascular and all-cause mortality only in patients with an indexed end-diastolic volume >97 ml/m2 (p = .0438 and .3363, respectively). In our series a MAG <40 mmHg was not found to be per se an independent risk factor for cardiac and all-cause mortality after transcatheter aortic valve replacement. The ejection fraction was found to be an independent risk factor only in the context of enlarged left ventricular dimensions.

111 Extravalvular cardiac damage and renal function following TAVI for severe aortic stenosis

Abstract Aims Acute kidney injury (AKI) represents a common complication following TAVI, that correlates strictly with in-hospital, short, and long-term mortality. Extra-valvular cardiac damage (EVCD) showed to affect long-term outcomes in patients with severe aortic stenosis (AS). We sought to determine the differences in the incidence of AKI and acute kidney recovery (AKR) among patients undergoing TAVI and their impact on clinical outcomes according to EVCD. Methods and results 706 symptomatic severe AS patients were selected and retrospectively analysed. Based on echocardiography findings, patients were classified based on the degree of EVCD. AKI was defined as a relative increase at 24–72H in sCr concentration of at least 0.3 mg/dl, and was classified according to AKIN stages. AKR was defined either as an increase of GFR of 25% or a decrease in sCr of at least 0.3 mg/dl, both measured at 24–72H after the procedure. After dichotomized analysis, patients in EVCD stage 3–4 reported a significantly higher rate of AKI (27.4% vs. 11.3%; P &amp;lt; 0.001), significant AKI (5.3% vs. 1.5%; P &amp;lt; 0.010) and the need for continuous renal replacement therapy (CRRT) after TAVI (2.7% vs. 0.7%; P = 0.052), whereas a lower incidence of AKR was reported (11.6% vs. 6.2%; P = 0.087). At the multivariate model higher EVCD stage, lower GFR and the amount of contrast used were found to be independent predictors of AKI, while early stages of cardiac damage (HR: 0.420; 95% CI: 0.224–0.785; P = 0.007) and lower GFR were found to be independent predictors of AKR. In the overall population, at a median 24-months follow-up, after multivariate analysis AKI was associated with a higher incidence of all-cause mortality [HR: 2.636; 95% CI: (1.360–5.108); P = 0.004] and MACEs [HR: 2.122; 95% CI: (1.170–3.849); P = 0.013]. Notably, at the multivariate analysis, AKI significantly impacted on survival in patients in stages 3–4 [HR: 2.461; 95% CI: (1.017–6.067); P = 0.046], but not in patients in stages 0–2 [HR: 1.301; 95% CI: (0.380–4.457); P = 0.675], with an interaction that achieved statistical significance (p for interaction 0.006). AKR did not reduce adverse clinical outcomes [HR: 0.742; 95% CI: (0.339–1.623); P = 0.455 for all-cause mortality; HR: 0.701; 95% CI: (0.351–1.397); P = 0.312 for MACEs] but was associated with an improvement of renal function at 12 months. Conclusions AKI demonstrated to negatively impact on 24-month all-cause mortality only when occurring in advanced stages of EVCD, but not in early stages. Conversely, early EVCD was associated with a higher incidence of AKR, which not significantly improved clinical outcomes but was associated with an improvement of renal function at 12-months. The application of this staging system may provide an additional tool for the decision-making process in patients with severe AS. 111 Figure

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.

Manifestation of Acute Coronary Syndrome in Critically Aortic Stenosis Patients

The clinical presentation of acute coronary syndromes (ACS) is broad, from cardiac arrest, electrical or haemodynamic instability with cardiogenic shock (CS) due to ongoing ischaemia or mechanical complications such as severe mitral regurgitation, to patients who are already pain free again at the time of presentation. Critical aortic stenosis (AS) can cause inadequate myocardial perfusion and in the absence of demonstrable coronary stenosis or occlusion which resulting in ACS manifestation. Critical AS (defined as valve area &lt;0.5 cm2) has been reported to cause mild increases in cardiac biomarkers such as troponin I. A 56-year-old man was admitted to hospital with chief complaint of typcal chest pain. Electrocardiogram (ECG) shows myocardial infarction in left main (LM) equivalent. Echocardiography revealed critical aortic stenosis. Cardiac marker also shows increasing. However, diagnostic coronary angiography (DCA) did not identify any lesions to account for the patient’s electrocardiographic changes and ongoing symptoms of chest pain. Consultation to cardiothorax surgeon to have urgent aortic valve replacement (AVR) were planned and underwent successful aortic valve (AV) replacement without coronary intervention. The definitive treatment for symptomatic severe AS is AVR. Some of the treatments that can be done are immediate coronary angiography and reperfusion procedure if there is suspicion of coronary artery occlusion or stenosis which may cause myocardial infarction; Intra-Aortic Ballon Pump (IABP) if there are signs of myocardial injury with take caution to the contraindications of IABP placement; Perform intervention procedure as soon as possible on aortic valve; Administration of medical therapy for heart failure in symptomatic severe AS patients. The case emphasizes the importance of initial physical examination, ECG, echocardiography, and cardiac markers as a whole that we do in aortic valve stenosis patient presenting with ACS.

Clinical Characteristics and Mid-Term follow-up of Elderly Patients with Severe Aortic Stenosis not Eligible for TAVI

Abstract Background: The treatment for symptomatic severe aortic stenosis (AS) is the correction of valve stenosis by surgical valve replacement and more recently by transcatheter aortic valve implant (TAVI). However, in some high risk surgical patients, TAVI is not possible for technical or clinical reasons or due to the unavailability of the endoprosthesis. Objective: The aim of this study was to evaluate a mid-term follow-up of symptomatic severe AS patients who are not eligible for TAVI trials, as well as [...]

Ten Years’ Experience of Transcatheter Aortic Valve Replacement at the Faculty of Medicine Siriraj Hospital: Transapical vs. Transfemoral Approach

Objective: To compare 30 days mortality and clinical outcomes between transapical transcatheter aortic valve replacement (TA-TAVR) and transfemoral transcatheter aortic valve replacement (TF-TAVR) in Thai patients who underwent transcatheter aortic valve replacement (TAVR). Materials and Methods: The observational study included 83 consecutive patients that attended the authors’ center for TAVR between January 2009 and December 2019. The patients’ baseline demographic data and surgical risks were recorded. The clinical outcomes at 30 days and one year were prespecified targets. Results: Eighty-three patients underwent TAVR at the authors’ center between 2009 and 2019, with 77% of them considered inoperable or at high surgical risk by the authors’ heart team. Of the 83 patients, 40 had a porcelain aorta (48.2%). The median Society of Thoracic Surgeons (STS) score and logistic EuroSCORE were 5.7 (4.6, 8.3) and 21.7 (15.2, 31.2), respectively. Twenty-two patients had a transapical approach (26.5%). The cardiovascular (CV) mortality rate was 2.4% at 30 days. The all-cause mortality 30-day rate and 1-year rate were 3.6% and 12.0%, respectively. Comparing between TA-TAVR and TF-TAVR, TA-TAVR had a significantly lower incidence of new permanent pacemaker placement after TAVR (p=0.032), but a longer length of hospital stay (p=0.087). There was a trend for a higher incidence of new onset atrial fibrillation in TA-TAVR. The all-cause mortality 30-day rate and 1-year rate were similar between TA-TAVR and TF-TAVR. Conclusion: In Thai symptomatic severe aortic stenosis patients, of whom most patients were considered inoperable or at high surgical risk, both TA-TAVR and TF-TAVR showed acceptable short- and long-term clinical outcomes. Keywords: Severe aortic stenosis (severe AS), Transcatheter aortic valve replacement (TAVR), Transfemoral (TF), Transapical (TA)

Proper Selection Does Make the Difference: A Propensity-Matched Analysis of Percutaneous and Surgical Cut-Down Transfemoral TAVR.

Background. Transcatheter aortic valve replacement (TAVR) is an established technique to treat severe symptomatic aortic stenosis patients with a wide range of surgical risk. Currently, the common femoral artery is the first choice as the main access route for the procedure. The objective of this observational study is to report our experience on percutaneous and surgical cut-down transfemoral TAVRs comparing the two approaches. Methods. From January 2014 to January 2019, five hundred eleven consecutive patients underwent TAVR for severe symptomatic aortic stenosis. We analyzed only elective transfemoral procedures. After propensity score-matching based on age, sex, EuroSCORE II, mean aortic gradient, and left ventricular ejection fraction, we obtained two homogeneous populations: surgical cut-down (n = 119) and percutaneous (n = 225), which were labeled Group 1 and Group 2, respectively. Results. The main findings were that there were no significant procedural outcome differences between the two groups, but Group 2 patients had a shorter length of hospital stay and were more frequently discharged home. At follow-up, Group 1 patients had lower survival rates. Conclusions. An accurate preoperative assessment of the femoral access is mandatory to achieve satisfactory outcomes with transfemoral TAVRs. Nevertheless, the percutaneous approach allows shorter in-hospital stay and the need for rehabilitation, thus potentially decreasing the costs of the procedure.

Transcatheter Aortic Valve Implantation in Patients with Connective Tissue Disease.

There is still no consensus on the treatment of patients with connective tissue disease (CTD) with severe symptomatic aortic stenosis (AS). The aim of this study was to evaluate the feasibility and safety of transcatheter aortic valve implantation (TAVI) in patients with CTD. Five hundred and fifty consecutive symptomatic severe AS patients who underwent TAVI between 2011 and 2019 were included in this retrospective study, of whom 14 had CTD. Follow-up was performed 30 days, 6 months, and 1 year after the procedure. Of the 14 (2.5%) patients who had CTD, most had rheumatoid arthritis (n = 10), followed by lupus erythematosus (n = 2), scleroderma (n = 1) and mixed (n = 1) CTD. The mean age was 77.6 ± 7.9 years, and there was no statistical difference between the CTD and no-CTD groups. In addition, significantly more of the CTD patients (85.7%) were female compared to the no-CTD group (p = 0.018). None of the patients in the CTD group had acute kidney injury, stroke, major bleeding, or pericardial effusion. However, significantly more patients in the CTD group (n = 4) needed permanent pacemaker implantation than in the no-CTD group (p = 0.008). There were no significant differences between the two groups in terms of mean discharge time (CTD 4.6 ± 2.0, no-CTD 4.5 ± 2.3 days, p = 0.926) and in-hospital mortality [CTD 1 (7.1%), no-CTD 21 (3.9%); p = 0.542]. In this study, we presented the results of TAVI in patients with and without CTD. The TAVI procedure had similar mid-term outcomes in the two groups, and the CTD group had numerically lower rates of major complications at the cost of a higher incidence of pacemaker implantation.