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Cerebral Embolism A Silent Iatrogenic Complication of TAVR That Needs Voiced  Consideration ∗
Transcatheter aortic valve replacement (TAVR) has rapidly and definitely changed the way patients with aortic stenosis are treated. Both the number of procedures and the indications have increased worldwide, allowing the inoperable patient to be treated, the high risk patient to be treated less invasively, and the intermediate risk patient to have the choice of an alternative to surgery (1–4). Clinical stroke or transient ischemic attack is not uncommon after aortic stenosis treatment, ranging in the randomized studies from 5% to 6% at 30 days to 8% to 10% at 1 year —one-half of them being major/disabling strokes (Tabl...
Source: Journal of the American College of Cardiology - August 2, 2016 Category: Cardiology Source Type: research

3-Year Outcomes in High-Risk Patients Who Underwent Surgical or Transcatheter Aortic Valve Replacement
This study sought to determine whether this clinical benefit was sustained over time.MethodsPatients with severe aortic stenosis deemed at increased risk for surgery by a multidisciplinary heart team were randomized 1:1 to TAVR or open surgical valve replacement (SAVR). Three-year clinical and echocardiographic outcomes were obtained in those patients with an attempted procedure.ResultsA total of 797 patients underwent randomization at 45 U.S. centers; 750 patients underwent an attempted procedure. Three-year all-cause mortality or stroke was significantly lower in TAVR patients (37.3% vs. 46.7% in SAVR; p = 0.006). Adver...
Source: Journal of the American College of Cardiology - May 30, 2016 Category: Cardiology Source Type: research

Outcomes After Transcatheter Aortic Valve Replacement With Balloon-Expandable Versus Self-Expandable Valves CHOICE Trial Results
We read with interest the paper by Abdel-Wahab et al. (1) on 1-year outcomes of the CHOICE (Randomized Comparison of Transcatheter Heart Valves in High Risk Patients With Severe Aortic Stenosis: Medtronic CoreValve Versus Edwards SAPIEN XT Trial) randomized clinical trial comparing transcatheter aortic valve replacement (TAVR) with the balloon-expandable (BE) Edwards SAPIEN XT valve (Edwards Lifesciences, Irvine, California) versus self-expandable (SE) Medtronic CoreValve (Medtronic, Minneapolis, Minnesota). Of interest, the authors concluded that mortality was not statistically different between the 2 groups, but there w...
Source: Journal of the American College of Cardiology - January 12, 2016 Category: Cardiology Source Type: research

Bivalirudin Versus Heparin Anticoagulation in Transcatheter Aortic Valve Replacement The Randomized BRAVO-3 Trial
BackgroundAnticoagulation is required during transcatheter aortic valve replacement (TAVR) procedures. Although an optimal regimen has not been determined, heparin is mainly used. Direct thrombin inhibition with bivalirudin may be an effective alternative to heparin as the procedural anticoagulant agent in this setting.ObjectivesThe goal of this study was to determine whether bivalirudin offers an alternative to heparin as the procedural anticoagulant agent in patients undergoing TAVR.MethodsA total of 802 patients with aortic stenosis were randomized to undergo transfemoral TAVR with bivalirudin versus unfractionated hepa...
Source: Journal of the American College of Cardiology - December 21, 2015 Category: Cardiology Source Type: research

2-Year Outcomes After Iliofemoral Self-Expanding Transcatheter Aortic Valve Replacement in Patients With Severe Aortic Stenosis Deemed Extreme Risk for Surgery
ConclusionsPatients with severe AS at extreme surgical risk treated with self-expanding TAVR continued to show good clinical outcomes and hemodynamic valve performance at 2 years. The presence of comorbid conditions rather than valve performance affected 2-year outcomes in these patients. (Safety and Efficacy Study of the Medtronic CoreValve System in the Treatment of Symptomatic Severe Aortic Stenosis in High Risk and Very High Risk Subjects Who Need Aortic Valve Replacement; NCT01240902)
Source: Journal of the American College of Cardiology - September 14, 2015 Category: Cardiology Source Type: research

Aortic Stenosis Valve Replacement or Valve Implantation? ∗
In this issue of the Journal, Tamburino et al. (1) have published a study that compares the clinical outcomes of aortic valve replacement (AVR) with transcatheter aortic valve replacement (TAVR) at 1 year from the OBSERVANT (Observational Study of Effectiveness of SAVR–TAVR Procedures for Severe Aortic Stenosis Treatment) registry, which investigates the management of aortic stenosis (AS) in 93 institutions in Italy. The registry had 7,618 patients with AS (5,707 treated with AVR and 1,991 with TAVR). The investigators excluded 2,150 patients because of combined procedures, porcelain aortas, “hostile thorax,” nonfem...
Source: Journal of the American College of Cardiology - August 10, 2015 Category: Cardiology Source Type: research

The Heart and the Head Neurological Implications of Transcatheter Aortic Valve Replacement ∗
In this issue of the Journal, Bosmans et al. (1) report much-awaited stroke outcomes from the ADVANCE study, a multicenter, prospective, nonrandomized cohort of patients undergoing transcatheter aortic valve replacement (TAVR) with the CoreValve prosthesis (Medtronic Inc., Minneapolis, Minnesota) at 44 mostly European sites between March 2010 and July 2011. In this real-world cohort of patients with severe aortic stenosis, the investigators observed stroke rates of 3.0% at 30 days post-TAVR and 5.6% at 2 years. They reported no significant predictors of periprocedural stroke or transient ischemic attack (TIA) occurring ...
Source: Journal of the American College of Cardiology - July 13, 2015 Category: Cardiology Source Type: research

The Incidence and Predictors of Early- and Mid-Term Clinically Relevant Neurological Events After Transcatheter Aortic Valve Replacement in Real-World Patients
ConclusionsTreatment of high-risk patients with aortic stenosis using a self-expandable system was associated with a low stroke rate at short- and long-term follow-up. Multivariable predictors of clinically relevant neurological events differed on the basis of the timing after TAVR. (CoreValve Advance International Post Market Study; NCT01074658)
Source: Journal of the American College of Cardiology - July 13, 2015 Category: Cardiology Source Type: research

2-Year Outcomes in Patients Undergoing Surgical or Self-Expanding Transcatheter Aortic Valve Replacement
BackgroundThe U.S. pivotal trial for the self-expanding valve found that among patients with severe aortic stenosis at increased risk for surgery, the 1-year survival rate was 4.9 percentage points higher in patients treated with a self-expanding transcatheter aortic valve bioprosthesis than in those treated with a surgical bioprosthesis.ObjectivesLonger-term clinical outcomes were examined to confirm if this mortality benefit is sustained.MethodsPatients with severe aortic stenosis who were at increased surgical risk were recruited. Eligible patients were randomly assigned in a 1:1 ratio to transcatheter aortic valve repl...
Source: Journal of the American College of Cardiology - July 6, 2015 Category: Cardiology Source Type: research

All Aortic Stenoses Are Not Created Equal ∗
With the advent and success of transcatheter aortic valve replacement (TAVR), new emphasis is being placed on patient selection to ensure successful outcomes after aortic valve replacement (AVR). In this regard, clinicians must appreciate that aortic stenosis (AS) is not a simple obstruction but involves a complex pathological interaction among the left ventricle (LV), aortic valve (AV), and peripheral vasculature (1). The most typical form of AS is normal flow high-gradient aortic stenosis (NFHGAS), which is characterized by patients with a normal left ventricular ejection fraction (EF), normal flow (left ventricular stro...
Source: Journal of the American College of Cardiology - February 16, 2015 Category: Cardiology Source Type: research

Systemic Vascular Load in Calcific Degenerative Aortic Valve Stenosis Insight From Percutaneous Valve Replacement
This study sought to characterize the interaction between valvular and vascular functions in patients with AS by using transcatheter aortic valve replacement (TAVR) as a clinical model of isolated intervention.MethodsAortic pressure and flow were measured simultaneously using high-fidelity sensors in 23 patients (mean 79 ± 7 years of age) before and after TAVR. Blood pressure and clinical response were registered at 6-month follow-up.ResultsSystolic and pulse arterial pressures, as well as indices of vascular function (vascular resistance, aortic input impedance, compliance, and arterial elastance), were significantly mo...
Source: Journal of the American College of Cardiology - February 2, 2015 Category: Cardiology Source Type: research

Management of Paradoxical Low-Flow, Low-Gradient Aortic Stenosis Need for an Integrated Approach, Including Assessment of Symptoms, Hypertension, and Stenosis Severity ∗
In 2007, we reported that a substantial proportion of patients with severe aortic stenosis may have a low flow (LF) (i.e., reduced stroke volume), and thus, often have a low transvalvular pressure gradient (LG), despite a preserved left ventricular ejection fraction (LVEF) (1). The 2014 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines (2) classified this “paradoxical” LF/LG entity as a D3 stage of aortic stenosis, which is defined as an aortic valve area (AVA) of 
Source: Journal of the American College of Cardiology - January 5, 2015 Category: Cardiology Source Type: research

Low-Gradient, Low-Flow Severe Aortic Stenosis With Preserved Left Ventricular Ejection Fraction Characteristics, Outcome, and Implications for Surgery
ConclusionsIn this study, the outcome of severe LG/LF aortic stenosis with preserved EF was similar to that of mild-to-moderate aortic stenosis and was not favorably influenced by aortic surgery. Further research is needed to better understand the natural history and the progression of LG/LF aortic stenosis.
Source: Journal of the American College of Cardiology - January 5, 2015 Category: Cardiology Source Type: research

New Transcatheter Aortic Valve Prosthesis Sets a New Standard ∗
When Cribier et al. (1) first described transcatheter aortic valve replacement (TAVR) for aortic stenosis (AS) in 2002, few envisioned the current widespread utilization of this novel technique. Initial randomized studies provided evidence for efficacy in patients not suitable for open surgical aortic valve replacement (2,3). Subsequent studies demonstrated noninferiority (4) and then superiority (5) to surgery for high-risk patients. Nonetheless, limitations of TAVR, particularly vascular complications, stroke, and paravalvular leaks (PVL) resulting in aortic regurgitation (AR), have combined to restrict TAVR to patients...
Source: Journal of the American College of Cardiology - November 24, 2014 Category: Cardiology Source Type: research

Multicenter Evaluation of a Next-Generation Balloon-Expandable Transcatheter Aortic Valve
ConclusionsThis third-generation device addresses major deficiencies of earlier valves in terms of ease of use, accuracy of positioning, and paravalvular sealing. The rates of mortality and stroke with transfemoral access are among the lowest reported and support further evaluation as an alternative to open surgery in intermediate-risk patients. (Safety and Performance Study of the Edwards SAPIEN 3 Transcatheter Heart Valve [SAPIEN3]; NCT01808287)
Source: Journal of the American College of Cardiology - November 24, 2014 Category: Cardiology Source Type: research

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