• SCAI TAVR Center
    Supported by:Medtronic

    March 2015 Journal Scan

    Presented by Kreton Mavromatis, MD, FSCAI and George Hanzel, MD, FSCAI

     

    Prosthetic valve endocarditis after transcatheter valve replacement: a systematic review.

    Amat-Santos IJ, Ribeiro HB, Urena M, Allende R, Houde C, Bédard E, Perron J, DeLarochellière R, Paradis JM, Dumont E, Doyle D, Mohammadi S, Côté M, San Roman JA, Rodés-Cabau J.
    JACC Cardiovasc Interv. 2015 Feb;8(2):334-46. doi: 10.1016/j.jcin.2014.09.013.

    • Authors' Conclusion: "Most cases of PVE post-TVR involved male patients, with a very high-risk profile (TAVR) or underlying stenotic conduit/valve (TPVR). Typical, but different, microorganisms of PVE were involved in one-half of the TAVR and TPVR cases. Most TPVR-PVE patients were managed surgically as opposed to TAVR patients, and the mortality rate was high, especially in the TAVR cohort."

    • Interpretation: In this review it is estimated that the rate of TAVR prosthetic valve endocarditis is < 1%. Patients who develop endocarditis are sicker (with high Euroscore) and have a higher incidence of diabetes, kidney disease, and immunosuppression. The majority of these patients are treated conservatively and only 41% underwent valve explantation. The in-hospital mortality rate is high at 34.4%. As more TAVR procedures are performed in the catheterization laboratory the maintenance of sterile technique is critical.

     

    Outcomes of Inoperable Symptomatic Aortic Stenosis Patients Not Undergoing Aortic Valve Replacement: Insight Into the Impact of Balloon Aortic Valvuloplasty From the PARTNER Trial (Placement of AoRtic TraNscathetER Valve Trial).

    Kapadia S, Stewart WJ, Anderson WN, Babaliaros V, Feldman T, Cohen DJ, Douglas PS, Makkar RR, Svensson LG, Webb JG, Wong SC, Brown DL, Miller DC, Moses JW, Smith CR, Leon MB, Tuzcu EM.
    JACC Cardiovasc Interv. 2015 Feb;8(2):324-33. doi: 10.1016/j.jcin.2014.08.015.

    • Authors' Conclusion: "BAV improves functional status and survival in the short term, but these benefits are not sustained. BAV for aortic stenosis patients who cannot undergo aortic valve replacement is a useful palliative therapy."

    • Interpretation: Several interesting conclusions can be drawn from this analysis. First, BAV improves quality of life and this benefit persists for approximately six months. Second, BAV improves mortality at three months but by six months mortality is similar between patients who undergo BAV and those who do not. So, if it is determined after BAV that a patient could benefit from TAVR or SAVR then definitive therapy should be performed promptly. Third, repeat BAV is associated with negligible hemodynamic gain and is unlikely to be of much benefit in most patients.

     

    Health Status After Transcatheter Aortic Valve Replacement in Patients at Extreme Surgical Risk: Results From the CoreValve U.S. Trial.

    Osnabrugge RL, Arnold SV, Reynolds MR, Magnuson EA, Wang K, Gaudiani VA, Stoler RC, Burdon TA, Kleiman N, Reardon MJ, Adams DH, Popma JJ, Cohen DJ; CoreValve U.S. Trial Investigators.
    JACC Cardiovasc Interv. 2015 Feb;8(2):315-23. doi: 10.1016/j.jcin.2014.08.016.

    • Authors' Conclusion: "Among patients with severe aortic stenosis, TAVR with a self-expanding bioprosthesis resulted in substantial improvements in both disease-specific and generic health-related quality of life, but there remained a large minority of patients who died or had very poor quality of life despite TAVR. Predictive models based on a combination of clinical factors as well as disability and frailty may provide insight into the optimal patient population for whom TAVR is beneficial." (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).

    • Interpretation: In the overall population of extreme risk or inoperable patients TAVR dramatically improves patients’ quantity and quality of life. However, in this analysis of the CoreValve US Trial 39% of patients either died or did not have a significant improvement in quality of life after TAVR. This is nearly identical to findings from the PARTNER IIB trial. Since a large minority of extreme risk patients have a poor outcome after TAVR it is imperative to develop risk models to aid in patient selection so TAVR can be offered in patients with a reasonable expectation for a good outcome but avoided in patients in whom TAVR may be futile.

     

    Temporal Trends in the Incidence and Prognosis of Aortic Stenosis: A Nationwide Study of the Swedish Population.

    Martinsson A, Li X, Andersson C, Nilsson J, Smith G, Sundquist K.
    Circulation. 2015 Feb 17 131:988-994: CIRCULATIONAHA.115.014846. [Epub ahead of print]

    • Authors' Conclusion: “Incidence and mortality rates in AS in Sweden declined between 1989 and 2009 to an extent similar to that observed for heart failure and acute myocardial infarction. These findings could suggest that improved risk factor control and cardiovascular therapy, combined with increased use of aortic valve replacement in the elderly and reduced perioperative mortality in aortic valve replacement, have translated into favorable effects for AS.”

    • Interpretation: It is assumed that with the aging of the population that the number of patients with AS will continue to grow. This study calls this assumption into question. Over a 20 year period the incidence of AS declined from 15.0 to 11.4 in men and 9.8 to 7.1 in women per 100,000. It is likley that the reduction in AS incidence resulted from more aggressive risk factor control. Additionally, the 1 and 3 year mortality rates dropped by approximately 40% over a 20 year period due to increased utilization of AVR and a reduction in post-operative mortality. This decrease in the incidence AS and improved survival in AS patients mirrors that recently noted with CHF and AMI.  

     

    Impact of classic and paradoxical low flow on survival after aortic valve replacement for severe aortic stenosis.

    Clavel MA, Berthelot-Richer M, Le Ven F, Capoulade R, Dahou A, Dumesnil JG, Mathieu P, Pibarot P.
    J Am Coll Cardiol. 2015 Feb 24;65(7):645-53. doi: 10.1016/j.jacc.2014.11.047.

    • Authors' Conclusion: “Patients with LEF or PLF AS have a higher operative risk, but pre-operative risk score accounted only for LEF and lower LVEF. Patients with LEF had the worst survival outcome, whereas patients with PLF and normal flow had similar survival rates after AVR. As a major predictor of perioperative mortality, SVi should be integrated in AS patients' pre-operative evaluation.”

    • Interpretation: Paradoxical low flow (PLF) is associated with increased perioperative surgical aortic valve replacement risk in addition to the conventional factors, and should be additionally considered when deciding between SAVR and TAVR. Interestingly, PLF is not associated with increased mortality after the perioperative period, supporting AVR in these patients.


    The prognostic value of acute and chronic troponin elevation after transcatheter aortic valve implantation.

    Sinning JM, Hammerstingl C, Schueler R, Neugebauer A, Keul S, Ghanem A, Mellert F, Schiller W, Müller C, Vasa-Nicotera M, Zur B, Welz A, Grube E, Nickenig G, Werner N.

    EuroIntervention. 2015 Feb 6. pii: 20140406-04. doi: 10.4244/EIJY15M02_02. [Epub ahead of print]

    • Authors' Conclusion: “Myocardial injury defined as ΔTroponin ≥15x URL after TAVI seems to be a procedure-related issue without impact on 30-day and one-year survival. However, monitoring of post-procedural troponin might be useful for prognostication after TAVI."

    • Interpretation: This study suggests that even relatively high troponin elevations (>15X) immediately post-transvascular TAVR are not predictive of outcomes if not associated with obvious coronary compromise or symptoms of myocardial infarction in revascularized patients. Whether this applies to patients with residual severe CAD, or patients with even higher troponin elevations, remains to be seen.


    Late cardiac death in patients undergoing transcatheter aortic valve replacement: incidence and predictors of advanced heart failure and sudden cardiac death.

    Urena M, Webb JG, Eltchaninoff H, Muñoz-García AJ, Bouleti C, Tamburino C, Nombela-Franco L, Nietlispach F, Moris C, Ruel M, Dager AE, Serra V, Cheema AN, Amat-Santos IJ, de Brito FS, Lemos PA, Abizaid A, Sarmento-Leite R, Ribeiro HB, Dumont E, Barbanti M, Durand E, Alonso Briales JH, Himbert D, Vahanian A, Immè S, Garcia E, Maisano F, Del Valle R, Benitez LM, García Del Blanco B, Gutiérrez H, Perin MA, Siqueira D, Bernardi G, Philippon F, Rodés-Cabau J.
    J Am Coll Cardiol. 2015 Feb 10;65(5):437-48. doi: 10.1016/j.jacc.2014.11.027.

    • Authors' Conclusion: “Advanced HF and SCD accounted for two-thirds of cardiac deaths in patients after TAVR. Potentially modifiable or treatable factors leading to increased risk of mortality for HF and SCD were identified. Future studies should determine whether targeting these factors decreases the risk of cardiac death."

    • Interpretation: Four specific therapeutic strategies may reduce cardiac death post-TAVR: 1) seeking alternatives to the transapical approach in patients at risk of advanced HF not suitable for transfemoral access; 2) further treatment of residual moderate or severe AR (especially if acute increase vs. baseline); 3) pacemaker implantation in patients with new-onset, persistent LBBB (particularly in the presence of QRS duration >160 ms); and 4) cardiac defibrillator implantation in patients with left ventricular dysfunction (particularly in the setting of new-onset, persistent LBBB). These strategies should be strongly considered in each individual patient until more data is available.


    Systemic vascular load in calcific degenerative aortic valve stenosis: insight from percutaneous valve replacement.

    Yotti R, Bermejo J, Gutiérrez-Ibañes E, Pérez Del Villar C, Mombiela T, Elízaga J, Benito Y, González-Mansilla A, Barrio A, Rodríguez-Pérez D, Martínez-Legazpi P, Fernández-Avilés F.
    J Am Coll Cardiol. 2015 Feb 10;65(5):423-33. doi: 10.1016/j.jacc.2014.10.067.

    • Authors' Conclusion: “Vascular function in calcific degenerative AS is conditioned by the upstream valvular obstruction that dampens forward and backward compression waves in the arterial tree. An increase in vascular load after TAVR limits the procedure's acute afterload relief.”

    • Interpretation: Acute hypertension should be aggressively treated post-TAVR, as it limits the unloading of the ventricle due to valve replacement and can limit clinical improvement.

    Impact of mitral regurgitation on clinical outcomes of patients with low-ejection fraction, low-gradient severe aortic stenosis undergoing transcatheter aortic valve implantation.

    O'Sullivan CJ, Stortecky S, Bütikofer A, Heg D, Zanchin T, Huber C, Pilgrim T, Praz F, Buellesfeld L, Khattab AA, Blöchlinger S, Carrel T, Meier B, Zbinden S, Wenaweser P, Windecker S.
    Circ Cardiovasc Interv. 2015 Feb;8(2):e001895. doi: 10.1161/CIRCINTERVENTIONS.114.001895.

    • Authors' Conclusion: “Moderate or severe MR is a strong independent predictor of late mortality in LEF-LG patients undergoing TAVI. However, LEF-LG patients assigned to medical therapy have a dismal prognosis independent of MR severity suggesting that TAVI should not be withheld from symptomatic patients with LEF-LG severe aortic stenosis even in the presence of moderate or severe MR.”

    • Interpretation: The best strategies to care for patients with severe AS and concomitant MR remain incompletely defined. However, this study suggests that TAVR is reasonable, with early consideration of further mitral valve treatment if mitral valve regurgitation improvement is not adequate.

     

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