scholarly journals Atrial Fibrillation Is Associated With Mortality in Intermediate Surgical Risk Patients With Severe Aortic Stenosis: Analyses From the PARTNER 2A and PARTNER S3i Trials

2021 ◽  
Author(s):  
Michael I. Brener ◽  
Isaac George ◽  
Ioanna Kosmidou ◽  
Tamim Nazif ◽  
Zixuan Zhang ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Aortic Stenosis ◽  
Severe Aortic Stenosis ◽  
Surgical Aortic Valve Replacement ◽  
Surgical Risk ◽  
All Cause Mortality ◽  
Risk Patients ◽  
Transcatheter Valve ◽  
The Impact

Background The impact of atrial fibrillation (AF) in intermediate surgical risk patients with severe aortic stenosis who undergo either transcatheter or surgical aortic valve replacement (AVR) is not well established. Methods and Results Data were assessed in 2663 patients from the PARTNER (Placement of Aortic Transcatheter Valve) 2A or S3i trials. Analyses grouped patients into 3 categories according to their baseline and discharge rhythms (ie, sinus rhythm [SR]/SR, SR/AF, or AF/AF). Among patients with transcatheter AVR (n=1867), 79.2% had SR/SR, 17.6% had AF/AF, and 3.2% had SR/AF. Among patients with surgical AVR (n=796), 71.7% had SR/SR, 14.1% had AF/AF, and 14.2% had SR/AF. Patients with transcatheter AVR in AF at discharge had increased 2‐year mortality (SR/AF versus SR/SR; hazard ratio [HR], 2.73; 95% CI, 1.68–4.44; P <0.0001; AF/AF versus SR/SR; HR, 1.56; 95% CI, 1.16–2.09; P =0.003); patients with SR/AF also experienced increased 2‐year mortality relative to patients with AF/AF (HR, 1.77; 95% CI, 1.04–3.00; P =0.03). For patients with surgicalAVR, the presence of AF at discharge was also associated with increased 2‐year mortality (SR/AF versus SR/SR; HR, 1.93; 95% CI, 1.25–2.96; P =0.002; and AF/AF versus SR/SR; HR, 1.67; 95% CI, 1.06–2.63; P =0.027). Rehospitalization and persistent advanced heart failure symptoms were also more common among patients with transcatheter AVR and surgical AVR discharged in AF, and major bleeding was more common in the transcatheter AVR cohort. Conclusions The presence of AF at discharge in patients with intermediate surgical risk aortic stenosis was associated with worse outcomes—especially in patients with baseline SR—including increased all‐cause mortality at 2‐year follow‐up. Registration URL: https://www.clinicaltrials.gov ; Unique identifiers: NCT01314313 and NCT03222128.

scholarly journals Mortality in low-risk patients with aortic stenosis undergoing transcatheter or surgical aortic valve replacement: a reconstructed individual patient data meta-analysis

2020 ◽  
Vol 31 (5) ◽  
pp. 587-594
Author(s):  
Mevlüt Çelik ◽  
Milan M Milojevic ◽  
Andras P Durko ◽  
Frans B S Oei ◽  
Ad J J C Bogers ◽  
...  
Keyword(s):  
Data Analysis ◽  
Aortic Stenosis ◽  
Individual Patient Data ◽  
Severe Aortic Stenosis ◽  
Mortality Rates ◽  
Patient Data ◽  
Low Risk ◽  
All Cause Mortality ◽  
Risk Patients

Abstract OBJECTIVES Although the standard of care for patients with severe aortic stenosis at low-surgical risk has included surgical aortic valve replacement (SAVR) since the mid-1960s, many clinical studies have investigated whether transcatheter aortic valve implantation (TAVI) can be a better approach in these patients. As no individual study has been performed to detect the difference in mortality between these 2 treatment strategies, we did a reconstructive individual patient data analysis to study the long-term difference in all-cause mortality. METHODS Randomized clinical trials and propensity score-matched studies that included low-risk adult patients with severe aortic stenosis undergoing either SAVR or TAVI and with reports on the mortality rates during the follow-up period were considered. The primary outcome was all-cause mortality of up to 5 years. RESULTS In the reconstructed individual patient data analysis, there was no statistically significant difference in all-cause mortality between TAVI and SAVR at 5 years of follow-up [30.7% vs 21.4%, hazard ratio (HR) 1.19, 95% confidence interval (CI) 0.96–1.48; P = 0.104]. However, landmark analyses in patients surviving up to 1 year of follow-up showed significantly higher all-cause mortality at 5 years of follow-up (27.5% vs 17.3%, HR 1.77, 95% CI 1.29–2.43; P &lt; 0.001) in patients undergoing TAVI compared to patients undergoing SAVR, respectively. CONCLUSIONS This reconstructed individual patient data analysis in low-risk patients with severe aortic stenosis demonstrates that the 5-year all-cause mortality rates are higher after TAVI than after SAVR, driven by markedly higher mortality rates between 1 and 5 years of follow-up in the TAVI group. The present results call for caution in expanding the TAVI procedure as the treatment of choice for the majority of all low-risk patients until long-term data from contemporary randomized clinical trials are available.

scholarly journals Transcatheter aortic valve implantation vs. surgical aortic valve replacement for treatment of symptomatic severe aortic stenosis: an updated meta-analysis

2019 ◽  
Vol 40 (38) ◽  
pp. 3143-3153 ◽  
Author(s):  
George C M Siontis ◽  
Pavel Overtchouk ◽  
Thomas J Cahill ◽  
Thomas Modine ◽  
Bernard Prendergast ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Transcatheter Aortic Valve Implantation ◽  
Severe Aortic Stenosis ◽  
Surgical Aortic Valve Replacement ◽  
Surgical Risk ◽  
Transcatheter Aortic Valve ◽  
All Cause Mortality ◽  
Aortic Valve Implantation ◽  
Valve Implantation

Abstract Aims  Owing to new evidence from randomized controlled trials (RCTs) in low-risk patients with severe aortic stenosis, we compared the collective safety and efficacy of transcatheter aortic valve implantation (TAVI) vs. surgical aortic valve replacement (SAVR) across the entire spectrum of surgical risk patients. Methods and results  The meta-analysis is registered with PROSPERO (CRD42016037273). We identified RCTs comparing TAVI with SAVR in patients with severe aortic stenosis reporting at different follow-up periods. We extracted trial, patient, intervention, and outcome characteristics following predefined criteria. The primary outcome was all-cause mortality up to 2 years for the main analysis. Seven trials that randomly assigned 8020 participants to TAVI (4014 patients) and SAVR (4006 patients) were included. The combined mean STS score in the TAVI arm was 9.4%, 5.1%, and 2.0% for high-, intermediate-, and low surgical risk trials, respectively. Transcatheter aortic valve implantation was associated with a significant reduction of all-cause mortality compared to SAVR {hazard ratio [HR] 0.88 [95% confidence interval (CI) 0.78–0.99], P = 0.030}; an effect that was consistent across the entire spectrum of surgical risk (P-for-interaction = 0.410) and irrespective of type of transcatheter heart valve (THV) system (P-for-interaction = 0.674). Transcatheter aortic valve implantation resulted in lower risk of strokes [HR 0.81 (95% CI 0.68–0.98), P = 0.028]. Surgical aortic valve replacement was associated with a lower risk of major vascular complications [HR 1.99 (95% CI 1.34–2.93), P = 0.001] and permanent pacemaker implantations [HR 2.27 (95% CI 1.47–3.64), P < 0.001] compared to TAVI. Conclusion  Compared with SAVR, TAVI is associated with reduction in all-cause mortality and stroke up to 2 years irrespective of baseline surgical risk and type of THV system.

Abstract 15617: Atrial Fibrillation Prevalence, Anticoagulation Practices, and Long-term Outcomes for Patients Discharged With Atrial Fibrillation After Tavr: Results From the Partner 2a and S3i Trials

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Michael I Brener ◽  
Susheel K Kodali ◽  
Tamim Nazif ◽  
Zixuan Zhang ◽  
Ioanna Kosmidou ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Aortic Valve ◽  
Aortic Valve Replacement ◽  
Long Term Outcomes ◽  
Surgical Aortic Valve Replacement ◽  
Surgical Risk ◽  
Risk Patients ◽  
Short And Long Term

Background: Atrial fibrillation (AF) is associated with worse outcomes, including increased mortality, in patients undergoing transcatheter and surgical aortic valve replacement (TAVR/SAVR). Objective: To assess: (i) the short- and long-term prevalence of AF in intermediate surgical risk patients undergoing TAVR and SAVR; (ii) determine rates of anticoagulation (AC) prescription in patients with AF; and (iii) evaluate differences in outcomes. Methods: A total of 2663 patients from the PARTNER 2A and S3i trials were categorized into 3 groups by their baseline and discharge rhythm (sinus rhythm [SR] vs. AF): SR/SR, SR/AF, and AF/AF. Patients were followed for up to two years. Results: Table 1 presents the frequency of AF, AC prescription, and outcomes at 30-days, 1-year, and 2-year follow-up. SR/AF TAVR and SAVR patients continued to manifest relatively high rates of AF at each follow-up point. SR/AF patients were prescribed AC less often than AF/AF patients. For TAVR patients, the development of and discharge in AF was associated with increased bleeding (OR 1.59, 95% CI 1.11-2.26, p=0.01, SR/AF vs. AF/AF) and mortality (OR 1.77, 95% CI 1.04-3.00, p=0.03, SR/AF vs. AF/AF), but not stroke. There were no significant differences in outcomes in the SAVR patients. Conclusion: TAVR/SAVR patients who developed and were discharged in AF (SR/AF) were often in AF at 30 days, 1 year, and 2 year follow-up. While anticoagulation rates were lower in the SR/AF vs. the AF/AF group, bleeding and mortality, but not stroke, rates were higher for TAVR SR/AF vs. AF/AF patients. Further analyses of the associations between AF development, anticoagulation use, and outcomes in TAVR and SAVR patients are warranted.

Comparison of Aortic Gradient and Ventricular Mass after Valve Replacement for Aortic Stenosis with Rapid Deployment, Sutureless, and Conventional Bioprostheses

Cardiology ◽  
2021 ◽  
pp. 1-11
Author(s):  
Rubén Taboada-Martín ◽  
José María Arribas-Leal ◽  
María Asunción Esteve-Pastor ◽  
José Abellán Alemán ◽  
Francisco Marín ◽  
...  
Keyword(s):  
Aortic Stenosis ◽  
Severe Aortic Stenosis ◽  
Left Ventricular ◽  
Ventricular Mass ◽  
Risk Of Mortality ◽  
Echocardiographic Parameters ◽  
Rapid Deployment ◽  
The Impact ◽  
Peak Gradient

<b><i>Background:</i></b> The use of rapid deployment and sutureless aortic prostheses is increasing. Previous reports have shown promising results on haemodynamic performance and mortality rates. However, the impact of these bioprostheses on left ventricular mass (LVM) regression remains unknown. We decided to study the changes in remodelling and LVM regression in isolated severe aortic stenosis treated with conventional or Perceval® or Intuity® valves. <b><i>Method and Results:</i></b> From January 2011 to January 2016, 324 bioprostheses were implanted in our centre. The collected characteristics were divided into 3 groups: conventional valves, Perceval®, and Intuity®, and they were analysed after 12 months. There were 183 conventional valves (56%), 72 Perceval® (22%), and 69 Intuity® (21.2%). The statistical analysis showed significant differences in transprosthetic postoperative peak gradient (23 [18–29] mm Hg vs. 21 [16–29] mm Hg and 18 [14–24] mm Hg, <i>p</i> &#x3c; 0.001), ventricular mass electrical criteria regression (Sokolow and Cornell products), and 1-year survival (90 vs. 93% and 97%, log rank <i>p</i> value = 0.04) in conventional, Perceval®, and Intuity® groups. <b><i>Conclusions:</i></b> We observed differences in haemodynamic, electrocardiographic, and echocardiographic parameters related to the different types of prosthesis. Patients with the Intuity® prosthesis had the highest reduction in peak aortic gradient and the higher ventricular mass regression. Besides, patients with the Intuity® prosthesis had less risk of mortality during follow-up than the other two groups. Further studies are needed to confirm these findings.

scholarly journals IMPULSE: the impact of gender on the presentation and management of aortic stenosis across Europe

Open Heart ◽  
2021 ◽  
Vol 8 (1) ◽  
pp. e001443
Author(s):  
Richard Paul Steeds ◽  
David Messika-Zeitoun ◽  
Jeetendra Thambyrajah ◽  
Antonio Serra ◽  
Eberhard Schulz ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Severe Aortic Stenosis ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Surgical Aortic Valve Replacement ◽  
Ventricular Ejection Fraction ◽  
Patient Profile ◽  
Transcatheter Aortic Valve ◽  
The Impact

AimsThere is an increasing awareness of gender-related differences in patients with severe aortic stenosis and their outcomes after surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI).MethodsData from the IMPULSE registry were analysed. Patients with severe aortic stenosis (AS) were enrolled between March 2015 and April 2017 and stratified by gender. A subgroup analysis was performed to assess the impact of age.ResultsOverall, 2171 patients were enrolled, and 48.0% were female. Women were characterised by a higher rate of renal impairment (31.7 vs 23.3%; p<0.001), were at higher surgical risk (EuroSCORE II: 4.5 vs 3.6%; p=0.001) and more often in a critical preoperative state (7.0vs 4.2%; p=0.003). Men had an increased rate of previous cardiac surgery (9.4 vs 4.7%; p<0.001) and a reduced left ventricular ejection fraction (4.9 vs 1.3%; p<0.001). Concomitant mitral and tricuspid valve disease was substantially more common among women. Symptoms were highly prevalent in both women and men (83.6 vs 77.3%; p<0.001). AVR was planned in 1379 cases. Women were more frequently scheduled to undergo TAVI (49.3 vs 41.0%; p<0.001) and less frequently for SAVR (20.3 vs 27.5%; p<0.001).ConclusionsThe present data show that female patients with severe AS have a distinct patient profile and are managed in a different way to males. Gender-based differences in the management of patients with severe AS need to be taken into account more systematically to improve outcomes, especially for women.

Asymptomatic Severe Aortic Stenosis and Noncardiac Surgery

2020 ◽  
pp. 108925322096957
Author(s):  
Stephanie K. Whitener ◽  
Loren R. Francis ◽  
Jeffrey D. McMurray ◽  
George B. Whitener
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Aortic Valve Replacement ◽  
Valve Replacement ◽  
Severe Aortic Stenosis ◽  
Noncardiac Surgery ◽  
Surgical Aortic Valve Replacement ◽  
Unique Challenge ◽  
Surgical Risk ◽  
Increased Risk

The patient with severe asymptomatic aortic stenosis presenting for elective noncardiac surgery poses a unique challenge. These patients are not traditionally offered surgical aortic valve replacement or transcatheter aortic valve replacement given their lack of symptoms; however, they are at increased risk for postsurgical complications given the severity of their aortic stenosis. The decision to proceed with elective noncardiac surgery should be based on individual and surgical risk factors. However, severity of aortic stenosis is not accounted for in current surgical risk factor assessment scoring; therefore, extensive communication with patients and surgical teams is necessary to minimize a patient’s risk. A clear intraoperative plan should be designed to manage the unique hemodynamics of these patients, and a discussion should address postoperative placement.

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