Cassandra J. Ramm

Transcatheter versus surgical aortic valve replacement in intermediate risk patients: a meta-analysis

BACKGROUND Transcatheter aortic valve replacement (TAVR) has been approved in patients with high or prohibited surgical risk for surgery for treatment of severe symptomatic aortic stenosis. Prospective studies examining the benefits of TAVR in intermediate risk patients are ongoing. Other smaller studies including lower risk patients have been conducted, but further meta-analysis of these studies is required to draw more broad comparisons. METHODS A Medline search was conducted using standard methodology to search for clinical trials and observational studies including intermediate risk patients. We limited our meta-analysis to studies matching patient populations by propensity scores or randomization and examined clinical outcomes between TAVR and surgical aortic valve replacement (SAVR). RESULTS Analysis of the TAVR and SAVR cohorts revealed no significant differences in the outcomes of 30-day [OR (95% CI): 0.85 (0.57, 1.26)] or 1-year mortality [OR (95% CI): 0.96 (0.75, 1.23)]. A trend towards benefit with TAVR was noted in terms of neurological events and myocardial infarction (MI) without statistical significance. A statistically significant decrease in risk of post-procedural acute renal failure in the TAVR group [OR (95% CI): 0.52 (0.27, 0.99)] was observed, but so was a significantly higher rate of pacemaker implantations for the TAVR group [OR (95% CI): 6.51 (3.23, 13.12)]. CONCLUSIONS We conclude that in intermediate risk patients undergoing aortic valve replacement, the risk of mortality, neurological outcomes, and MI do not appear to be significantly different between TAVR and SAVR. However, there appears to be a significant reduction in risk of acute renal failure at the expense of an increased risk of requiring a permanent pacemaker in low and intermediate risk patients undergoing TAVR compared to SAVR.

Transcatheter Versus Surgical Aortic Valve Replacement in Patients With Lower Surgical Risk Scores: A Systematic Review and Meta-Analysis of Early Outcomes

BACKGROUND The results from the PARTNER 2 trial showed the feasibility of transcatheter aortic valve replacement (TAVR) in intermediate surgical risk patients. Although low risk clinical trials will take time to conclude, some data has emerged comparing TAVR with surgical aortic valve replacement (SAVR) in lower risk patients. METHODS A Medline search was conducted using standard methodology to search for studies reporting results comparing TAVR and SAVR. Studies were included if the overall mean Society of Thoracic Surgeons Score was less than 4% (or equivalent Euroscore). A meta-analysis comparing the 30-day risk of clinical outcomes between TAVR and SAVR in the lower surgical risk population was conducted. RESULTS A total of four studies, including one clinical trial and three propensity-matched cohort studies met the inclusion criteria. Compared to SAVR, TAVR had a lower risk of 30-day mortality (RR 0.67, 95% CI 0.41, 1.10), stroke (RR 0.60, 95% CI 0.30, 1.22), bleeding complications (RR 0.51, 95% CI 0.40, 0.67) and acute kidney injury (RR 0.66, 95% CI 0.47, 0.94). However, a higher risk of vascular complications (RR 11.72, 95% CI 3.75, 36.64), moderate or severe paravalvular leak (RR 5.04, 95% CI 3.01, 8.43), and permanent pacemaker implantations (RR 4.62, 95% CI 2.63, 8.12) was noted for TAVR. CONCLUSION Among lower risk patients, TAVR and SAVR appear to be comparable in short term outcomes. Additional high quality studies among patients classified as low risk are needed to further explore the feasibility of TAVR in all surgical risk patients.

Application of a Multidisciplinary Enhanced Recovery After Surgery Pathway to Improve Patient Outcomes After Transcatheter Aortic Valve Implantation.

Enhanced recovery after surgery (ERAS) protocols have proven effective in a variety of surgical specialties. Published reports on these pathways within cardiac surgery and interventional cardiology are limited. Invasive aortic valve replacement procedures are increasingly being performed by hybrid groups of interventional cardiologists and surgeons through transcatheter aortic valve implantation (TAVI). The TAVI patient population is at a higher surgical risk compared with those undergoing surgical aortic valve replacement since they are older, frailer, and have significant co-morbidities which result in an increased risk of perioperative complications. ERAS protocols have the potential to help these patients undergoing TAVI procedures. In conclusion, we propose a TAVI ERAS protocol with a call-to-action for other centers to implement an ERAS protocol to improve hospital and cardiac outcomes.

Early transcatheter valve prosthesis degeneration and future ramifications

Transcatheter aortic valve replacement (TAVR) has become the treatment of choice for patients with severe, symptomatic aortic stenosis with prohibitive risk for valve replacement surgery (SAVR) and is now considered a favourable alternative to surgical management for patients considered to be high risk (1). Recently published results of the PARTNER 2 trial have demonstrated that TAVR is an acceptable treatment option for patients with intermediate surgical risk and may hold an advantage over surgery if feasible via transfemoral approach (2). As we continue to explore the possibility of TAVR for lower risk patients who are typically younger and good candidates for surgical therapy, the durability of the prosthesis becomes an important consideration. Bioprosthetic valve failure after surgical aortic valve replacement (SAVR) is well described and well investigated. Structural valve deterioration is the most common noted cause with incidence of <1%, 10–30%, and 20–50% at 1, 10 and 15 years respectively (3,4). A recent report highlighting concerns regarding the long-term durability of the early SAPIEN prosthesis has certainly compelled the structural heart community to take a step back and better evaluate the future of TAVR for patients at low surgical risk (5). Currently, clinical trials are recruiting patients in the United States to examine the efficacy of TAVR in low risk patients, both studying the Medtronic CoreValve Evolut R System (NCT02701283) and the Edwards S3 system (PARTNER 3 trial, NCT02675114).

Meta‐analysis of transfemoral TAVR versus surgical aortic valve replacement

In the recently concluded PARTNER 2 trial, TF‐TAVR cohort was shown to have lower risks of death or disabling strokes as compared to SAVR, whereas the outcomes with transthoracic TAVR were comparable with SAVR.

A heart team and multi-modality imaging approach to percutaneous closure of a post-myocardial infarction ventricular septal defect

Post-infarction ventricular septal defect (PI-VSD) is a devastating complication that carries a high mortality with or without surgical repair. Percutaneous closure is an attractive alternative in select patients though requires appropriate characterization of the PI-VSD as well as careful device and patient selection. We describe a multidisciplinary and multi-modality imaging approach to successful percutaneous closure of a PI-VSD.

General Anesthesia for Transcatheter Aortic Valve Replacement: Total Intravenous Anesthesia is Associated with Less Delirium as Compared to Volatile Agent Technique

OBJECTIVE Investigate the effect of volatile anesthesia versus total intravenous anesthesia on the incidence of postoperative delirium and length of stay in patients undergoing transcatheter aortic valve replacement under general anesthesia. DESIGN Retrospective study. SETTING Single institution, academic medical center. PARTICIPANTS Adult patients who underwent transcatheter aortic valve replacement under general anesthesia between November 2014 and February 2017. INTERVENTIONS This study was not an interventional study. MEASUREMENTS AND MAIN RESULTS Electronic medical records were reviewed for intraoperative maintenance anesthetic technique, hospital and intensive care unit length of stay, 30-day mortality, and documentation of delirium. Delirium was defined as either 1) positive Confusion Assessment Method for the Intensive Care Unit score or 2) documentation of delirium or confusion by the care team within 2 days of surgery. Overall, 116 patients were included and 84 (72%) received a total intravenous anesthesia technique. Twenty-three patients (20%) had postoperative delirium. The odds of delirium were lower in patients undergoing transcatheter aortic valve replacement with total intravenous anesthesia, compared with volatile anesthesia, even after adjusting for procedure approach (odds ratio 0.22, 95% confidence interval 0.06, 0.79, p = 0.02). No significant difference in hospital or intensive care unit length of stay was seen after adjusting for procedural characteristics. CONCLUSIONS While postoperative delirium is a complex and multifactorial problem, the type of general anesthetic maintenance may contribute to the incidence of postoperative delirium in patients undergoing transcatheter aortic valve replacement, and total intravenous anesthesia may be an attractive alternative to volatile-based general anesthesia maintenance.

Evaluating Health of Emerging Economies Through the Eyes of Heart Valve Disease in the Transcatheter Era

China and India are the 2 fastest growing major world economies. However, they suffer from great differences in health policies, demographics, and rates of population growth. Whereas China has seen a steep decline in rheumatic heart disease (RHD) and a rise in life expectancy, India continues to suffer from a significant burden of RHD due to insufficient distribution of economic prosperity to health care, denser population, and ineffective application of World Health Organization RHD prevention guidelines. As China faces the burden of the worlds largest geriatric population, focus has shifted to calcific aortic stenosis for which it prepares by expansions in the field of transcatheter aortic valve replacement. Conversely, India has a younger population and a lower average life expectancy. Therefore, focus in India has still not shifted to calcific aortic stenosis as a major cause of morbidity and mortality as RHD continues to constitute the bulk of valvular heart disease.