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Rodighiero J, Alakhtar AM, Baker N, Zgheib A, de Varennes B, Lachapelle K, Cecere R, Ergina P, Tchervenkov C, Shum-Tim D, Martucci G, Piazza N, Afilalo J, Spaziano M. Outcomes in Patients Undergoing Surgical Aortic Valve Replacement With vs Without a Preoperative Heart Team Assessment. CJC Open 2022; 5:24-34. [PMID: 36700182 PMCID: PMC9869348 DOI: 10.1016/j.cjco.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 10/07/2022] [Indexed: 11/07/2022] Open
Abstract
Background This study sought to compare characteristics and outcomes of patients who underwent surgical aortic valve replacement (SAVR) after being referred to a heart team (HT), to those of patients referred directly for SAVR. Methods An analysis of patients who underwent SAVR from 2015 to 2020 was conducted. Patients were categorized into 3 groups, as follows: (i) H-HT: patients referred to the HT from 2015 to 2017 (historical cohort); (ii) C-HT: patients referred to the HT from 2018 to 2020 (contemporary cohort); and (iii) No-HT: patients referred directly to cardiac surgery from 2018 to 2020. Two subanalyses were performed: H-HT vs C-HT patients, and C-HT vs No-HT patients. The primary outcome was a composite of in-hospital mortality, prolonged intubation, reoperation, sternal wound infection, and stroke. Results This study consisted of 288 patients, distributed as follows: H-HT (n = 45); C-HT (n = 51); and No-HT (n = 192). The mean ages of H-HT, C-HT, and No-HT patients was 76.3 ± 6.9 years, 73.3 ± 7.6 years, and 69.6 ± 9.7 years, respectively (P = 0.0001). H-HT, C-HT, and No-HT patients had average Society of Thoracic Surgeons scores of 4.8 ± 2.2, 3.2 ± 1.6, and 4.2 ± 2 (P = 0.002), respectively. The composite outcome rate was more than 5 times higher among H-HT patients compared to that among the C-HT patients (20.0 vs 3.9%, P = 0.02), and was numerically higher in No-HT compared to C-HT patients (13.0 vs 3.9%, P = 0.07). Conclusions Referral to an HT appears to be primarily driven by higher chronological age rather than overall risk profile. Patients assessed by the HT prior to undergoing SAVR have a low incidence of complications, comparable to that among patients referred directly to cardiac surgery.
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Affiliation(s)
- Julia Rodighiero
- Division of Cardiology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Ali M. Alakhtar
- Division of Cardiac Surgery, McGill University Health Centre, Montreal, Quebec, Canada,Division of Surgery, Qassim University, Qassim, Kingdom of Saudi Arabia
| | - Nouf Baker
- Division of Cardiac Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Ali Zgheib
- Division of Cardiology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Benoit de Varennes
- Division of Cardiac Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Kevin Lachapelle
- Division of Cardiac Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Renzo Cecere
- Division of Cardiac Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Patrick Ergina
- Division of Cardiac Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Christo Tchervenkov
- Division of Cardiac Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Dominique Shum-Tim
- Division of Cardiac Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Giuseppe Martucci
- Division of Cardiology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Nicolo Piazza
- Division of Cardiology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Jonathan Afilalo
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Marco Spaziano
- Division of Cardiology, McGill University Health Centre, Montreal, Quebec, Canada,Corresponding author: Dr Marco Spaziano, Division of Cardiology, McGill University Health Centre, 1001 Decarie Blvd, Montreal, Quebec H4A 3J1, Canada. Tel.: +1-514-934-1934
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Zhao PY, Wang YH, Liu RS, Zhu JH, Wu JY, Song B. The noninferiority of transcatheter aortic valve implantation compared to surgical aortic valve replacement for severe aortic disease: Evidence based on 16 randomized controlled trials. Medicine (Baltimore) 2021; 100:e26556. [PMID: 34260533 PMCID: PMC8284753 DOI: 10.1097/md.0000000000026556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 06/07/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Currently, transcatheter aortic valve implantation (TAVI) as an effective and convenient intervention has been adopted extensively for patients with severe aortic disease. However, the efficacy and safety of TAVI have not yet been well evaluated and its noninferiority compared with traditional surgical aortic valve replacement (sAVR) still lack sufficient evidence. This meta-analysis was designed to comprehensively compare the noninferiority of TAVI with sAVR for patients with severe aortic disease. METHODS A systematic search of PubMed, Embase, Cochrane Library, and Web of Science up to October 1, 2020 was conducted for relevant studies that comparing TAVI and sAVR in the treatment of severe aortic disease. The primary outcomes were early, midterm and long term mortality. The secondary outcomes included early complications and other late outcomes. Two reviewers assessed trial quality and extracted the data independently. All statistical analyzes were performed using the standard statistical procedures provided in Review Manager 5.2. RESULTS A total of 16 studies including 14394 patients were identified. There was no difference in 30-day, 1-year, 2-year, and 5-year all-cause or cardiovascular mortality as well as stroke between TAVI and sAVR. Regarding to the 30-day outcomes, compared with sAVR, TAVI experienced a significantly lower incidence of myocardial infarction (risk ratio [RR] 0.62; 95% confidence interval [CI] 0.40-0.97; 5441 pts), cardiogenic shock (RR 0.34; 95% CI 0.19-0.59; 1936 pts), acute kidney injury (AKI) > stage 2 (RR 0.37; 95% CI 0.25-0.54; 5371 pts), and new-onset atrial fibrillation (NOAF) (RR 0.29; 95% CI 0.24-0.35; 5371 pts) respectively, but higher incidence of permanent pacemaker implantation (RR 3.16; 95% CI 1.61-6.21; 5441 pts) and major vascular complications (RR 2.22; 95% CI 1.14-4.32; 5371 pts). Regarding to the 1- and 2-year outcomes, compared with sAVR, TAVI experienced a significantly lower incidence of NOAF, but higher incidence of neurological events, transient ischemic attacks (TIA), permanent pacemaker and major vascular complications respectively. Regarding to the 5-year outcomes, compared with sAVR, TAVI experienced a significantly lower incidence of NOAF, but higher incidence of TIA and reintervention respectively. CONCLUSIONS Our analysis shows that TAVI was equal to sAVR in early, midterm and long term mortality for patients with severe aortic disease. In addition, TAVI may be favorable in reducing the incidence of both early, midterm and long term NOAF. However, pooled results showed superiority of sAVR in reducing permanent pacemaker implantation, neurological events, TIA, major vascular complications and reintervention.
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Affiliation(s)
- Peng-Ying Zhao
- Department of Cardiovascular Surgery, Lanzhou University First Affiliated Hospital, Lanzhou, China
| | - Yong-Hong Wang
- Department of Cardiovascular Surgery, Qinghai University Affiliated Hospital, Xi’ning, China
- Medical College of Qinghai University, Qinghai University, Xi’ning, China
| | - Rui-Sheng Liu
- Department of Cardiovascular Surgery, Lanzhou University First Affiliated Hospital, Lanzhou, China
| | - Ji-Hai Zhu
- Department of Cardiovascular Surgery, Qinghai University Affiliated Hospital, Xi’ning, China
- Medical College of Qinghai University, Qinghai University, Xi’ning, China
| | - Jian-Ying Wu
- Department of Cardiovascular Surgery, Qinghai University Affiliated Hospital, Xi’ning, China
- Medical College of Qinghai University, Qinghai University, Xi’ning, China
| | - Bing Song
- Department of Cardiovascular Surgery, Lanzhou University First Affiliated Hospital, Lanzhou, China
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3
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Ding Y, Wan M, Zhang H, Wang C, Dai Z. Comparison of postprocedural new-onset atrial fibrillation between transcatheter and surgical aortic valve replacement: A systematic review and meta-analysis based on 16 randomized controlled trials. Medicine (Baltimore) 2021; 100:e26613. [PMID: 34260547 PMCID: PMC8284731 DOI: 10.1097/md.0000000000026613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 06/22/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Presently, transcatheter aortic valve replacement (TAVR) as an effective and convenient intervention has been adopted extensively for patients with severe aortic disease. However, after surgical aortic valve replacement (SAVR) and TAVR, the incidence of new-onset atrial fibrillation (NOAF) is prevalently found. This meta-analysis was designed to comprehensively compare the incidence of NOAF at different times after TAVR and SAVR for patients with severe aortic disease. METHODS A systematic search of PubMed, Embase, Cochrane Library, and Web of Science up to October 1, 2020 was conducted for relevant studies that comparing TAVR and SAVR in the treatment of severe aortic disease. The primary outcomes were the incidence of NOAF with early, midterm and long term follow-up. The secondary outcomes included permanent pacemaker (PM) implantation, myocardial infarction (MI), cardiogenic shock, as well as mortality and other complications. Two reviewers assessed trial quality and extracted the data independently. All statistical analyses were performed using the standard statistical procedures provided in Review Manager 5.2. RESULTS A total of 16 studies including 13,310 patients were identified. The pooled results indicated that, compared with SAVR, TAVR experienced a significantly lower incidence of 30-day/in-hospital, 1-year, 2-year, and 5-year NOAF, with pooled risk ratios (RRs) of 0.31 (95% confidence interval [CI] 0.23-0.41; 5725 pts), 0.30 (95% CI 0.24-0.39; 6321 pts), 0.48 (95% CI 0.38-0.61; 3441 pts), and 0.45 (95% CI 0.37-0.55; 2268 pts) respectively. In addition, TAVR showed lower incidence of MI (RR 0.62; 95% CI 0.40-0.97) and cardiogenic shock (RR 0.34; 95% CI 0.19-0.59), but higher incidence of permanent PM (RR 3.16; 95% CI 1.61-6.21) and major vascular complications (RR 2.22; 95% CI 1.14-4.32) at 30-day/in-hospital. At 1- and 2-year after procedure, compared with SAVR, TAVR experienced a significantly higher incidence of neurological events, transient ischemic attacks (TIA), permanent PM, and major vascular complications, respectively. At 5-year after procedure, compared with SAVR, TAVR experienced a significantly higher incidence of TIA and re-intervention respectively. There was no difference in 30-day, 1-year, 2-year, and 5-year all-cause or cardiovascular mortality as well as stroke between TAVR and SAVR. CONCLUSIONS Our analysis showed that TAVR was superior to SAVR in decreasing the both short and long term postprocedural NOAF. TAVR was equal to SAVR in early, midterm and long term mortality. In addition, TAVR showed lower incidence of 30-day/in-hospital MI and cardiogenic shock after procedure. However, pooled results showed that TAVR was inferior to SAVR in reducing permanent pacemaker implantation, neurological events, TIA, major vascular complications, and re-intervention.
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Affiliation(s)
| | - Minmin Wan
- Outpatient Department, Zhebei Mingzhou hospital, Huzhou, China
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Rossi PJ, Wood JC, Jim J. Concomitant transcarotid artery revascularization and transcatheter aortic valve replacement. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2020; 6:205-208. [PMID: 32322777 PMCID: PMC7162957 DOI: 10.1016/j.jvscit.2020.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 02/08/2020] [Indexed: 11/24/2022]
Abstract
Concomitant carotid artery disease and aortic valve disease is common. Whereas carotid stenosis does not appear to have an effect on outcomes of patients undergoing aortic valve replacement, the management of a patient with symptomatic carotid disease and severe aortic stenosis is challenging. The advent of minimally invasive endovascular techniques has provided less invasive and effective treatment options for these respective conditions. In this report, we describe two cases of patients successfully treated with concomitant transcatheter aortic valve replacement and transcarotid artery revascularization.
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Affiliation(s)
- Peter J Rossi
- Division of Vascular and Endovascular Surgery, Medical College of Wisconsin, Milwaukee, Wisc
| | - Jacob C Wood
- Division of Vascular and Endovascular Surgery, Medical College of Wisconsin, Milwaukee, Wisc
| | - Jeffrey Jim
- Section of Vascular Surgery, Washington University in St. Louis, St. Louis, Mo
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5
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Anderson RD, Gargus N, Randall MH. Editorial: The use of Fascia iliaca Block with Minimal Conscious Sedation in Transcatheter Aortic Valve Replacement: Advances in TAVR Anesthesia. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 21:602-603. [PMID: 32201210 DOI: 10.1016/j.carrev.2020.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 03/10/2020] [Indexed: 11/19/2022]
Affiliation(s)
- R David Anderson
- University of Florida, Division of Cardiovascular Medicine, 1329 SW 16th St., PO Box 100288, Gainesville, FL 32608, United States of America.
| | - Nathan Gargus
- University of Florida, Division of Cardiovascular Medicine, 1329 SW 16th St., PO Box 100288, Gainesville, FL 32608, United States of America
| | - Morgan H Randall
- University of Florida, Division of Cardiovascular Medicine, 1329 SW 16th St., PO Box 100288, Gainesville, FL 32608, United States of America
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Takagi H, Hari Y, Nakashima K, Kuno T, Ando T. Mortality after transcatheter versus surgical aortic valve replacement: an updated meta-analysis of randomised trials. Neth Heart J 2020; 28:320-333. [PMID: 32166571 PMCID: PMC7270388 DOI: 10.1007/s12471-020-01378-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background To determine whether transcatheter aortic valve implantation (TAVI) improves early (30-day) and midterm (1-year) mortality compared with surgical aortic valve replacement (SAVR), we performed an updated meta-analysis of all the currently available randomised controlled trials (RCTs). Methods To identify all RCTs providing both 30-day and 1‑year mortality after TAVI versus SAVR, PubMed and ClinicalTrials.gov were searched up to and including July 2019. A risk difference (RD) and its 95% confidence interval were generated using data of prespecified outcomes in both the TAVI and SAVR groups. Study-specific estimates were pooled using inverse variance-weighted averages of RDs in the random-effects model. Results We identified seven eligible high-quality RCTs including a total of 7631 as-treated patients. Pooled analyses demonstrated significantly lower 30-day (RD −0.60%; p = 0.046) and 1‑year all-cause mortality (RD −1.12%; p = 0.03) after TAVI than after SAVR. No funnel plot asymmetry was detected for 30-day and 1‑year mortality. Meta-regression analyses indicated that RDs of 30-day and 1‑year mortality between TAVI and SAVR were not modulated by mean Society of Thoracic Surgeons Predicted Risk of Mortality score. Bleeding complications at 30 days and 1 year and stage 2/3 acute kidney injury at 30 days were significantly less frequent after TAVI than after SAVR, whereas major vascular complications and new permanent pacemaker implantation at 30 days and 1 year were significantly more frequent after TAVI than after SAVR. Conclusion The best evidence from the present meta-analysis of all the currently available RCTs suggests that TAVI may reduce 30-day and 1‑year all-cause mortality compared with SAVR. Electronic supplementary material The online version of this article (10.1007/s12471-020-01378-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- H Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan.
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Japan.
| | - Y Hari
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - K Nakashima
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - T Kuno
- Department of Medicine, Mount Sinai Beth Israel Medical Center, New York, NY, USA
| | - T Ando
- Division of Interventional Cardiology, Department of Cardiology, New York Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
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7
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Vipparthy SC, Ravi V, Avula S, Kambhatla S, Mahmood M, Kabour A, Ali SS, Barzallo M, Mungee S. Meta-Analysis of Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement in Patients With Low Surgical Risk. Am J Cardiol 2020; 125:459-468. [PMID: 31784051 DOI: 10.1016/j.amjcard.2019.10.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 10/28/2019] [Accepted: 10/30/2019] [Indexed: 11/29/2022]
Abstract
Transcatheter aortic valve implantation (TAVI) is the current standard of care for patients with severe aortic stenosis who are at high risk for surgery. However, several recent studies have demonstrated the comparable safety and efficacy of TAVI in low-risk patients as well. We sought to pool the existing data to further assert its comparability. MEDLINE, Cochrane, and Embase databases were evaluated for relevant articles published from January 2005 to June 2019. Studies comparing outcomes of TAVI versus surgical aortic valve replacement in patients who are at low risk for surgery were included. Twelve studies (5 randomized controlled trials and 7 observational studies) totaling 27,956 patients were included. Follow-up ranged from 3 months to 5 years. Short-term all-cause mortality, short-term, and 1-year cardiac mortality were significantly lower in the TAVI group. One-year all-cause mortality, short-term, and 1-year stroke and myocardial infarction were similar in both groups. Rate of acute kidney injury and new-onset atrial fibrillation were lower in the TAVI group, whereas permanent pacemaker implantation and major vascular complications were higher in the TAVI group. Subgroup analysis of randomized controlled trials showed significantly lower 1-year all-cause mortality in the TAVI group. In conclusion, in severe aortic stenosis patients at low surgical risk, TAVI when compared with surgical aortic valve replacement, demonstrated a lower rate of short-term all-cause mortality, short-term, and 1-year cardiac mortality and similar in terms of 1-year all-cause mortality. TAVI is emerging as a safe and efficacious alternative for low surgical risk patients.
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Affiliation(s)
| | | | | | | | | | | | | | - Marco Barzallo
- OSF St. Francis Medical Center, UICOMP, Peoria, Illinois
| | - Sudhir Mungee
- OSF St. Francis Medical Center, UICOMP, Peoria, Illinois
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8
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Kundu A, Sardar P, Malhotra R, Qureshi WT, Kakouros N. Cardiovascular Outcomes with Transcatheter vs. Surgical Aortic Valve Replacement in Low-Risk Patients: An Updated Meta-Analysis of Randomized Controlled Trials. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2019; 21:453-460. [PMID: 31669113 DOI: 10.1016/j.carrev.2019.08.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 08/11/2019] [Accepted: 08/12/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND TAVR is an established treatment option in high and intermediate-risk patients with severe AS. There is less data regarding the efficacy of TAVR in low-risk patients. This meta-analysis evaluated efficacy and safety outcomes of transcatheter aortic valve replacement (TAVR) in comparison to surgical aortic valve replacement (SAVR) in low-risk patients with severe aortic stenosis (AS). METHODS Databases were searched for randomized controlled trials (RCTs) that compared TAVR with SAVR for the treatment of low-risk patients with severe AS. We calculated pooled odds ratios (ORs) and 95% confidence intervals (CIs) using the random-effects model. RESULTS The final analysis included 2953 patients from 5 studies. Compared to SAVR, TAVR was associated with similar mid-term mortality [OR 0.67; 95% CI 0.37-1.21; p = 0.18], as well as similar short-term mortality [OR 0.51; 95% CI 0.24-1.11; p = 0.09]. Randomization to TAVR was associated with a reduced risk of developing acute kidney injury [OR 0.26; 95% CI 0.13-0.52; p < 0.001], short-term major bleeding [OR 0.27; 95% CI 0.12-0.60; p < 0.001] and new-onset atrial fibrillation [OR 0.17; 95% CI 0.14-0.21; p < 0.001]. However, TAVR was associated with a higher risk of requiring permanent pacemaker implantation [OR 4.25; 95% CI 1.86-9.73; p < 0.001]. There was no significant difference in the risk of myocardial infarction, stroke, endocarditis or aortic valve re-intervention between the two groups. CONCLUSIONS Our meta-analysis showed that TAVR has similar clinical efficacy to SAVR, with a more favorable safety profile, in patients with severe AS who are at low-surgical risk.
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Affiliation(s)
- Amartya Kundu
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, MA, United States.
| | - Partha Sardar
- Division of Cardiology, Brown University, Rhode Island Hospital, Providence, RI, United States
| | - Rohit Malhotra
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | - Waqas T Qureshi
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | - Nikolaos Kakouros
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, MA, United States
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9
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Dowling C, Kondapally Seshasai SR, Firoozi S, Brecker SJ. Transcatheter aortic valve replacement versus surgery for symptomatic severe aortic stenosis: A reconstructed individual patient data meta-analysis. Catheter Cardiovasc Interv 2019; 96:158-166. [PMID: 31566902 DOI: 10.1002/ccd.28504] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 08/07/2019] [Accepted: 09/05/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVES We wished to undertake a reconstructed individual patient data meta-analysis of randomized clinical trials comparing transcatheter aortic valve replacement (TAVR) and surgery for patients with severe symptomatic aortic stenosis. BACKGROUND TAVR and surgery are both well-established methods for treating patients with symptomatic severe aortic stenosis who are at low, intermediate, and high risk for surgery. METHODS Data were identified by searches of Medline, Embase, CENTRAL and ClinicalTrials.gov for all randomized clinical trials, which compared TAVR and surgery that had published at least 1 year of follow-up. Individual patient data were reconstructed from Kaplan-Meier curves. RESULTS A total of 7,770 patients from seven randomized clinical trials were included in this meta-analysis. At 1 year, TAVR was associated with a lower risk of death from any cause (hazard ratio [HR], 0.85, 95% confidence interval [CI], 0.73-0.98; p = .03), disabling stroke (HR, 0.71; 95% CI, 0.54-0.93; p = .01) and the composite end point of death or disabling stroke (HR, 0.79; 95% CI, 0.67-0.92; p = .002). Significant interactions were found for access suitability, with TAVR associated with a lower risk of these end points in patients suitable for transfemoral access. TAVR was associated with a lower risk of periprocedural events, whereas the risk of late events was similar between TAVR and surgery. CONCLUSIONS At 1 year, TAVR was associated with a lower risk of death, disabling stroke and the composite end point, when compared with surgery. These associations were strongest within the subgroup of patients in whom transfemoral access was feasible.
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Affiliation(s)
- Cameron Dowling
- Cardiology Clinical Academic Group, St. George's, University of London and St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Sreenivasa Rao Kondapally Seshasai
- Cardiology Clinical Academic Group, St. George's, University of London and St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Sami Firoozi
- Cardiology Clinical Academic Group, St. George's, University of London and St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Stephen J Brecker
- Cardiology Clinical Academic Group, St. George's, University of London and St. George's University Hospitals NHS Foundation Trust, London, UK
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10
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Khan MM, Lanctôt KL, Fremes SE, Wijeysundera HC, Radhakrishnan S, Gallagher D, Gandell D, Brenkel MC, Hazan EL, Docteur NG, Herrmann N. The value of screening for cognition, depression, and frailty in patients referred for TAVI. Clin Interv Aging 2019; 14:841-848. [PMID: 31190770 PMCID: PMC6512610 DOI: 10.2147/cia.s201615] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 03/19/2019] [Indexed: 12/18/2022] Open
Abstract
Background: Current surgical risk assessment tools fall short of appreciating geriatric risk factors including cognitive deficits, depressive, and frailty symptoms that may worsen outcomes post-transcatheter aortic valve implantation (TAVI). This study hypothesized that a screening tool, SMARTIE, would improve detection of these risks pre-TAVI, and thus be predictive of postoperative delirium (POD) and 30-day mortality post-TAVI. Design: Prospective observational cohort study, using a historical cohort for comparison. Participants: A total of 234 patients (age: 82.2±6.7 years, 59.4% male) were included. Half were screened using SMARTIE. Methods: The SMARTIE cohort was assessed for cognitive deficits and depressive symptoms using the Mini-Cog test and PHQ-2, respectively. Measures of frailty included activities of daily living inventory, the Timed Up and Go test and grip strength. For the pre-SMARTIE cohort, we extracted cognitive deficits, depression and frailty symptoms from clinic charts. The incidence of POD and 30-day mortality were recorded. Bivariate chi-square analysis or t-tests were used to report associations between SMARTIE and pre-SMARTIE groups. Multivariable logistic regression models were employed to identify independent predictors of POD and 30-day mortality. Results: More patients were identified with cognitive deficits (χ2=11.73, p=0.001), depressive symptoms (χ2=8.15, p=0.004), and physical frailty (χ2=5.73, p=0.017) using SMARTIE. Cognitive deficits were an independent predictor of POD (OR: 8.4, p<0.01) and 30-day mortality (OR: 4.04, p=0.03). Conclusion: This study emphasized the value of screening for geriatric risk factors prior to TAVI by demonstrating that screening increased identification of at-risk patients. It also confirmed findings that cognitive deficits are predictive of POD and mortality following TAVI.
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Affiliation(s)
- Maisha M Khan
- Neuropsychopharmacology Research Group, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Krista L Lanctôt
- Neuropsychopharmacology Research Group, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
- Department of Psychiatry, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario, Canada
| | - Stephen E Fremes
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Sam Radhakrishnan
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Damien Gallagher
- Department of Psychiatry, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario, Canada
| | - Dov Gandell
- Department of Geriatric Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Megan C Brenkel
- Neuropsychopharmacology Research Group, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Elias L Hazan
- Neuropsychopharmacology Research Group, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Natalia G Docteur
- Neuropsychopharmacology Research Group, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Nathan Herrmann
- Neuropsychopharmacology Research Group, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Department of Psychiatry, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario, Canada
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Martín Gutiérrez E, Martínez Comendador JM, Gualis Cardona J, Maiorano P, Castillo Pardo L, Cuellas Ramón C, Fernández Vázquez F, Castaño Ruiz M. Implante valvular aórtico transcatéter frente a sustitución valvular aórtica en pacientes de riesgo quirúrgico intermedio. Revisión bibliográfica y metaanálisis. CIRUGIA CARDIOVASCULAR 2018. [DOI: 10.1016/j.circv.2018.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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12
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Schymik G, Varsami C, Bramlage P, Conzelmann LO, Würth A, Luik A, Schröfel H, Tzamalis P. Two-Year Outcomes of Transcatheter Compared With Surgical Aortic Valve Replacement in "Minimal-Risk" Patients Lacking EuroSCORE Co-morbidities (from the TAVIK Registry). Am J Cardiol 2018; 122:149-155. [PMID: 29861048 DOI: 10.1016/j.amjcard.2018.02.053] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 02/16/2018] [Accepted: 02/26/2018] [Indexed: 12/20/2022]
Abstract
We aimed to compare the outcomes of transcatheter aortic valve implantation (TAVI) with surgical aortic valve replacement (SAVR) in an elderly but nonfrail, minimally co-morbid population. Although data comparing these 2 procedures in intermediate- and low-risk patients are mounting, no distinction has been made between co-morbidity and age/gender as driving forces for surgical risk. Patients undergoing isolated TAVI or SAVR between May 2008 and March 2015 were documented. Data for 225 patients (TAVI 132, SAVR 93) aged ≥75 and <86 years and fulfilling minimal-risk criteria were analyzed. Patients who underwent TAVI were older (80.7 vs 77.4 years, p <0.0001) and had a higher mean Society of Thoracic Surgeons score (2.16% vs 1.72%, p <0.0001). Mild prosthetic valve regurgitation (odds ratio [OR] 4.9, 95% confidence interval [CI] 3.34 to 7.20) was more likely after TAVI, as were renal complications (predominantly stage I acute kidney injury; OR 2.86, 95% CI 1.79 to 4.55) and new pacemaker implantation (OR 3.33, 95% CI 1.76 to 6.26) at 30 days; however, life-threatening bleeding (OR 0.58, 95% CI 0.36 to 0.93) and reintervention for bleeding (OR 0.03, 95% CI 0.01 to 0.13) were less likely. Survival was comparable between groups at 30 days (99.2% vs 100%, p = 1.0) and 1 year (96.2% vs 96.8%, OR 0.85, 95% CI 0.20 to 3.63, p = 0.823), but it was poorer for patients who underwent TAVI at 2 years (OR 0.31, 95% CI 0.16 to 0.61). In conclusion, the short-term outcomes of TAVI in elderly, low-risk, minimally co-morbid patients appear to be similar to those of SAVR, with access-specific complications. Although these results point toward the potential for more liberal use of TAVI in minimal-risk patients, poorer midterm survival remains a concern, requiring further exploration.
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Ghosh R, Marom G, Rotman O, Slepian MJ, Prabhakar S, Horner M, Bluestein D. Comparative Fluid-Structure Interaction Analysis of Polymeric Transcatheter and Surgical Aortic Valves' Hemodynamics and Structural Mechanics. J Biomech Eng 2018; 140:2686528. [PMID: 30029207 DOI: 10.1115/1.4040600] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Indexed: 02/28/2024]
Abstract
Transcatheter aortic valve replacement (TAVR) has emerged as an effective alternative to conventional surgical aortic valve replacement (SAVR) in high-risk elderly patients with calcified aortic valve disease. All currently FDA-approved TAVR devices use tissue valves that were adapted to but not specifically designed for TAVR use. Emerging clinical evidence indicates that these valves may get damaged during crimping and deployment- leading to valvular calcification, thrombotic complications, and limited durability. This impedes the expected expansion of TAVR to lower-risk and younger patients. Viable polymeric valves have the potential to overcome such limitations. We have developed a polymeric SAVR valve, which was optimized to reduce leaflet stresses and offer a thromboresistance profile similar to that of a tissue valve. This study compares the polymeric SAVR valve's hemodynamic performance and mechanical stresses to a new version of the valve- specifically designed for TAVR. Fluid-structure interaction (FSI) models were utilized and the valves' hemodynamics, flexural stresses, strains, orifice area, and wall shear stresses were compared. The TAVR valve had 42% larger opening area and 27% higher flow rate versus the SAVR valve, while wall shear stress distribution and mechanical stress magnitudes were of the same order, demonstrating the enhanced performance of the TAVR valve prototype. The TAVR valve FSI simulation and Vivitro pulse duplicator experiments were compared in terms of the leaflets' kinematics and the effective orifice area. The numerical methodology presented can be further used as a predictive tool for valve design optimization for enhanced hemodynamics and durability.
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Affiliation(s)
- Ram Ghosh
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY 11794-8151, USA
| | - Gil Marom
- School of Mechanical Engineering, Faculty of Engineering, Tel Aviv University, Tel Aviv 6997801, Israel; Biomedical Engineering Department, Stony Brook University, Stony Brook 11794, NY, USA
| | - Oren Rotman
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY 11794-8151, USA
| | - Marvin J Slepian
- Department of Biomedical Engineering and Department of Medicine, Sarver Heart Center, University of Arizona, Tucson, AZ 85724, USA
| | - Saurabh Prabhakar
- ANSYS Fluent India Pvt Ltd., MIDC, Plot No. 34/1, Rajiv Gandhi IT Park, Hinjewadi, Pune 411057, India
| | - Marc Horner
- ANSYS, Inc., 1007 Church St, Suite 250, Evanston, IL 60201, USA
| | - Danny Bluestein
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY 11794-8151, USA
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Eggebrecht H, Bestehorn K, Rassaf T, Bestehorn M, Voigtländer T, Fleck E, Schächinger V, Schmermund A, Mehta RH. In-hospital outcomes after transcatheter or surgical aortic valve replacement in younger patients less than 75 years old: a propensity-matched comparison. EUROINTERVENTION 2018; 14:50-57. [DOI: 10.4244/eij-d-17-01051] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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15
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Takagi H, Mitta S, Ando T. Long-term survival after transcatheter versus surgical aortic valve replacement for aortic stenosis: A meta-analysis of observational comparative studies with a propensity-score analysis. Catheter Cardiovasc Interv 2018; 92:419-430. [DOI: 10.1002/ccd.27521] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 12/24/2017] [Accepted: 01/08/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Hisato Takagi
- Department of Cardiovascular Surgery; Shizuoka Medical Center; Shizuoka Japan
| | - Shohei Mitta
- Department of Cardiovascular Surgery; Shizuoka Medical Center; Shizuoka Japan
| | - Tomo Ando
- Department of Cardiology; Detroit Medical Center; Detroit Michigan
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