Incidence, Predictive Factors, and Prognostic Value of New-Onset Atrial Fibrillation Following Transcatheter Aortic Valve Implantation

Common Risk Factors for Atrial Fibrillation After Transcatheter Aortic Valve Implantation: A Systematic Review from 2009 to 2024

Transcatheter Aortic Valve Implantation (TAVI) is an effective treatment for severe aortic stenosis in high-risk patients; however, atrial fibrillation (AF) is a common complication associated with the procedure. New-Onset Atrial Fibrillation (NOAF) after TAVI is linked to increased mortality and additional complications. This study aimed to evaluate the incidence of NOAF following TAVI and identify risk factors associated with mortality and the development of thromboembolic events. A systematic review of 18 studies was conducted using databases such as MEDLINE/PubMed, EMBASE, Web of Science, Scopus, Cochrane Library, Google Scholar, Wiley Online Library, SciELO, and Redalyc. No language restrictions were applied, and the search covered studies from 2009 to 2024. The follow-up period ranged from 48 h to 730 days, with a mean of 180 days. Early monitoring and management of AF are essential in patients undergoing TAVI. The incidence of NOAF ranged up to 29.04%, meaning about 29 out of every 100 patients were affected. AF rates varied between 7.2% and 37%, with an average of around 20. Standardizing anticoagulation strategies is important to reduce complications. Randomized studies are needed to evaluate the relationship between AF and post-TAVI mortality and to determine whether AF is a marker of higher risk or an independent factor in these patients.

Neurological Complications After Transcatheter Aortic Valve Replacement: A Review

Transcatheter aortic valve replacement (TAVR) has become the dominant procedural modality for aortic valve replacement in the United States. The reported rates of neurological complications in patients undergoing TAVR have changed over time and are dependent on diagnostic definitions and modalities. Most strokes after TAVR are likely embolic in origin, and the incidence of stroke has decreased over time. Studies have yielded conflicting results when comparing stroke rates between TAVR and surgical aortic valve replacement (SAVR), especially due to differences in diagnostic criteria and neurocognitive testing. In this narrative review, we summarize the available data on the incidence of stroke, delirium, and cognitive decline after TAVR and highlight potential areas in need of future research. We also discuss silent cerebral ischemic lesions (SCILs) and their association with a decline in postoperative neurocognitive status after TAVR. Finally, we describe that the risk of delirium and postoperative decline is increased when nonfemoral access routes are used, and we highlight the need for standardized imaging and valid, repeatable methodologies to assess cognitive changes after TAVR.

Machine Learning of Cardiac Anatomy and the Risk of New-Onset Atrial Fibrillation After TAVR

BACKGROUND

New-onset atrial fibrillation (NOAF) occurs in 5% to 15% of patients who undergo transfemoral transcatheter aortic valve replacement (TAVR). Cardiac imaging has been underutilized to predict NOAF following TAVR.

OBJECTIVES

The objective of this analysis was to compare and assess standard, manual echocardiographic and cardiac computed tomography (cCT) measurements as well as machine learning-derived cCT measurements of left atrial volume index and epicardial adipose tissue as risk factors for NOAF following TAVR.

METHODS

The study included 1,385 patients undergoing elective, transfemoral TAVR for severe, symptomatic aortic stenosis. Each patient had standard and machine learning-derived measurements of left atrial volume and epicardial adipose tissue from cardiac computed tomography. The outcome of interest was NOAF within 30 days following TAVR. We used a 2-step statistical model including random forest for variable importance ranking, followed by multivariable logistic regression for predictors of highest importance. Model discrimination was assessed by using the C-statistic to compare the performance of the models with and without imaging.

RESULTS

Forty-seven (5.0%) of 935 patients without pre-existing atrial fibrillation (AF) experienced NOAF. Patients with pre-existing AF had the largest left atrial volume index at 76.3 ± 28.6 cm3/m2 followed by NOAF at 68.1 ± 26.6 cm3/m2 and then no AF at 57.0 ± 21.7 cm3/m2 (P < 0.001). Multivariable regression identified the following risk factors in association with NOAF: left atrial volume index ≥76 cm2 (OR: 2.538 [95% CI: 1.165-5.531]; P = 0.0191), body mass index <22 kg/m2 (OR: 4.064 [95% CI: 1.500-11.008]; P = 0.0058), EATv (OR: 1.007 [95% CI: 1.000-1.014]; P = 0.043), aortic annulus area ≥659 mm2 (OR: 6.621 [95% CI: 1.849-23.708]; P = 0.004), and sinotubular junction diameter ≥35 mm (OR: 3.891 [95% CI: 1.040-14.552]; P = 0.0435). The C-statistic of the model was 0.737, compared with 0.646 in a model that excluded imaging variables.

CONCLUSIONS

Underlying cardiac structural differences derived from cardiac imaging may be useful in predicting NOAF following transfemoral TAVR, independent of other clinical risk factors.

Predictors, clinical impact, and management strategies for conduction abnormalities after transcatheter aortic valve replacement: an updated review

Transcatheter aortic valve replacement (TAVR) has increasingly become a safe, feasible, and widely accepted alternative surgical treatment for patients with severe symptomatic aortic stenosis. However, the incidence of conduction abnormalities associated with TAVR, including left bundle branch block (LBBB) and high-degree atrioventricular block (HAVB), remains high and is often correlated with risk factors such as the severity of valvular calcification, preexisting conditions in patients, and procedural factors. The existing research results on the impact of post-TAVR conduction abnormalities and permanent pacemaker (PPM) requirements on prognosis, including all-cause mortality and rehospitalization, remain contradictory, with varied management strategies for post-TAVR conduction system diseases across different institutions. This review integrates the latest research in the field, offering a comprehensive discussion of the mechanisms, risk factors, consequences, and management of post-TAVR conduction abnormalities. This study provides insights into optimizing patient prognosis and explores the potential of novel strategies, such as conduction system pacing, to minimize the risk of adverse clinical outcomes.

Causal association of calcific aortic valve stenosis and atrial fibrillation: a Mendelian randomization study

Calcific aortic valve stenosis (CAVS) is associated with an increased risk of atrial fibrillation (AF) in observational studies, but whether these associations are causal has not been determined. This study aimed to explore the potential causal relationship between CAVS and AF via Mendelian randomization (MR). Genetic variants from the genome-wide association study (GWAS) summary data of the European population for CAVS were used to investigate the association with AF. The inverse variance weighted (IVW) approach was used to obtain the primary causal inference, and several sensitivity analysis approaches, such as the MR‒Egger and weighted median (WM), were performed to assess the robustness of the results. A total of nineteen valid and independent genetic SNPs associated with CAVS were obtained from the GWAS database. Genetically predicted CAVS (OR: 1.105; 95% CI: 1.072-1.139; p = 8.60E-11) was associated with an increased risk of AF. Similar results were discovered in the sensitivity analyses by using MR Egger and weighted median approaches. An MR design was used to reduce confounding variables and the potential for reverse causality bias. The results provide genetic evidence that CAVS considerably increased the risk of AF.

Late Bleeding Events in Patients Undergoing Percutaneous Coronary Intervention in the Workup Pre-TAVR

BACKGROUND

In patients undergoing percutaneous coronary intervention (PCI) in the work-up pre-transcatheter aortic valve replacement (TAVR), the incidence and clinical impact of late bleeding events (LBEs) remain largely unknown.

OBJECTIVES

This study sought to determine the incidence, clinical characteristics, associated factors, and outcomes of LBEs in patients undergoing PCI in the work-up pre-TAVR.

METHODS

This was a multicenter study including 1,457 consecutive patients (mean age 81 ± 7 years; 41.5% women) who underwent TAVR and survived beyond 30 days. LBEs (>30 days post-TAVR) were defined according to the Valve Academic Research Consortium-2 criteria.

RESULTS

LBEs occurred in 116 (7.9%) patients after a median follow-up of 23 (IQR: 12-40) months. Late bleeding was minor, major, and life-threatening or disabling in 21 (18.1%), 63 (54.3%), and 32 (27.6%) patients, respectively. Periprocedural (<30 days post-TAVR) major bleeding and the combination of antiplatelet and anticoagulation therapy at discharge were independent factors associated with LBEs (P ≤ 0.02 for all). LBEs conveyed an increased mortality risk at 4-year follow-up compared with no bleeding (43.9% vs 36.0; P = 0.034). Also, LBE was identified as an independent predictor of all-cause mortality after TAVR (HR: 1.39; 95% CI: 1.05-1.83; P = 0.020).

CONCLUSIONS

In TAVR candidates with concomitant significant coronary artery disease requiring percutaneous treatment, LBEs after TAVR were frequent and associated with increased mortality. Combining antiplatelet and anticoagulation regimens and the occurrence of periprocedural bleeding determined an increased risk of LBEs. Preventive strategies should be pursued for preventing late bleeding after TAVR, and further studies are needed to provide more solid evidence on the most safe and effective antithrombotic regimen post-TAVR in this challenging group of patients.

Mechanical thrombectomy in ischemic stroke after cardiovascular procedures: a propensity-matched cohort analysis

BACKGROUND

Stroke after a cardiovascular procedure (CVP) is a devastating complication adversely affecting outcome. Mechanical thrombectomy (MT) has not been investigated systematically in this population.

OBJECTIVE

To carry out a retrospective study in patients undergoing MT for early stroke after CVP, aiming to further characterize this cohort of patients, and to evaluate the efficacy, safety, procedural characteristics, and outcome of MT.

METHODS

A single-center stroke registry of patients who received MT was analyzed. Baseline and procedural parameters, mortality, functional outcome, recanalization rates, and complications were evaluated. Propensity score matching was carried out, identifying a control cohort with non-periprocedural large vessel occlusion (LVO).

RESULTS

Overall 913 patients were included (mean age 73.0 (±13.0) years, 52.5% female, median National Institutes of Health Stroke Scale score 15 (10-19)). Eleven patients with a LVO after a recent (<30 days postoperatively) CVP were identified (n=3 transcatheter aortic valve and n=1 surgical aortic valve replacements (SAVR), n=3 coronary bypass grafting (CABG) surgeries, n=2 SAVR+CABG, and n=2 aortic surgeries). After matching, 8 patients in the CVP group were compared with 16 patients in the matched cohort. Comparable rates of reperfusion were achieved. Time from symptom onset to groin puncture (171.5 min (136.3, 178.3) vs 284.0 min (215.0, 490.5); p=0.039), as well as recanalization (195.0 min (146.0, 201.0) vs 419.0 min (274.0, 613.0); p=0.028) was faster in the CVP group. However, this was not reflected by an improved outcome (modified Rankin Scale score after 90 days: 5.5 (3.3, 6.0) vs 5.0 (4.0, 6.0), mortality after 90 days 50.0% vs 37.5%). Complications did not differ between the groups.

CONCLUSIONS

Use of MT for LVO stroke in patients after a recent CVP is a safe and efficient treatment in comparison with patients with a non-periprocedural LVO undergoing MT.

Management of Atrial Fibrillation Post Transcatheter Aortic Valve Implantation

Atrial fibrillation (AF) is a common complication in patients who underwent transcatheter aortic valve implantation. Some of these patients have preexisting AF as well. The management of these patients is complex, especially after the procedure, when there is a sudden change in hemodynamics. There are no established guidelines about the management of the patients who underwent transcatheter aortic valve replacement with preexisting or new-onset AF. This review article discusses the management of these patients with rate and rhythm control strategies with medications. This article also highlights the role of newer oral anticoagulation medications and left atrial occlusion devices to prevent stroke after the procedure. We will also discuss new advances in the care of this patient population to prevent the occurrence of AF after transcatheter aortic valve implantation. In conclusion, this article is a synopsis of both pharmacologic and device interventions for the management of AF in patients who underwent transcatheter aortic valve replacement.

Safety and efficacy of cerebral embolic protection devices for patients undergoing transcatheter aortic valve replacement: An updated meta-analysis

Background and Aims

Cerebral embolic protection (CEP) devices are employed to capture embolic debris and reduce the risk of stroke during transcatheter aortic valve replacement (TAVR). Evidence is mixed regarding the safety and efficacy of CEP. We aimed to summarize the safety and effectiveness of CEP use during TAVR.

Methods

Electronic databases, including PubMed, PubMed Central, Scopus, Cochrane Library, and Embase, were searched using relevant search terms for articles relating to CEP. All relevant data from 20 studies were extracted into a standardized form. Statistical analyses were performed using Revman 5.4. Odds ratio (OR) or mean differences (MDs) were used to estimate the desired outcome with a 95% confidence interval (CI).

Results

Twenty studies (eight randomized controlled trials [RCTs]) involving 210,871 patients (19,261 in the CEP group and 191,610 in TAVR without the CEP group) were included. The use of CEP was associated with a lower odds of 30-day mortality by 39% (OR: 0.61, 95% CI: 0.53-0.70) and stroke by 31% (OR: 0.69, 95% CI: 0.52-0.92). Comparing devices, benefit in terms of mortality and stroke was observed with the use of the Sentinel device (Boston Scientific), but not among other devices. No differences were observed in the outcomes of acute kidney injury, major or life-threatening bleeding events, or major vascular complications between groups. When only RCTs were included, there were no observed differences in the primary or secondary outcomes for CEP versus no CEP use during TAVR.

Conclusions

The totality of evidence suggests a net benefit for the use of CEP, weighted by studies in which the Sentinal device was used. However, given the RCT subanalysis, additional evidence is needed to identify patients at the highest risk of stroke for optimal decision-making.

Impact of Atrial Fibrillation on Patients Undergoing Transcatheter Aortic Valve Implantation (TAVI): The K-TAVI Registry

PURPOSE

The incidence and prognostic implications of atrial fibrillation (AF) in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI) are controversial, especially for Korean patients. Furthermore, the pattern of antithrombotic therapy for these patients is unknown. The present study sought to identify the impact of AF on Korean patients undergoing TAVI and demonstrate the status of antithrombotic therapy for these patients.

MATERIALS AND METHODS

A total of 660 patients who underwent TAVI for severe AS were recruited from the nationwide K-TAVI registry in Korea. The enrolled patients were stratified into sinus rhythm (SR) and AF groups. The primary endpoint was all-cause death at 1-year.

RESULTS

AF was recorded in 135 patients [pre-existing AF 108 (16.4%) and new-onset AF 27 (4.1%)]. The rate of all-cause death at 1 year was significantly higher in patients with AF than in those with SR [16.2% vs. 6.4%, adjusted hazard ratio (HR): 2.207, 95% confidence interval (CI): 1.182-4.120, p=0.013], regardless of the onset timing of AF. The rate of new pacemaker insertion at 1 year was also significantly higher in patients with AF than in those with SR (14.0% vs. 5.5%, adjusted HR: 3.137, 95%CI: 1.621-6.071, p=0.001). Among AF patients, substantial number of patients received the combination of multiple antithrombotic agents (77.8%), and the most common combination was that of aspirin and clopidogrel (38.1%).

CONCLUSION

AF was an independent predictor of 1-year mortality and new pacemaker insertion in Korean patients undergoing TAVI.

Cerebral Embolic Protection Devices: Current State of the Art

Transcatheter aortic valve replacement (TAVR) has become a first-line treatment for severe aortic stenosis with intermediate to high-risk population with its use increasingly expanding into younger and low-risk cohorts as well. Cerebrovascular events are one of the most serious consequential complications of TAVR, which increase morbidity and mortality. The most probable origin of such neurological events is embolic in nature and the majority occur in the acute phase after TAVR when embolic events are most frequent. Cerebral embolic protection devices have been designed to capture or deflect these emboli, reducing the risk of peri-procedural ischaemic events. They also carry the potential to diminish the burden of new silent ischemic lesions during TAVR. Our review explores different types of these device systems, their rationale, and the established clinical data.

Incidence and clinical impact of tachyarrhythmic events following transcatheter aortic valve replacement: A review

Transcatheter aortic valve replacement (TAVR) is well established for treating severe symptomatic aortic stenosis. Whereas broad information on the epidemiology, clinical implications, and management of bradyarrhythmias after TAVR is available, data about tachyarrhythmic events remain scarce. Despite the progressively lower risk profile of TAVR patients and the improvement in device characteristics and operator skills, approximately 10% of patients develop new-onset atrial fibrillation (NOAF) after TAVR. The proportion of patients in whom NOAF actually corresponds to previously undiagnosed silent atrial fibrillation (AF) has not been properly determined. The transapical approach, the need for pre- or post- balloon dilation, and the presence of periprocedural complications have been associated with a higher risk of NOAF. Older age, left atrial volume, or worse functional class are patient-derived risk factors shared with preprocedural AF. NOAF after TAVR has been associated with poorer survival and a higher incidence of cerebrovascular events. However, patient management differs markedly among different centers, especially with regard to anticoagulation in patients with short-duration AF episodes detected in the periprocedural setting and in cases of silent NOAF detected during continuous electrocardiographic (ECG) monitoring. Evidence about ventricular arrhythmias is even more scarce than for AF. Some case reports of sudden cardiac death after TAVR in patients with a pacemaker have identified ventricular tachycardia or ventricular fibrillation in device interrogation. TAVR has been shown to reduce the arrhythmic burden, but a significant proportion of patients (16%) present with complex premature ventricular complex arrhythmias within the year after TAVR. Whether these events are related to poorer outcomes is unknown. Continuous ECG monitoring after TAVR may help describe the frequency, risk factors, and prognostic implications of tachyarrhythmias in this population.

Edoxaban vs. Vitamin K Antagonist for Atrial Fibrillation After Transcatheter Aortic Valve Replacement in Japanese Patients - A Subanalysis of the ENVISAGE-TAVI AF Trial

BACKGROUND

Japanese patients undergoing transcatheter aortic valve replacement (TAVR) are often female and have a small body size, potentially impacting bleeding risk with antithrombotic therapy. Outcomes of direct oral anticoagulant use in these patients with atrial fibrillation (AF) need to be clarified.

METHODS AND RESULTS

This prespecified analysis included Japanese patients from ENVISAGE-TAVI AF, a prospective, randomized, open-label, adjudicator-masked trial that compared treatment with edoxaban and vitamin K antagonists (VKAs) in patients with AF after TAVR. The primary efficacy and safety outcomes were net adverse clinical events (NACE; composite of all-cause death, myocardial infarction, ischemic stroke, systemic embolic event, valve thrombosis, and International Society on Thrombosis and Haemostasis [ISTH]-defined major bleeding) and ISTH-defined major bleeding, respectively. Intention-to-treat (ITT) and on-treatment analyses were performed. Overall, 159 Japanese patients were enrolled (edoxaban group: 82, VKA group: 77) and followed for on average 483 days. Mean patient age was 83.8 years; 52.2% were female. In the ITT analysis, NACE rates were 10.9%/year with edoxaban and 12.5%/year with VKA (hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.38-1.90); major bleeding occurred in 8.9%/year and 7.3%/year, respectively (HR, 1.17; 95% CI, 0.45-3.05). In edoxaban- and VKA-treated patients, rates of ischemic stroke were 1.8%/year and 1.0%/year, respectively; fatal bleeding rates were 0.9%/year and 2.0 %/year. On-treatment results were similar to ITT.

CONCLUSIONS

In Japanese patients with AF after successful TAVR, edoxaban and VKA treatment have similar safety and efficacy profiles.

Antithrombotic Therapy After Transcatheter Aortic Valve Replacement: An Overview

Transcatheter aortic valve replacement (TAVR) is an established procedure for the treatment of patients with severe aortic stenosis. The optimal antithrombotic regimen following TAVR, currently unknown and inconsistently applied, is impacted by thromboembolic risk, frailty, bleeding risk, and comorbidities. There is a quickly growing body of literature examining the complex issues underlying antithrombotic regimens post-TAVR. This review provides an overview of thromboembolic and bleeding events following TAVR, summarizes the evidence regarding optimal antiplatelet and anticoagulant use post-TAVR, and highlights current challenges and future directions. By understanding appropriate indications and outcomes associated with different antithrombotic regimens post-TAVR, morbidity and mortality can be minimized in a generally frail and elderly patient population.

Assessment of New Onset Arrhythmias After Transcatheter Aortic Valve Implantation Using an Implantable Cardiac Monitor

Background

Transcatheter aortic valve implantation (TAVI) is associated with new onset brady- and tachyarrhythmias which may impact clinical outcome.

Aims

To investigate the true incidence of new onset arrhythmias within 12 months after TAVI using an implantable cardiac monitor (ICM).

Methods

One hundred patients undergoing TAVI received an ICM within 3 months before or up to 5 days after TAVI. Patients were followed-up for 12 months after discharge from TAVI for the occurrence of atrial fibrillation (AF), bradycardia (≤30 bpm), advanced atrioventricular (AV) block, sustained ventricular and supraventricular tachycardia.

Results

A previously undiagnosed arrhythmia was observed in 31 patients (31%) and comprised AF in 19 patients (19%), advanced AV block in 3 patients (3%), and sustained supraventricular and ventricular tachycardia in 10 (10%) and 2 patients (2%), respectively. Three patients had a clinical diagnosis of sick-sinus-syndrome. A permanent pacemaker (PPM) was implanted in six patients (6%). The prevalence of pre-existing AF was 28%, and 47% of the patients had AF at the end of the study period. AF burden was significantly higher in patients with pre-existing [26.7% (IQR 0.3%; 100%)] compared to patients with new-onset AF [0.0% (IQR 0.0%; 0.06%); p = 0.001]. Three patients died after TAVI without evidence of an arrhythmic cause according to the available ICM recordings.

Conclusions

Rhythm monitoring for 12 months after TAVI revealed new arrhythmias, mainly AF, in almost one third of patients. Atrial fibrillation burden was higher in patients with prevalent compared to incident AF. Selected patients may benefit from short-term remote monitoring.

Trial Registration

https://clinicaltrials.gov/: NCT02559011.

Stroke events after transcatheter aortic valve implantation: Temporal relationships and affected brain regions

BACKGROUND

Despite continuous improvements in transcatheter aortic valve implantation (TAVI), periprocedural strokes remain a devastating complication. Randomized controlled trials failed to demonstrate a reduction in clinically apparent strokes or mortality after TAVI due to cerebral embolic protection (CEP). To identify potential targets of CEP strategies during TAVI, we evaluated affected brain regions, and temporal patterns of stroke onset in a routine clinical sample.

METHODS AND RESULTS

A total of 3,164 consecutive patients treated with TAVI from 2008 to 2019 at a single center were screened for cerebrovascular events. Affected cerebral regions were determined according to clinical symptoms and brain imaging. Rates of disabling stroke and non-disabling stroke at 30 days were 2.2% and 1.4%, respectively. The frequency of all strokes decreased from 5.0% to 3.0% over time (P = .012). Patients with impaired left-ventricular function (OR 2.19), increased CHA2DS2-VASc (OR 1.39) and moderate/severe spontaneous echo contrast (OR 3.60) had a higher stroke risk. Acute symptom onset occurred during TAVI (19.4%), within 24 hours (40.3%) or later (25.0%); 98.3% of strokes were of ischemic origin. In intraprocedural strokes, 53.2% of lesions were found in locations considered protected by current CEP devices, and 37.5% of patients with intraprocedural strokes were exclusively affected in these areas. Baseline or procedural parameters were not associated with embolic distribution patterns.

CONCLUSIONS

Most strokes occurred early after TAVI - but not necessarily during the procedure - and affected multiple brain regions only partially protected by current CEP devices. Efficient prevention of cerebrovascular events may require strategies beyond the TAVI procedure to minimize stroke risk and additional randomized controlled trials will be required to clarify the role of CEP in efficient stroke prevention during TAVI.

Late-onset cerebral embolism after transcatheter aortic valve implantation under direct oral anticoagulant therapy

Ischemic stroke is a devastating complication of transcatheter aortic valve implantation (TAVI), mainly occurring in the early postoperative period. The risk of a transplanted heart valve (THV) thrombosis causing stroke may be underestimated in the late postoperative phase. We describe the case of a 92-year-old woman with delayed valve thrombosis causing stroke after TAVI, who developed recurrent strokes eight months after TAVI for severe aortic valve stenosis. Transesophageal echocardiography and cardiac computed tomography revealed a string-like thrombus attached to the implanted valve. With the administration of warfarin, the clot regressed, and the patient was discharged home without recurrence of stroke. Our case demonstrates the importance of THV thrombosis as an embolic source of stroke even in the late postoperative phase and provides a discussion on optimal antithrombotic therapy after TAVI.

Bioprosthetic valve failure. Comparative trial of two balloon-expandable transcatheter heart valve systems in intermediate-risk patients: a propensity score analysis

BACKGROUND

The comparative mid and long-term durability, including the rates of bioprosthetic valve failure (BVF) of the Sapien XT^® and Sapien 3^® transcatheter heart valve (THV) in patients with intermediate surgical risk has not been reported.

METHODS

Consecutive intermediate-risk patients with severe aortic stenosis from the Mexican registry of transcatheter aortic valve replacement (TAVR) with Sapien^® THVs were included. The primary endpoint was to compare the BVF rate between THVs at 2 years of follow-up. Secondary endpoints were comparisons of the composite of global mortality, cardiovascular mortality, and neurological events at 30 d and 24 months of follow-up.

RESULTS

During 2014-2019, 115 (60 Sapien XT^® and 55 Sapien 3^®) patients met the inclusion criteria in five medical centres. The mean age was 77.3 ± 8.4 years. The average Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) was 5.6 ± 2.9. There was no statistically significant difference between the groups in BVF rate. At 30 d, overall, cardiovascular and non-cardiovascular mortality was 4.3%, 2.6%, and 1.7%, respectively. Neurological events rate was 1.73%. The mean long-term follow-up was 25.3 ± 14.2 months with an overall mortality of 9.56% but lower for the Sapien 3^® group (15% vs. 3.6%, p=.037). The only independent predictor of composite mortality and neurological events that occurred in the long term was using a Sapien XT^® [OR 1.6, CI 95%, 1.0-24.9; p=.049].

CONCLUSIONS

The BVF rate at 25 months of follow-up was similar with the XT and S3 systems. During this follow-up period, the major composite events of death from any cause and neurological events were significantly lower with the S3 system.

Impact of new-onset versus pre-existing atrial fibrillation on outcomes after transcatheter aortic valve replacement/implantation

Patients with aortic stenosis who undergo transcatheter aortic valve replacement/transcatheter aortic valve implantation (TAVR/TAVI) experience a high incidence of pre-existing atrial fibrillation (pre-AF) and new-onset atrial fibrillation (NOAF) post-operatively. This systematic review and meta-analysis aimed to update current evidence concerning the incidence of 30-day mortality, stroke, acute kidney injury (AKI), length of stay (LOS), and early/late bleeding in patients with NOAF or pre-AF who undergo TAVR/TAVI. PubMed, Google Scholar, JSTOR, Cochrane Library, and Web of Science were searched for studies published between January 2012 and December 2020 reporting the association between NOAF/pre-AF and clinical complications after TAVR/TAVI. A total of 15 studies including 158,220 adult patients with TAVI/TAVR and NOAF or pre-AF were identified. Compared to patients in sinus rhythm, patients who developed NOAF had a higher risk of 30-day mortality, AKI, early bleeding events, extended LOS, and stroke after TAVR/TAVI (odds ratio [OR]: 3.18 [95% confidence interval [CI] 1.58, 6.40]) (OR: 3.83 [95% CI 1.18, 12.42]) (OR: 1.70 [95% CI 1.05, 2.74]) (OR: 13.96 [95% CI, 6.41, 30.40]) (OR: 2.51 [95% CI 1.59, 3.97], respectively). Compared to patients in sinus rhythm, patients with pre-AF had a higher risk of AKI and early bleeding episodes after TAVR/TAVI (OR: 2.43 [95% CI 1.10, 5.35]) (OR: 17.41 [95% CI 6.49, 46.68], respectively). Atrial fibrillation is associated with a higher risk of all primary and secondary outcomes. Specifically, NOAF but not pre-AF is associated with a higher risk of 30-day mortality, stroke, and extended LOS after TAVR/TAVI.

Futility in Transcatheter Aortic Valve Implantation: A Search for Clarity

Although transcatheter aortic valve implantation (TAVI) has revolutionised the landscape of treatment for aortic stenosis, there exists a cohort of patients where TAVI is deemed futile. Among the pivotal high-risk trials, one-third to half of patients either died or received no symptomatic benefit from the procedure at 1 year. Futility of TAVI results in the unnecessary exposure of risk for patients and inefficient resource utilisation for healthcare services. Several cardiac and extra-cardiac conditions and frailty increase the risk of mortality despite TAVI. Among the survivors, these comorbidities can inhibit improvements in symptoms and quality of life. However, certain conditions are reversible with TAVI (e.g. functional mitral regurgitation), attenuating the risk and improving outcomes. Quantification of disease severity, identification of reversible factors and a systematic evaluation of frailty can substantially improve risk stratification and outcomes. This review examines the contribution of pre-existing comorbidities towards futility in TAVI and suggests a systematic approach to guide patient evaluation.

Incidence of Early Atrial Fibrillation After Transcatheter versus Surgical Aortic Valve Replacement: A Meta-Analysis of Randomized Controlled Trials

Background

Post-operative atrial fibrillation (POAF) is common after aortic valve replacement (AVR) and is associated with worse outcomes. We performed a meta-analysis of randomized controlled trials comparing Surgical Aortic Valve Replacement (SAVR) and Transcatheter Aortic Valve Replacement (TAVR) for incidence of POAF at 30 days.

Methods

We searched databases from 1/1/1990 to 1/1/2020 for randomized studies comparing TAVR and SAVR. POAF was defined as either worsening or new-onset atrial fibrillation. Random effects model was used to estimate the risk of POAF with TAVR vs SAVR in all trials, and in subgroups (low, intermediate, high risk, and in self-expandable vs balloon expandable valves). Sensitivity analysis was performed including only studies reporting new-onset atrial fibrillation.

Results

Seven RCTs were identified that enrolled 7,934 patients (3,999 to TAVR and 3,935 to SAVR). The overall incidence of POAF was 9.7% after TAVR and 33.3% after SAVR. TAVR was associated with a lower risk of POAF compared with SAVR (OR 0.21 [0.18-0.24]; P < 0.0001). Compared with SAVR, TAVR was associated with a significantly lower risk of POAF in the high-risk cohort (OR 0.37 [0.27-0.49]; P < 0.0001), in the intermediate-risk cohort (OR 0.23 [0.19-0.28]; P < 0.0001), low-risk cohort (OR 0.13 [0.10-0.16]; P < 0.0001). Sensitivity analysis of 4 trials including only new-onset POAF showed similar summary estimates (OR 0.21, 95% CI [0.18-0.25]; P< 0.0001).

Conclusions

TAVR is associated with a significantly lower risk of post-operative atrial fibrillation compared with SAVR in all strata. Further studies are needed to identify the contribution of post-operative atrial fibrillation to the differences in clinical outcomes after TAVR and SAVR.

Outcomes of transcatheter aortic valve replacement in patients with and without atrial fibrillation: Insight from national inpatient sample

BACKGROUND

Atrial fibrillation (AF) is one of the most frequent rhythm disturbance encountered in the population in general. Our study aims to evaluate the in-hospital outcomes of TAVR with AF.

METHODS

We used National Inpatient Sample database from 2011 to 2018. Baseline characteristics and in-hospital outcomes were evaluated in TAVR based on AF status or not in both unmatched and propensity-matched cohorts.

RESULTS

A total of 215,938 patients underwent TAVR during our study period and out of these AF was encountered in 89,587 (41.5%) patients. AF patients undergoing TAVR had a higher mean age and had an increased burden of key co-morbidities in the unmatched cohort. With propensity matched 1:1 analysis, AF had higher mortality as compared to no-AF group (2.4% vs. 2.1%, p < 0.01). The rate of cardiogenic shock (2.9% vs 2.1%), respiratory complications (9.9% vs 8.2%), acute kidney injury (15.6% vs 12.0%), vascular complications (5.0% vs 4.7%), and blood transfusion (10.4% vs 8.6%) was higher in TAVR patients with AF. A lower proportion of patients had routine discharge to home for TAVR with AF (80.8% vs 74.4%). Cost of hospitalization (23,0171[SD, 20,5242] vs 210,608[28,4203]) and length of stay (5.7[SD, 11.8] vs 4.29[7.2] days) were considerably higher in patients undergoing TAVR with AF.

CONCLUSION

Patients undergoing TAVR with concomitant AF tended to have increased mortality, complications, length, and cost of stay compared to non-AF patients.

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

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.

Postoperative Atrial Fibrillation or Flutter Following Transcatheter or Surgical Aortic Valve Replacement: PARTNER 3 Trial

OBJECTIVES

The aim of this study was to assess the incidence and prognostic impact of early and late postoperative atrial fibrillation or flutter (POAF) in patients with severe aortic stenosis (AS) treated with transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR).

BACKGROUND

There is an ongoing controversy regarding the incidence, recurrence rate, and prognostic impact of early (in-hospital) POAF and late (postdischarge) POAF in patients with AS undergoing TAVR or SAVR.

METHODS

In the PARTNER (Placement of Aortic Transcatheter Valve) 3 trial, patients with severe AS at low surgical risk were randomized to TAVR or SAVR. Analyses were performed in the as-treated population excluding patients with preexistent atrial fibrillation or flutter.

RESULTS

Among 781 patients included in the analysis, early POAF occurred in 152 (19.5%) (18 of 415 [4.3%] and 134 of 366 [36.6%] following TAVR and SAVR, respectively). Following discharge, 58 new or recurrent late POAF events occurred within 1 year following the index procedure in 55 of 781 patients (7.0%). Early POAF was not an independent predictor of late POAF following discharge (odds ratio: 1.04; 95% CI: 0.52-2.08; P = 0.90). Following adjustment, early POAF was not an independent predictor of the composite outcome of death, stroke, or rehospitalization (hazard ratio: 1.10; 95% CI: 0.64-1.92; P = 0.72), whereas late POAF was associated with an increased adjusted risk for the composite outcome (hazard ratio: 8.90; 95% CI: 5.02-15.74; P < 0.0001), irrespective of treatment modality.

CONCLUSIONS

In the PARTNER 3 trial, early POAF was more frequent following SAVR compared with TAVR. Late POAF, but not early POAF, was significantly associated with worse outcomes at 2 years, irrespective of treatment modality.

Mechanical Thrombectomy Improves Outcome for Large Vessel Occlusion Stroke after Cardiac Surgery

BACKGROUND

Stroke is a feared complication of cardiac surgery. Modern clot-retrieval techniques provide effective treatment for large vessel occlusion (LVO) strokes. The purpose of this study was to 1) report the incidence of LVO stroke after cardiac surgery at a large academic center, and 2) describe outcomes of postoperative LVO strokes.

METHODS

All patients experiencing stroke within 30 days after undergoing cardiac surgery at a single center in 2014-2018 were reviewed. LVOs were identified through review of imaging and medical records, and their characteristics and clinical courses were examined.

RESULTS

Over the study period, 7,112 cardiac surgeries, including endovascular procedures, were performed. Acute ischemic stroke within 30 days after surgery was noted in 163 patients (2.3%). Among those with a stroke, 51/163 (31.3%) had a CTA or MRA, and 15/163 (9.2%) presented with LVO stroke. For all stroke patients, the median time from surgery to stroke was 2 days (interquartile range, IQR, 0-6 days), and for patients with LVO, the median time from surgery to stroke was 4 days (IQR 0-6 days). The overall rate of postoperative LVO was 0.2% (95% CI 0.1-0.4%), though only 6/15 received thrombectomy. LVO patients receiving thrombectomy were significantly more likely to return to independent living compared to those managed medically (n = 4/6, 66.6% for mechanical thrombectomy vs. n = 0/9, 0% for medical management, P = .01). Of the 9 patients who did not get thrombectomy, 6 may currently be candidates for thrombectomy given new expanded treatment windows.

CONCLUSIONS

The rate of LVO after cardiac surgery is low, though substantially elevated above the general population, and the majority do not receive thrombectomy currently. Patients receiving thrombectomy had improved neurologic outcomes compared to patients managed medically. Optimized postoperative care may increase the rate of LVO recognition, and cardiac surgery patients and their caregivers should be aware of this effective therapy.

Valve Academic Research Consortium 3: updated endpoint definitions for aortic valve clinical research

Aims 

The Valve Academic Research Consortium (VARC), founded in 2010, was intended to (i) identify appropriate clinical endpoints and (ii) standardize definitions of these endpoints for transcatheter and surgical aortic valve clinical trials. Rapid evolution of the field, including the emergence of new complications, expanding clinical indications, and novel therapy strategies have mandated further refinement and expansion of these definitions to ensure clinical relevance. This document provides an update of the most appropriate clinical endpoint definitions to be used in the conduct of transcatheter and surgical aortic valve clinical research.

Methods and results 

Several years after the publication of the VARC-2 manuscript, an in-person meeting was held involving over 50 independent clinical experts representing several professional societies, academic research organizations, the US Food and Drug Administration (FDA), and industry representatives to (i) evaluate utilization of VARC endpoint definitions in clinical research, (ii) discuss the scope of this focused update, and (iii) review and revise specific clinical endpoint definitions. A writing committee of independent experts was convened and subsequently met to further address outstanding issues. There were ongoing discussions with FDA and many experts to develop a new classification schema for bioprosthetic valve dysfunction and failure. Overall, this multi-disciplinary process has resulted in important recommendations for data reporting, clinical research methods, and updated endpoint definitions. New definitions or modifications of existing definitions are being proposed for repeat hospitalizations, access site-related complications, bleeding events, conduction disturbances, cardiac structural complications, and bioprosthetic valve dysfunction and failure (including valve leaflet thickening and thrombosis). A more granular 5-class grading scheme for paravalvular regurgitation (PVR) is being proposed to help refine the assessment of PVR. Finally, more specific recommendations on quality-of-life assessments have been included, which have been targeted to specific clinical study designs.

Conclusions 

Acknowledging the dynamic and evolving nature of less-invasive aortic valve therapies, further refinements of clinical research processes are required. The adoption of these updated and newly proposed VARC-3 endpoints and definitions will ensure homogenous event reporting, accurate adjudication, and appropriate comparisons of clinical research studies involving devices and new therapeutic strategies.

Valve Academic Research Consortium 3: Updated Endpoint Definitions for Aortic Valve Clinical Research

AIMS

The Valve Academic Research Consortium (VARC), founded in 2010, was intended to (i) identify appropriate clinical endpoints and (ii) standardize definitions of these endpoints for transcatheter and surgical aortic valve clinical trials. Rapid evolution of the field, including the emergence of new complications, expanding clinical indications, and novel therapy strategies have mandated further refinement and expansion of these definitions to ensure clinical relevance. This document provides an update of the most appropriate clinical endpoint definitions to be used in the conduct of transcatheter and surgical aortic valve clinical research.

METHODS AND RESULTS

Several years after the publication of the VARC-2 manuscript, an in-person meeting was held involving over 50 independent clinical experts representing several professional societies, academic research organizations, the US Food and Drug Administration (FDA), and industry representatives to (i) evaluate utilization of VARC endpoint definitions in clinical research, (ii) discuss the scope of this focused update, and (iii) review and revise specific clinical endpoint definitions. A writing committee of independent experts was convened and subsequently met to further address outstanding issues. There were ongoing discussions with FDA and many experts to develop a new classification schema for bioprosthetic valve dysfunction and failure. Overall, this multi-disciplinary process has resulted in important recommendations for data reporting, clinical research methods, and updated endpoint definitions. New definitions or modifications of existing definitions are being proposed for repeat hospitalizations, access site-related complications, bleeding events, conduction disturbances, cardiac structural complications, and bioprosthetic valve dysfunction and failure (including valve leaflet thickening and thrombosis). A more granular 5-class grading scheme for paravalvular regurgitation (PVR) is being proposed to help refine the assessment of PVR. Finally, more specific recommendations on quality-of-life assessments have been included, which have been targeted to specific clinical study designs.

CONCLUSIONS

Acknowledging the dynamic and evolving nature of less-invasive aortic valve therapies, further refinements of clinical research processes are required. The adoption of these updated and newly proposed VARC-3 endpoints and definitions will ensure homogenous event reporting, accurate adjudication, and appropriate comparisons of clinical research studies involving devices and new therapeutic strategies.

Minimally invasive surgery versus transcatheter aortic valve replacement: a systematic review and meta-analysis

Transcatheter aortic valve replacement (TAVR) has recently been approved for use in patients who are at intermediate and low surgical risk. Moreover, recent years have witnessed a renewed interest in minimally invasive aortic valve replacement (miAVR). The present meta-analysis compared the outcomes of TAVR and miAVR in the management of aortic stenosis (AS). We conducted an electronic search across six databases from 2002 (TAVR inception) to December 2019. Data from relevant studies regarding the clinical and length of hospitalisation outcomes were extracted and analysed using R software. We identified a total of 11 cohort studies, of which seven were matched/propensity matched. Our analysis demonstrated higher rates of midterm mortality (≥1 year) with TAVR (risk ratio (RR): 1.93, 95% CI: 1.16 to 3.22), but no significant differences with respect to 1 month mortality (RR: 1.00, 95% CI: 0.55 to 1.81), stroke (RR: 1.08, 95% CI: 0.40 to 2.87) and bleeding (RR: 1.45, 95% CI: 0.56 to 3.75) rates. Patients undergoing TAVR were more likely to experience paravalvular leakage (RR: 14.89, 95% CI: 6.89 to 32.16), yet less likely to suffer acute kidney injury (RR: 0.38, 95% CI: 0.21 to 0.69) compared with miAVR. The duration of hospitalisation was significantly longer in the miAVR group (mean difference: 1.92 (0.61 to 3.24)). Grading of Recommendations Assessment, Development and Evaluation assessment revealed ≤moderate quality of evidence in all outcomes. TAVR was associated with lower acute kidney injury rate and shorter length of hospitalisation, yet higher risks of midterm mortality and paravalvular leakage. Given the increasing adoption of both techniques, there is an urgent need for head-to-head randomised trials with adequate follow-up periods.

Management of atrial fibrillation after transcatheter aortic valve replacement: Challenges and therapeutic considerations

Atrial Fibrillation (AF) is very common among patients with severe aortic stenosis. Moreover, new onset AF (NOAF) is a frequent finding after Transcatheter Aortic Valve Replacement (TAVR). There is a significant impact of AF on outcomes in patients undergoing TAVR including mortality, thrombo-embolic and bleeding events. There is lack of clear evidence about the optimal management of AF in TAVR patients. This review aims to summarize the epidemiology, predictors, prognosis, therapeutic considerations and challenges in the management of AF in patients undergoing TAVR.

The effect of P wave indices on new onset atrial fibrillation after trans-catheter aortic valve replacement

OBJECTIVES

Data is scarce regarding the relation between P wave indices and new onset atrial fibrillation (NOAF) after trans-catheter aortic valve replacement (TAVR).

AIMS

The present study aimed to find out certain characteristics of P wave that may predict NOAF after TAVR procedure.

METHOD

Patients with severe calcific aortic stenosis who had undergone TAVR procedure between 2013 and 2019 in two centers were investigated. P wave abnormalities that have been resumed to reflect impaired atrial conduction; partial and advanced inter atrial block (IAB), P-wave terminal force in lead V1, P wave dispersion, reduced amplitude of P- wave in lead I, P wave peak time in D2 and V1 were evaluated on pre- procedural 12 derivation surface electrocardiography (ECG). The relationship between these parameters and incidence of NOAF during index hospitalization was evaluated.

RESULTS

A total of 227 consecutive patients (median age 79 [74-83]; 134 [59%] female) were included in the study. NOAF occurred in 46 (20.3%) patients. P wave duration, P wave dispersion, number of patients with partial and advanced IAB, left atrium diameter, STS score were higher in NOAF patients. Use of general anesthesia and history of prior open heart surgery were also more frequent in NOAF group. In multivariable logistic regression analysis; advanced IAB (OR 6.413 [2.555-16.095] p < 0.01), P wave dispersion (OR 3.544 [1.431-8.780] p = 0.006) and use of general anesthesia (OR 2.736 [1.225-6.109] p = 0.014) were independent predictors of NOAF.

CONCLUSION

Among P wave abnormalities evaluated on pre-procedural 12-derivation surface ECG, advanced IAB and P wave dispersion may predict NOAF after TAVR procedure.

Renal Injury in All-Comers After Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis

Background Acute kidney injury (AKI) following aortic valve replacement is associated with poor prognosis. Transcatheter aortic valve replacement (TAVR) is a novel strategy with a percutaneous approach and early recovery time. We conducted this meta-analysis to compare TAVR to surgical aortic valve replacement (SAVR) and their respective renal outcomes. Methods We searched for randomized controlled trials (RCTs) using MEDLINE, PUBMED, and Google Scholar databases from their inception till April 6, 2019, and included eight trials comparing TAVR to SAVR in cases that reported AKIs. Results We found a significant reduction in AKI after TAVR compared to SAVR at 30 days [n = 66 vs. n = 160, respectively; odds ratio (OR) = 0.38, 95% confidence interval (CI) = 0.28-0.51; p: <0.00001, I2 = 0%]. At one year, a trend towards reduced renal failure was noted in the TAVR arm compared to the SAVR arm (n = 74 vs. n = 129, respectively; OR = 0.57, 95% CI = 0.32-1.01; p = 0.05, I2 = 69%). Conclusion Based on our findings and analysis, we have concluded that TAVR is associated with significantly reduced renal injury at 30 days when compared to SAVR.

New Onset Atrial Fibrillation Following Transcatheter and Surgical Aortic Valve Replacement: A Systematic Review and Meta-Analysis

BACKGROUND

New-onset atrial fibrillation (NOAF) is a well-recognised, although variably reported complication following surgical aortic valve replacement (SAVR). Rates of NOAF following transcatheter aortic valve implantation (TAVI) seem to be notably less than SAVR, even though this population is typically older and of higher risk. The aim of this study was to determine the prevalence of NOAF in both these populations and associated postoperative outcomes.

METHODS

We conducted a systematic review and meta-analysis of studies reporting rates of NOAF post SAVR or TAVI, along with early postoperative outcomes. Twenty-five (25) studies with a total of 13,010 patients were included in the final analysis.

RESULTS

The prevalence of NOAF post SAVR was 0.4 (95% CI 0.36-0.44) and post TAVI 0.15 (95% CI 0.11-0.18). NOAF was associated with an increased risk of postoperative cerebrovascular accident (CVA) for SAVR and TAVI (RR 1.44 95% CI 1.01-2.06 and RR 2.24 95% CI 1.46-3.45 respectively). NOAF was associated with increased mortality in the TAVI group (RR 3.02 95% CI 1.55-5.9) but not the SAVR group (RR 1.00, 95% CI 0.54-1.84). Hospital length of stay was increased for both TAVI and SAVR patients with NOAF (MD 2.54 days, 95% CI 2.0-3.00) and (MD 1.64 days, 95% CI 0.04-3.24 respectively).

CONCLUSIONS

The prevalence of NOAF is significantly less following TAVI, as compared to SAVR. While NOAF is associated with increased risk of postoperative stroke for both groups, for TAVI alone NOAF confers increased risk of early mortality.

Antithrombotic Therapy After Transcatheter Aortic Valve Implantation

The development of transcatheter aortic valve implantation has represented one of the greatest advances in the cardiology field in recent years and has changed clinical practice for patients with aortic stenosis. Despite the continuous improvement in operators’ experience and techniques, and the development of new generation devices, thromboembolic and bleeding complications after transcatheter aortic valve implantation remain frequent, and are a major concern due to their negative impact on prognosis in this vulnerable population. In addition, the optimal antithrombotic regimen in this scenario is not known, and current recommendations are mostly empirical and not evidence based. The present review aims to provide an overview of the current status of knowledge, including relevant on-going randomised trials, on antithrombotic treatment strategies after transcatheter aortic valve implantation.

Novel Perspective for Antithrombotic Therapy in TAVI

While surgical aortic valve replacement (SAVR) was for years the only available treatment for symptomatic aortic stenosis, the introduction of transcatheter aortic valve implantation (TAVI) in 2002 and the improvement of its technical aspects in the following years, has holistically changed the synchronous therapeutic approach of aortic valve stenosis. Recent evidence has expanded the indication of TAVI from high to lower surgical risk populations with symptomatic aortic stenosis. The administration of antithrombotic therapy periprocedurally and its maintenance after a successful TAVI is crucial for the prevention of complications and affects postprocedural survival. Randomized controlled trials investigating the appropriate combination and the duration of antithrombotic treatment after TAVI are for the moment scarce. This review article sheds light on the underlying pathogenetic mechanisms contributing in periprocedural TAVI thrombotic complications and discuss the efficacy of current antithrombotic policies as evaluated in randomized trials.

The Predictors of Peri-Procedural and Sub-Acute Cerebrovascular Events Following TAVR from OCEAN-TAVI Registry

BACKGROUND

Cerebrovascular events (CVEs) are not uncommon complications of transcatheter aortic valve replacement (TAVR). Our study aimed to determine the predictors of peri-procedural and sub-acute CVEs following TAVR.

METHODS

Using the Japanese multicenter registry, we evaluated 1613 patients undergoing TAVR between October-2013 and July-2016. Occurrences of 24-hour and 1- to 30-day CVEs were evaluated to clarify the predictors of CVEs following TAVR.

RESULTS

The mean age was 84.4 years and mean Society of Thoracic Surgeons score was 8.3%. Overall 24-hour and 30-day CVE rates were 1.2% and 2.7%, respectively. A multivariate analysis demonstrated that independent predictor of 24-hour CVEs was index aortic valve area (iAVA) [adjusted OR (adjusted-OR), 0.001; 95% CI, 0.001-0.13; p = .005]. The receiver operator curve derived cut-off value of iAVA for the prediction of 24-hour CVEs was 0.40 cm²/m². In contrast, independent predictors of 1- to 30-day CVEs were paroxysmal atrial fibrillation (PAF; adjusted-OR, 3.35; 95% CI, 1.36-8.27; p = .009) and iAVA after TAVR (adjusted-OR, 0.11; 95% CI, 0.02-0.66; p = .02). Consequently, independent predictors of 30-day CVEs were prior stroke (adjusted-OR, 2.18; 95% CI, 1.07-4.45; p = .03), PAF (adjusted-OR, 2.18; 95% CI, 1.05-4.56; p = .04), and prior coronary artery disease (adjusted-OR, 1.88; 95% CI, 1.01-3.48; p = .05).

CONCLUSIONS

Within 24 h, small iAVA impacted the increased risk of CVEs, whereas PAF and iAVA after TAVR impacted the increased risk of 1- to 30-day CVEs following TAVR. The mechanism of CVEs might differ according to onset.

Antithrombotic Therapy for Percutaneous Cardiovascular Interventions: From Coronary Artery Disease to Structural Heart Interventions

Percutaneous cardiovascular interventions have changed dramatically in recent years, and the impetus given by the rapid implementation of novel techniques and devices have been mirrored by a refinement of antithrombotic strategies for secondary prevention, which have been supported by a significant burden of evidence from clinical studies. In the current manuscript, we aim to provide a comprehensive, yet pragmatic, revision of the current available evidence regarding antithrombotic strategies in the domain of percutaneous cardiovascular interventions. We revise the evidence regarding antithrombotic therapy for secondary prevention in coronary artery disease and stent implantation, the complex interrelation between antiplatelet and anticoagulant therapy in patients undergoing percutaneous coronary intervention with concomitant atrial fibrillation, and finally focus on the novel developments in the secondary prevention after structural heart disease intervention. A special focus on treatment individualization is included to emphasize risk and benefits of each therapeutic strategy.

Incidence, 30-day readmission rates and predictors of readmission after new onset atrial fibrillation who underwent transcatheter aortic valve replacement

INTRODUCTION

New onset Atrial Fibrillation (NOAF) is frequently seen post transcatheter aortic valve replacement (TAVR). NOAF in the setting of TAVR has also been recognized as predictor of worse outcomes, including higher readmission rates. Data assessing the effect and predictors of NOAF on 30-day readmission rates post TAVR is limited.

OBJECTIVE

To assess the incidence, 30-day readmission rate and predictors of NOAF in patients who underwent TAVR.

METHODS

Nationwide Readmissions Database was used to identify patients who developed NOAF post-TAVR between 2012 and 2015.

RESULTS

A total of 24,076 patients were included in this study, of which 54% were males, and the mean age was 82.4 ± 7.2. NOAF was developed in 10,847 (45%) patients. Overall readmission rates with NOAF was 19.7% and trend in the readmissions reduced during the course of the study (21.9% to 18.7%, P_trend < 0.001). Thirty-day readmission rate in patients who developed NOAF post-TAVR was significantly higher compared to TAVR patients without NOAF (OR 1.39; 95% CI, 1.28-1.51; p < 0.001). Similarly, rate of ischemic stroke was significantly higher among patients who developed NOAF (OR 1.22; 95% CI, 1.07-1.4; p = 0.004). Predictors of readmissions in NOAF group were mostly non-cardiac, and included age, and comorbidities with chronic liver disease, renal failure and chronic lung disease been the most common comorbidities, in that order.

CONCLUSIONS

Incidence of NOAF is associated with increased risk of readmissions and ischemic stroke. Future research should focus on interventions to prevent avoidable readmissions and associated morbidity and mortality.

Evaluation of the Incidence of New-Onset Atrial Fibrillation After Aortic Valve Replacement

IMPORTANCE

Data on the burden of new-onset atrial fibrillation after transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (AVR) is limited mostly to small series or post hoc analyses of clinical trials.

OBJECTIVES

To evaluate the incidence of new-onset atrial fibrillation and assess the incidence of in-hospital mortality associated with new-onset atrial fibrillation after TAVI and AVR.

DESIGN, SETTING, AND PARTICIPANTS

In this population-based observational study using the National Inpatient Sample and a validation cohort from the New York state inpatient database, the National Inpatient Sample was queried from January 1, 2012, to September 30, 2015, and the New York state inpatient database was queried from January 1, 2012, to December 31, 2014. Hospitalizations of adults undergoing TAVI or isolated AVR were examined. The incidence of in-hospital mortality across groups with new-onset atrial fibrillation was assessed in the National Inpatient Sample cohort using multivariable logistic regression modeling. Statistical analysis was conducted from August 20, 2018, to March 19, 2019.

MAIN OUTCOMES AND MEASURES

The primary outcome was the occurrence of new-onset atrial fibrillation, which was identified by excluding hospitalizations in which atrial fibrillation was present on admission. The secondary outcome was in-hospital mortality in TAVI and AVR hospitalizations with and without new-onset atrial fibrillation.

RESULTS

A total of 48 715 TAVI hospitalizations (47.4% women and 52.6% men; mean [SD] age, 81.3 [8.1] years; 82.3% white) and 122 765 AVR hospitalizations (39.0% women and 61.0% men; mean [SD] age, 67.8 [12.0] years; 78.0% white) were identified. New-onset atrial fibrillation occurred in 50.4% of TAVI hospitalizations and 50.1% of AVR hospitalizations. In the multivariable-adjusted model, TAVI and AVR hospitalizations with new-onset atrial fibrillation had higher odds of in-hospital mortality compared with hospitalizations without new-onset atrial fibrillation (TAVI: odds ratio, 1.57; 95% CI, 1.21-2.04; and AVR: odds ratio, 1.36; 95% CI, 1.08-1.70). The results were then confirmed with the New York state inpatient database, which contains a present on arrival indicator. The incidence of new-onset atrial fibrillation was 14.1% (244 of 1736 hospitalizations) after TAVI and 30.6% (1573 of 5141 hospitalizations) after AVR in the New York state inpatient database.

CONCLUSIONS AND RELEVANCE

In this large nationwide study, a substantial burden of new-onset atrial fibrillation was observed after TAVI and AVR. The incidence of new-onset atrial fibrillation was higher after AVR than after TAVI in a patient-level state inpatient database.

Non-Transfemoral Transcatheter Aortic Valve Replacement Approach is Associated with a Higher Risk of New-Onset Atrial Fibrillation: A Systematic Review and Meta-Analysis

BACKGROUND

New-onset atrial fibrillation (NOAF) is a frequent arrhythmic complication following transcatheter aortic valve replacement (TAVR). Choice of access routes for TAVR could be a factor that determines the risk of NOAF although the data is still not well-characterised. We aimed to assess the association between different access routes for TAVR (transfemoral versus non-transfemoral) and the risk of NOAF.

METHODS

A comprehensive literature review was performed through September 2018 using EMBASE and Medline. Eligible studies must compare the incidence of NOAF in patients without pre-existing atrial fibrillation who underwent TAVR. Relative risk (RR) and 95% confidence intervals (CI) were extracted from each study and combined together using the random-effects model, generic inverse variance method of DerSimonian and Laird.

RESULTS

Seven (7) retrospective studies with 18,425 patients who underwent TAVR (12,744 with the transfemoral approach and 5,681 with the non-transfemoral approach) met the eligibility criteria. After the procedures, 2,205 (12.0%) patients developed NOAF (656 [5.1%] patients in the transfemoral group and 1,549 [27.3%] patients in the non-transfemoral group). There was a significant association between the non-transfemoral approach and an increased risk of NOAF with the pooled RR of 2.94 (95%CI, 2.53-3.41; p < 0.00001). Subgroup analysis showed the highest risk of NOAF in the transapical subgroup with the pooled RR of 3.20 (95% CI, 2.69-3.80; I² 33%).

CONCLUSIONS

A significantly increased risk of NOAF following TAVR among those who underwent a non-transfemoral approach compared with transfemoral approach was observed in this meta-analysis.

T wave positivity in lead aVR is associated with mortality after transcatheter aortic valve implantation

Introduction

Transcatheter aortic valve implantation (TAVI) is an alternative to surgical aortic valve replacement (SAVR) in patients with increased comorbidity. Lead aVR in surface ECG has valuable information about prediction of mortality in many cardiovascular diseases. Our aim was to determine the relationship between ischemic changes in lead aVR and mortality in TAVI patients.

Material and methods

We retrospectively examined 86 patients with TAVI. The ST segment deviation in lead aVR (STaVR) and T wave polarity (TPaVR) on surface ECG were measured. The absolute values of TPaVR and STaVR were calculated. A ratio (TP/STaVR or vice versa) was obtained from the division of the larger absolute value by the smaller one.

Results

The patients were divided into two groups as living and deceased. The living group had 68 patients, and the deceased group had 18 patients. The number of positive TPaVR patients after TAVI, TPaVR after TAVI, and TP/STaVR ratio after TAVI were significantly higher in the deceased group. The deceased group had a significantly shorter aortic annulus-LMCA distance. Presence of positive TPaVR (OR = 8.765, 95% CI: 1.088–70.618, p = 0.041), aortic annulus-LMCA distance (for each 1 mm increase, OR = 0.306, 95% CI: 0.158–0.595, p < 0.001) and TP/STaVR ratio (for each 0.1 increase, OR = 1.966, 95% CI: 1.276–3.024, p = 0.002) were determined as independent predictors for mortality.

Conclusions

Ischemic changes in lead aVR may provide valuable information about mortality after TAVI.

New-Onset Atrial Fibrillation in Adult Patients After Cardiac Surgery

Purpose of Review

An overview of recent literature regarding pathophysiology, risk factors, prophylaxis, and treatment of new-onset atrial fibrillation (AF) in post-cardiac surgical patients.

Recent Findings

AF is the most frequent adverse event after cardiac surgery with significant associated morbidity, mortality, and financial cost. Its causes are multifactorial, and models to stratify patients into risk categories are progressing but a consistent, evidence-based system has not yet been developed. Pharmacologic and surgical interventions to prevent and treat this complication have been an area of ongoing research and recent societal guidelines reflect this.

Summary

Inconsistencies remain surrounding how to best identify higher-risk AF patients, which interventions should be used to prevent and treat AF, and which patient groups should receive these interventions. The evidence for these available strategies and their place in contemporary guidelines are summarized.

Complications after Transfemoral Transcatheter Aortic Valve Replacement with a Balloon-Expandable Prosthesis: The Importance of Preventative Measures and Contingency Planning

Transcatheter aortic valve replacement (TAVR) with balloon-expandable Edwards-SAPIEN valve was superior to standard therapy in inoperable patients and noninferior to surgical aortic valve replacement in high surgical-risk, but operable patients, with severe symptomatic aortic stenosis in the randomized controlled PARTNER trial. Since the first case of TAVR with a balloon-expandable valve in 2002, several groups have reported their experience with balloon-expandable valves with high-procedural success. In the United States, the balloon-expandable Edwards-SAPIEN valve is the only transcatheter heart valve approved by the FDA for commercial use. Moreover, this is only in high-risk inoperable patients. Despite increasing experience with the TAVR procedure, it can be associated with complications, which can be technically challenging, even for an experienced operator. Complications associated with TAVR include vascular complications, valve malpositioning, regurgitation, embolization, coronary compromise, conduction abnormalities, stroke/transient ischemic attack, acute kidney injury, cardiac tamponade, and hemodynamic collapse. A thorough understanding of the procedure is essential for pre-emptive planning for procedural complications and early identification and management of complications are necessary for procedural success. We hereby review our experience of transfemoral TAVR with balloon-expandable valves, offer practical tips to maximize the likelihood of procedural success, describe pre-emptive strategies to prevent peri-procedural complications and bailout measures to manage them, should they occur. © 2018 Wiley Periodicals, Inc.

Incidence, Predictors, Management, and Clinical Significance of New-Onset Atrial Fibrillation After Transcatheter Aortic Valve Implantation

There is limited information on the incidence, management, and prognostic impact of new-onset atrial fibrillation (NOAF) following transcatheter aortic valve implantation (TAVI) for severe aortic valve stenosis. In the prospective ASAN-TAVI registry, we evaluated a total of 347 consecutive patients who underwent TAVI from March 2010 to August 2017. The primary end point was a composite of stroke or systemic embolism at 12 months. The study subjects were categorized into 3 groups; pre-existing AF (50 patients), NOAF (31 patients), and non-AF (266 patients) group. NOAF developed in 10.4% of patients without pre-existing AF after TAVI and most cases were paroxysmal type (93.6%). Pharmacologic and electrical cardioversion were tried in 13 (41.9%) and 6 (19.4%) patients and success rates were 61.5% and 33.3%, respectively. NOAF-associated case rate for primary end point was 22.6%. Transfemoral access and cardiac tamponade were independent predictors of NOAF. Patients with NOAF, as compared with those with pre-existing AF and those without AF, had an increased 1-year rate of primary end point (24.0% vs 9.9% vs 7.2%, respectively; p <0.001). By multivariable analysis, NOAF was an independent predictor of 1-year rate of primary end point (adjusted hazard ratio: 3.31; 95% CI: 1.34 to 8.20; p = 0.010). In conclusion, patients with severe aortic valve stenosis who underwent TAVI, NOAF occurred in 10% and 1 of 4 NOAF patients experienced stroke or systemic embolization. The presence of NOAF was associated with a substantially higher risk of stroke or systemic embolization.

Position paper of French Interventional Group (GACI) for TAVI in France in 2018

Aortic stenosis is a frequent disease in the elderly. Its prevalence is 0.4% with a sharp increase after the age of 65, and its outcome is very poor when the patient becomes symptomatic. The interventional procedure known as TAVI (trans-catheter aortic valve implantation), which was developed in France and carried out for the first time in Rouen by Prof. Alain Cribier and his team in 2002, has proven to be a valid alternative to surgical aortic valve replacement. At first, this technique was shown to be efficient in patients with contra-indications to surgical treatment or deemed to be at high surgical risk. Given the very promising outcomes achieved as a result of close heart team collaboration, appropriate patient selection, simplified procedures and reduced complication rates, transfemoral (TF) TAVI is now preferred in symptomatic intermediate risk patients>75 years old according to the latest ESC guidelines. In 2017, in France, TAVI is currently performed in 50 centers with on-site cardiac surgery. The 2016 TAVI outcomes recorded in the French national TAVI registry (France TAVI) are very encouraging and show that for 7133 patients treated (age 83.4±7 years, logistic Euroscore 14%), 87% of whom via the TF approach, cross-over to surgery was very low (0.5%) with a 3.0% in-hospital mortality rate. The substantial increase in TAVI indications and the improvement of its outcomes may in the near future call for a reconsideration of the number of high volume centers authorized to carry out this technique.