Minimally invasive, surgical, and transcatheter aortic valve replacement: A network meta-analysis

Prevalence and clinical outcomes of permanent conduction disturbances after transcatheter aortic valve replacement

BACKGROUND

A new-onset conduction disturbance is a major concern in patients undergoing transcatheter aortic valve replacement (TAVR) but can resolve over time. This study aimed to evaluate the recovery in conduction disturbances post-TAVR and its association with clinical outcomes.

METHODS

This retrospective study included 780 TAVR patients at St. Marianna University between January 2016 and March 2023. Patients were stratified into four groups based on conduction status at six months post-TAVR: no conduction disturbance, recovered conduction disturbance [defined as a post-procedural pacemaker implantation with cumulative right ventricular pacing <40 % or complete left bundle branch block (CLBBB) at discharge but not at six months], permanent conduction disturbance (defined as pacemaker implantation with cumulative right ventricular pacing ≥40 % or CLBBB at both discharge and six months), and preprocedural conduction disturbance. The primary outcomes were all-cause mortality and heart failure hospitalization. The secondary outcome was the change in cardiac damage from pre-procedure to one-year post-TAVR.

RESULTS

Of 780 patients, 220 (28 %) had new-onset CLBBB or required a pacemaker implantation at discharge. Among these, 99 (45 %) had permanent conduction disturbances at six months. Over a median follow-up of 788 days, both permanent and preprocedural conduction disturbances were significantly associated with a higher incidence of heart failure hospitalization [hazard ratio (HR) 3.63; 95 % confidence interval (CI): 2.04-6.47, p < 0.01 and HR 2.50; 95 % CI: 1.27-4.90, p < 0.01), although no difference in all-cause mortality was observed. In contrast, the prognosis of patients with recovered conduction disturbance was comparable with those with no conduction disturbance. Patients with permanent and preprocedural conduction disturbances showed significant worsening cardiac damage.

CONCLUSION

Permanent and preprocedural conduction disturbances after TAVR were associated with increased heart failure hospitalizations, while the prognostic impact of recovered conduction disturbance may be limited.

Transcaval access for transcatheter aortic valve replacement: a systematic review and meta-analysis

Background

Transfemoral access is considered the standard route for transcatheter aortic valve replacement (TAVR). However, in some cases, this access route is contraindicated. Alternative access routes, such as transaxillary, are emerging as first-line approaches to address these limitations, while the transcaval approach remains uncertain. Our Meta-analysis aims to evaluate the safety of the transcaval approach compared to other access routes for TAVR.

Methods

We searched five databases, PubMed, SCOPUS, Web of Science, Cochrane Library, and Embase, from inception until April 2024 for any study that reports transcaval access alone or compares it to any alternative access in TAVR patients. We used Risk ratio (RR) for dichotomous outcomes and Mean Difference (MD) for continuous outcomes with a 95% confidence interval.

Results

Eleven studies with 1003 patients were included, transcaval showed non-statistically significant difference over alternatives in terms of intra-hospital, 30 days, and long-term all-cause mortality with a RR of 0.08 (95% CI -0.83 to 0.99, P = 0.86), 0.11 (95% CI -0.48 to 0.7, P = 0.71), and 1.08 (95% CI -0.50 to 2.66, P = 0.18), respectively. Furthermore, in our single-arm analysis, transcaval access has a low pooled 30-day all-cause mortality rate of 7% (95% CI 5-10) and long-term mortality of 21% (95% CI 2-77). The mean difference in length of stay in the hospital after the operation was 4.88 (95% CI 4.45-5.31), and the major bleeding rate was 14% (95% CI 8-23).

Conclusion

Transcaval access for TAVR is a safe and feasible method that can be considered a new alternative when trans-femoral access is contraindicated.

2025 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2025 AHA Statistical Update is the product of a full year's worth of effort in 2024 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. This year's edition includes a continued focus on health equity across several key domains and enhanced global data that reflect improved methods and incorporation of ≈3000 new data sources since last year's Statistical Update.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Transcatheter versus surgical aortic valve replacement in patients with aortic stenosis with a small aortic annulus: A meta-analysis with reconstructed time to event data

Background

Aortic stenosis (AS) remains a prevalent and serious global health concern, exacerbated by an aging population worldwide. This valvular disease, when symptomatic and without appropriate intervention, severe AS can drastically reduce life expectancy. In our systematic review and meta-analysis, we aim to synthesize available evidence to guide clinical decision-making by comparing the performance of TAVR and SAVR, specifically in patients with severe AS and a small aortic annulus.

Methods

We searched PubMed, EMBASE, Cochrane, Web of Science, and Scopus from inception till May 2024. The risk ratio (RR) and mean difference (MD) with a 95 % confidence interval (CI) are provided as effect size estimates, with all analyses being conducted using RevMan 5.4.

Results

Eleven studies with 3,670 patients were included. TAVR significantly increased the risk of 2-year new permanent pacemaker implantation (PPI) (RR = 2.42; 95 % CI: [1.70-3.44], P < 0.0001) and major vascular complications (RR = 3.73; 95 % CI: [1.98-6.99], P < 0.0001) than SAVR. However, TAVR significantly decreased the risk of patient-prosthesis mismatch (PPM) (RR = 0.56; 95 % CI: [0.48-0.65], P < 0.00001) and new-onset atrial fibrillation (AF) (RR = 0.31; 95 % CI: [0.23-0.41], P < 0.00001). Also, SAVR reduced the risk of paravalvular leak (PVL) (RR = 3.35; 95 % CI: [1.79-6.27], P = 0.0002).

Conclusion

TAVR had a significantly reduced risk of PPM and new-onset AF but with increased PPI and vascular complications. Also, TAVR significantly improved EOA and iEOA. Furthermore, SAVR had less risk of PVL, and better LVEF improvement at predischarge. Therefore, TAVR and SAVR remain valid alternatives, and decisions should be based on anatomy of the annulus and aortic root,operative risk, and comorbidities.

Less Is More? Combined Approaches to Improve Mortality and Morbidity after Aortic Valve Replacement

BACKGROUND

Nowadays, one of the main goals of aortic valve surgery is to reduce the biological impact, mortality, and complications. It is well-known that long operative times in terms of the extracorporeal circulation, but above all, of the aortic cross-clamp time (ACC), represent a risk factor for mortality in patients undergoing cardiac surgery. In order to shorten the aortic cross-clamp time, many technological improvements, such as sutureless prostheses, have been introduced, but their actual effectiveness has not been proven yet. The aim of this study was to assess the 30-day outcomes of patients undergoing aortic valve replacement surgery, focusing on the ACC length.

METHODS

All 3139 patients undergoing aortic valve replacement between January 2013 and July 2022 at our institution were enrolled. The data were retrospectively collected and the baseline characteristics and intraoperative variables were recorded. In order to adjust the results according to the differences in the baseline characteristics, propensity score matching was performed and four groups of 351 patients were obtained based on the first, second, third, and fourth quartile of the ACC time.

RESULTS

The patient population included 132 redo surgeries (9.4%) and 61 cases of active endocarditis (4.3%), with an overall median EuroSCORE II of 1.8 (IQR 1.2-3.1). An increase across the groups was observed in terms of the acute kidney failure (p < 0.001) incidence, the number of blood transfusions (p = 0.022), prolonged hospital stays (p < 0.001), the and respiratory failure (p < 0.001) incidence. A p of < 0.1 was found for the 30-day mortality (p = 0.079). The predictors of an early 30-day mortality were standard full sternotomy (OR 2.48, 95% CI 1.14-5.40, p = 0.022), EuroSCORE II (OR 1.10, 95% CI 1.05-1.16, p < 0.001), and a trend for a longer ACC time (Q4 vs. Q1: OR 2.62, 95% CI 0.89-7.68, p = 0.080).

CONCLUSIONS

Shortening the operative times resulted in marked improvements of the patients' outcomes. The combined use of minimally invasive approaches and sutureless aortic valve prostheses allows for a lower 30-day events rate. New technologies should be assessed to obtain the best results with the least risk.