Faculty Bibliography

IMPORTANCE/UNASSIGNED:As transcatheter aortic valve replacement (TAVR) is considered for younger and lower-risk populations, the durability of bioprosthetic valves is increasingly important. Limited data exist on long-term (7 years and beyond) valve durability. OBJECTIVE/UNASSIGNED:To report 7-year valve durability outcomes for low-risk patients with symptomatic severe aortic stenosis treated with TAVR vs surgery. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:Between March 2016 and October 2017, a total of 1000 patients were enrolled at 71 centers in the US and Canada and randomized to undergo TAVR vs surgery. The patient population for the present analysis consisted of all patients who underwent valve implantation (495 with TAVR and 453 with surgery). The last 7-year follow-up occurred in March 2025. INTERVENTIONS/UNASSIGNED:Patients were randomized to balloon-expandable TAVR with the SAPIEN 3 valve or surgery with any commercially available valve. MAIN OUTCOMES AND MEASURES/UNASSIGNED:The main outcomes of this analysis were stage 2 or 3 bioprosthetic valve dysfunction (BVD) related to structural valve deterioration (SVD), thrombosis, or endocarditis; all-cause bioprosthetic valve failure (BVF); BVF related to SVD; and aortic valve reintervention at 7 years. Analyses are presented as cumulative incidence rates with death as a competing risk. RESULTS/UNASSIGNED:The mean (SD) age of the study population was 73.5 (6.0) years, and 657 participants (69.3%) were male. Of 671 patients who were still alive and enrolled in the study at 7-year follow-up, 537 (80.0%) were available for echocardiographic analysis. Cumulative incidence rates of stage 2 or 3 SVD-related BVD (7.3% vs 7.6%; hazard ratio [HR], 0.96; 95% CI, 0.59-1.57; P = .88), all-cause BVF (6.9% vs 7.5%; HR, 0.91; 95% CI, 0.55-1.49; P = .69), SVD-related BVF (3.9% vs 5.3%; HR, 0.72; 95% CI, 0.39-1.36; P = .31), and valve reintervention (6.0% vs 5.5%; HR, 1.09; 95% CI, 0.62-1.90; P = .77) were low and similar for TAVR and surgery, respectively. Stage 2 or 3 thrombosis-related BVD (subclinical and clinical) occurred more frequently with TAVR (5.2% vs 0.9%; HR, 5.52; 95% CI, 1.92-15.85; P < .001), although most events occurred within 3 years and few progressed to BVF. Rates of stage 2 or 3 endocarditis-related BVD were also low and similar (0.4% in the TAVR group vs 0.5% in the surgery group; HR, 0.85; 95% CI, 0.12-6.07; P = .87). The proportion of patients alive and free of all-cause BVF was 73.4% (331/451) with TAVR vs 74.8% (288/385) with surgery (P = .69). CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this ad hoc analysis of a randomized clinical trial among low-risk patients with symptomatic severe aortic stenosis randomized to TAVR or surgery, both TAVR and surgery demonstrated comparable and sustained valve durability, with low and similar rates of SVD, all-cause BVF, and reintervention through 7 years. These findings may inform discussions of valve replacement strategies. TRIAL REGISTRATION/UNASSIGNED:ClinicalTrials.gov Identifier: NCT02675114.

• The authors present supravalvular stenosis from congenital and iatrogenic etiologies. • Multimodality imaging is essential for diagnosing supravalvular stenosis. • Echocardiography assesses severity, while CCT provides diagnostic clarity.

BACKGROUND:Transcatheter aortic valve replacement (TAVR) has become a cornerstone in the management of aortic valve disease. However, delayed complications after hospital discharge and readmission remain in an issue following TAVR. We aimed to evaluate the impact of remote monitoring systems on clinical outcomes after TAVR. METHODS:All patients who underwent TAVR from September 2014 through January 2019 were included retrospectively. Additionally, all patients, clinically indicated for TAVR from 9/1/2018 through 8/30/2021, were screened, and patients who agreed were prospectively enrolled. Medtronic Care Management Service (MCMS) was used to monitor patients following TAVR after discharge (Medtronic, Minneapolis, MN). RESULTS:A total of 1078 patients were included. Among them, 843 (78.2 %) patients were discharged with MCMS (MCMS group) and 235 (21.8 %) patients were discharged without (non-MCMS group). Overall, the mean age was 81.5 years, and mean STS-PROM was 5.53 %. Baseline conduction defect was observed in 427 (39.6 %). Peripheral artery disease was more common in the MCMS group while a history of myocardial infarction was more likely seen in the non-MCMS group. After propensity-score matching, length of hospital stays was significantly shorter in the MCMS group (1.42 days vs. 1.82 days in the non-MCMS group, p < 0.001). Readmission rates and new permanent pacemaker insertion rates were similar between the two groups. All-cause mortality, 30-day and 90-day mortality were comparable between the groups. CONCLUSIONS:MCMS was easily applicable to a clinical practice and may reduce length of hospital stays in patients undergoing TAVR without increasing readmission or mortality.

BACKGROUND/UNASSIGNED:The EARLY TAVR trial demonstrated that early transcatheter aortic valve replacement (TAVR) was superior to clinical surveillance (CS) in asymptomatic severe aortic stenosis. The relative impact of early TAVR versus a CS strategy by age is unknown. METHODS/UNASSIGNED:The study population of the EARLY TAVR trial was stratified into 4 age groups: 65 to 69 years (n=141), 70 to 74 years (n=263), 75 to 79 years (n=250), and ≥80 years (n=247). Associations between age and the trial primary end point of death, stroke, or unplanned cardiovascular hospitalization; the composite end point of death, stroke, or heart failure hospitalization; and its individual components were examined. Interaction tests evaluated whether the treatment effect of early TAVR versus CS differed by age. RESULTS/UNASSIGNED:=0.06). CONCLUSIONS/UNASSIGNED:In the EARLY TAVR trial, the relative benefit of early TAVR over CS was consistent among all age groups. The greatest absolute reduction in stroke rate with early TAVR compared with CS appeared in the youngest and oldest groups, whereas reduction in heart failure hospitalization was most pronounced in the oldest patients. These data suggest that early TAVR should be considered in all age groups above 65 years. REGISTRATION/UNASSIGNED:URL: https://www.clinicaltrials.gov; Unique identifier: NCT03042104.

IMPORTANCE/UNASSIGNED:Transcatheter tricuspid valve replacement (TTVR) demonstrated superior outcomes over medical therapy in patients with severe tricuspid regurgitation (TR) in the Edwards EVOQUE Transcatheter Tricuspid Valve Replacement: Pivotal Clinical Investigation of Safety and Clinical Efficacy Using a Novel Device II (TRISCEND II) randomized clinical trial, and received regulatory approval in the US in 2024. Contemporary real-world data on its effectiveness and safety remain limited. OBJECTIVE/UNASSIGNED:To evaluate 30-day clinical, echocardiographic, and health status outcomes of TTVR in real-world use. DESIGN, SETTING, AND POPULATION/UNASSIGNED:Retrospective cohort study of all consecutive patients who underwent TTVR in the US from February 2024 through March 2025 in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. Patients had symptomatic, severe TR despite optimal medical therapy and TTVR was deemed appropriate by a heart team. Statistical analysis was conducted from September 2025 to February 2026. EXPOSURE/UNASSIGNED:Device-enabled TTVR. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Thirty-day event rates (all-cause death, stroke, bleeding, new cardiac implantable electronic device [CIED] implantation, heart failure hospitalizations), TR reduction, and changes in health status (New York Heart Association [NYHA] functional class and Kansas City Cardiomyopathy Questionnaire Overall Summary [KCCQ-OS] score) are reported. Subgroup analyses examined the impact of baseline CIED status on outcomes. RESULTS/UNASSIGNED:Among 1034 attempted procedures at 82 centers (mean [SD] age, 77.1 [10.6] years; 69.1% female; 73.2% NYHA functional class III/IV), a valve was successfully implanted in 1017 patients (98.4%). Mild or less TR was achieved in 98.4% of patients post procedure and in 97.7% at 30 days. At 30 days, all-cause mortality was 3.1%; stroke, 0.2%; bleeding, 7.9%; new CIED, 15.9% in CIED-naive patients; and heart failure hospitalization, 3.1%. There were significant improvements in NYHA functional class (class I/II, 82.7%; P < .001) and mean KCCQ-OS score (22.4 points; P < .001) from baseline to 30 days. There were no significant differences in 30-day mortality (P = .47), heart failure hospitalization (P > .99), and functional outcomes (P = .55) when patients were stratified by baseline CIED status. CONCLUSIONS AND RELEVANCE/UNASSIGNED:Early US real-world experience with TTVR confirms safety and effectiveness in patients with severe TR. Thirty-day outcomes are consistent with the TRISCEND II pivotal trial, demonstrating acceptable safety, near-complete TR elimination, and significant health status improvements in an older, comorbid population. Rates of new CIED implantation and bleeding were lower than randomized clinical trial experience.

OBJECTIVE/UNASSIGNED:Prolonged intubation is associated with worse outcomes and longer intensive care unit (ICU) and hospital length of stay (LOS). Extubation in the operating room for patients undergoing isolated coronary artery bypass grafting is feasible, safe, and decreases ICU and hospital LOS. Aortic root and arch procedures are lengthy and often require circulatory arrest. Here, we present our experience with the safety and feasibility of operating room extubation following simple and complex aortic surgery. METHODS/UNASSIGNED:All consecutive patients who underwent aortic surgery from August 2023 to April 2025 were included in this descriptive study. We evaluated 30-day postoperative outcomes for patients who were extubated in the operating room and those in the ICU. Outcomes of interest were time to chair, ICU and hospital LOS, as well as reintubation and reoperation rates. RESULTS/UNASSIGNED:< .001). Thirty-day outcomes were excellent and comparable in both groups with no deaths or myocardial infarctions for operating room extubation compared with ICU extubation, respectively: atrial fibrillation (n = 49 [21.9%] vs n = 9 [60%]), stroke (n = 1 [0.4%]) vs n = 0), reoperation for bleeding (n = 1 vs n = 0), reintubation for respiratory failure (n = 0 vs n = 1), and 30-day readmission (n = 11 [4.9%] vs n = 2 [11.8%]). CONCLUSIONS/UNASSIGNED:Routine extubation in the operating room is safe and feasible for a wide variety of patients undergoing both simple and complex aortic surgery, even when most of them undergo circulatory arrest. Operating room extubation may accelerate recovery and early ICU and hospital discharge, without increasing readmission or morbidity.

BACKGROUND/UNASSIGNED:Although infective endocarditis during pregnancy is rare, it carries significant morbidity and mortality for both mother and foetus. While professional societies provide recommendations for the treatment of infective endocarditis, there are no specific guidelines for the management of pregnancy-associated infective endocarditis. In this report, we present two cases of infective endocarditis presenting during the second trimester of pregnancy that required surgical intervention, focusing on the unique considerations when caring for pregnant individuals. CASE SUMMARIES/UNASSIGNED:Two patients in the second trimester of pregnancy presented with fevers and malaise. Both were found to have positive blood cultures and mitral valve vegetations, leading to diagnoses of mitral valve endocarditis. Their hospital courses were complicated by embolic strokes, and one patient required transcatheter embolization of a mycotic aneurysm. Both patients underwent surgical valve replacements with bioprosthetic valves. Ultimately, both patients delivered at term without complication. DISCUSSION/UNASSIGNED:In addition to the standard management of infective endocarditis, pregnancy-associated infective endocarditis requires multidisciplinary collaboration regarding the relative timing of cardiac surgery and delivery, the use of intraoperative foetal monitoring, and the choice of valve replacement and anticoagulation. Each of these decisions requires balancing the risk of morbidity and mortality to the patient, the risk of neonatal prematurity and associated complications and disability, and the risk of foetal death during cardiopulmonary bypass. We discuss our teams' decision-making processes with a focus on the relevant considerations for each of these challenging decisions.