Faculty Bibliography

BACKGROUND:Transcatheter aortic valve replacement (TAVR) for low gradient (LG) severe aortic stenosis (AS) with preserved left ventricular ejection fraction (LVEF) remains an area of clinical uncertainty. METHODS:Retrospective review identified 422 patients who underwent TAVR between September 4, 2014 and July 1, 2016. Procedural indication other than severe AS (n = 22) or LVEF <50% (n = 98) were excluded. Outcomes were defined by valve academic research consortium two criteria when applicable and compared between LG (peak velocity <4.0 m/s and mean gradient <40 mmHg; n = 73) and high gradient (HG) (n = 229) groups. The LG group was further categorized as low stroke volume index (SVI) (n = 41) or normal SVI (n = 32). Median follow-up was 747 days [interquartile range 220-1013]. RESULTS: = 0.39). CONCLUSION/CONCLUSIONS:Patients with preserved LVEF undergoing TAVR for severe AS with LG, including LG with low SVI, have no significant difference in adverse outcomes when compared to patients with HG.

A 78 year-old man with remote type-A dissection presented with acute-onset dyspnea. Twenty-two years prior, treatment for his aortic disease required replacement of ascending and arch aneurysms with a Dacron graft using graft inclusion technique. He presented currently in cardiogenic shock. Echocardiography demonstrated new severe hypokinesis of all apical segments. Left-heart catheterization revealed a 120mmHg intra-graft gradient. CT arteriography was unrevealing, but intra-aortic ultrasound demonstrated critical intra-graft stenosis. A Palmaz stent was deployed in the stenotic region with gradient resolution. He later underwent aortic root replacement and ascending aneurysm repair (Bio-Bentall technique) and is doing well at 24 months.

BACKGROUND:The PARTNER-2A randomized trial compared outcomes of transfemoral transcatheter (TAVR) and surgical aortic valve replacement (SAVR) in intermediate-risk patients with severe aortic stenosis. The purpose of the current study was to perform an in-depth analysis of outcomes after SAVR in PARTNER-2A. METHODS:From 1/2012-1/2014, 937 patients underwent SAVR at 57 centers. Mean age was 82±6.7 and 55% were men. Less-invasive operations were performed in 140 (15%) and concomitant procedures in 198 (21%). Major outcomes and echocardiograms were adjudicated by an independent events committee. Follow-up was 94% complete to 2 years. RESULTS:Operative mortality was 4.1% (n=38, STS PROM 5.2±2.3%), O/E 0.8, and in-hospital stroke 5.4% (n=51), twice expected. Aortic clamp and bypass times were 75±30 and 104±46 minutes. Patients having severe prosthesis-patient mismatch (n=260, 33%) had similar survival to those without (P>.9), as did those undergoing less-invasive SAVR (P=.3). Risk factors for death included cachexia (P=.004), tricuspid regurgitation (P=.01), coronary artery disease (P=.02), preoperative atrial fibrillation (P=.001), higher white cell count (P<.0001), and lower hemoglobin (P=.0002). CONCLUSIONS:In this adjudicated prospective study, SAVR in intermediate-risk patients had excellent results at 2 years. However, there were more in-hospital strokes than expected, most likely attributable to mandatory neurologic assessment post-procedure. There was no significant structural valve deterioration during 2-year follow-up. Continued long-term surveillance remains important.