Urgent/Emergent TAVR Feasible But Mortality Higher Than When Performed Electively

MedicalResearch.com Interview with:

Dawn Abbott, MD, FACC, FSCAI Associate Chief, Faculty Development and Academic Advancement Director, Interventional Cardiology and Structural Fellowship Programs Associate Professor of Medicine Warren Alpert Medical School, Brown Providence, RI 02903

Dr. Abbott

Dawn Abbott, MD, FACC, FSCAI
Associate Chief, Faculty Development and Academic Advancement
Director, Interventional Cardiology and Structural Fellowship Programs
Associate Professor of Medicine
Warren Alpert Medical School, Brown
Providence, RI 02903 

MedicalResearch.com: What is the background for this study?

Response: Approximately 35,000 transcatheter aortic valve replacement (TAVR) procedures are now performed annually in the United States (US). TAVR is usually performed as an elective procedure in hemodynamically stable patients. Approximately 1 in 5 hospitalizations for severe aortic stenosis (AS) are emergent with acute decompensation. Balloon aortic valvuloplasty (BAV) is a therapeutic option in patients with acute decompensated AS; however, long-term survival after BAV remains poor with a high incidence of valvular re-stenosis. Data on the outcomes of urgent/emergent TAVR as a rescue therapy in patients with acute decompensated severe AS are extremely limited.

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LPA Gene Variant May Help Identify Increased Risk of Aortic Stenosis 

MedicalResearch.com Interview with:

Aortic Stenosis Blaus Image Wikipedia

Aortic Stenosis Blaus Image Wikipedia

Hao Yu Chen, MSc
Department of Medicine
McGill University
Montreal, Quebec, Canada
Senior author: George Thanassoulis, MD, MSc

MedicalResearch.com: What is the background for this study?

Response: Aortic stenosis, a narrowing of the main valve of the heart, is the most common type of valve disease in the US. Present in more than 2.5 million individuals in North America, aortic stenosis can lead to heart failure and death. However, there is little known about the causes of aortic stenosis and how it should be treated.

Previously, we have demonstrated that variants of the gene LPA are associated with the development of aortic stenosis. A better understanding of how this region contributes to aortic stenosis could identify higher-risk individuals and inform the development of new medical therapies for aortic stenosis.  Continue reading

Association Between Cardiovascular Risk Factors and Aortic Stenosis

MedicalResearch.com Interview with:
Andrew T. Yan, MD
Terrence Donnelly Heart Centre
St Michael’s Hospital
University of Toronto
Toronto, Ontario, Canada

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: The pathogenesis of aortic stenosis is complex and incompletely understood. Previous experimental data and epidemiologic studies (mostly cross-sectional) have demonstrated an association between conventional cardiovascular risk factors such as hypertension, diabetes, and dyslipidemia, and aortic sclerosis or stenosis. However, there is a paucity of longitudinal data from large population studies. Therefore, we sought to examine the relationship between conventional cardiovascular risk factors and incident severe aortic stenosis during extended follow-up in a large unselected elderly population in Ontario, Canada.

In over 1 million individuals older than 65 who were followed for a median of 13 years, hypertension, diabetes and dyslipidemia were all significantly and independently associated with development of severe aortic stenosis requiring hospitalization or intervention. Furthermore, we observed a positive dose-response relationship between the number and duration of cardiac risk factors, and the risk of aortic stenosis. Together, these risk factors accounted for approximately one third of the incidence of severe aortic stenosis at a population level.

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TAVR Bests Standard Therapy For Sick, Elderly Patients With Severe AS

Prof Samir R Kapadia MD
Director, Sones Cardiac Catheterization Laboratories
Cleveland Clinic Cleveland, OH

For patients with severe symptomatic aortic stenosis (AS) who are not candidates for surgical valve replacement, transcatheter aortic valve replacement (TAVR) offers superior benefit to standard therapy, as measured by all-cause mortality, cardiovascular mortality, repeat hospital admission and functional status. PARTNER 1B 5 year data were published simultaneously with PARTNER 1A 5 year data in 2 separate manuscripts in the Lancet (March 15 2105).

In this landmark trial, TAVR produced a 22 percent survival benefit and a 28 percent reduced risk of cardiovascular mortality, compared with standard treatment.

According to Cleveland Clinic interventional cardiologist Samir Kapadia, MD, lead author of PARTNER 1B, these findings have changed the treatment paradigm for severe Aortic Stenosis patients who can’t undergo surgical Aortic Valve Replacement.

“This trial is the first—and will probably be the only—randomized AS trial that includes a standard treatment group, since these results will make it unethical to treat severe AS patients with medical therapy alone without aortic valve replacement. ” he says.

Superior survival benefit with TAVR

PARTNER 1B is the only rigorous randomized trial of extreme-risk aortic stenosis patients that has prospectively reported the outcomes of TAVR versus standard treatment in patients for whom the estimated probability of death or serious irreversible morbidity after surgical aortic valve replacement was 50 percent or greater.

The trial enrolled 358 patients between May 11, 2007 and March 16, 2009; 179 patients were assigned to TAVR with the first-generation Sapien valve and 179 to standard therapy which includes medical therapy and balloon aortic valvuloplasty. TAVR was performed under general anesthesia with common femoral artery access. Guidance was provided by transesophagel echocardiography and fluoroscopy. The mean age of participants was 83.

The primary endpoint was all-cause survival. Secondary endpoints included cardiovascular mortality, stroke, vascular complications, major bleeding and functional status.

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Biomarker BNP Linked To Severity of Aortic Stenosis

Philippe Pibarot, DVM, PhD, FAHA, FACC, FESC, FASE Professeur titulaire, Département de Médecine, Université Laval Professor, Department of Medicine, Laval University Directeur,  Chaire de Recherche du Canada sur les Maladies Valvulaires Cardiaques Chair,  Canada Research Chair in Valvular Heart Diseases Institut Universitaire de Cardiologie et de Pneumologie de QuébecQuébec Heart & Lung Institute - Local Y4165MedicalResearch.com Interview with :
Philippe Pibarot, DVM, PhD, FAHA, FACC, FESC, FASE
Professeur titulaire, Département de Médecine, Université Laval
Professor, Department of Medicine, Laval University
Directeur,  Chaire de Recherche du Canada sur les Maladies Valvulaires Cardiaques
Chair,  Canada Research Chair in Valvular Heart Diseases
Institut Universitaire de Cardiologie et de Pneumologie de QuébecQuébec Heart & Lung Institute – Local Y4165

Medical Research: What are the main findings of the study?

Dr. Pibarot: The optimal timing of aortic valve replacement (AVR) in asymptomatic patients with severe aortic stenosis (AS) remains a matter of debates. Both the American and European guidelines recommend AVR for patients with severe AS who present with symptoms or left ventricular (LV) systolic dysfunction. However, patients with aortic stenosis are often older, less physically active and have more comorbidities, which make the assessment of AS-related symptoms challenging and unreliable. In this study by Capoulade et al, plasma levels of brain natriuretic peptide (BNP) were obtained in 157 patients with severe asymptomatic aortic stenosis and preserved LV ejection fraction at peak of exercise-stress echocardiography. Patients in the upper (>95 pg/ml) and mid (>45 pg/ml) tertiles of exercise BNP respectively had a 5- and 3- fold increase in the risk of events (i.e. AVR or death) compared to those in the lower tertile. Similar results were obtained in the subset of patients with low resting BNP.
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TAVR vs Surgical Aortic Valve Replacement for Aortic Stenosis with LV Dysfunction

Sammy Elmariah, MD, MPH Massachusetts General Hospital Boston, MAMedicalResearch.com Interview with:
Sammy Elmariah, MD, MPH
Massachusetts General Hospital
Boston, MA

 

MedicalResearch.com: What are the main findings of the study?

Dr. Elmariah: Within the randomized PARTNER I trial, we evaluated the effect of left ventricular (LV) dysfunction on clinical outcomes after transcatheter and surgical aortic valve replacement (TAVR and SAVR, respectively) and the impact of valve replacement technique on recovery of LV function. We found that LV dysfunction, defined as an LV ejection fraction < 50%, had no impact on 30-day and 1-year mortality after either TAVR or SAVR. In those with baseline LV dysfunction, marked improvement in LV ejection fraction was observed within 30-days of valve replacement in approximately half of patients, with an equivalent degree of improvement observed after TAVR and SAVR. Permanent pacemaker at study entry, low mean aortic valve gradient, and high LV ejection fraction were associated with reduced odds of LV functional recovery after valve replacement.

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TAVR for Aortic Stenosis: Improvement in Quality of Life

MedicalResearch.com Interview with:
Caroline A. Kim, MD, MS;
Beth Israel Deaconess Medical Center
Boston, MA 02215.

MedicalResearch.com: What are the main findings of the study?

Dr. Kim: We conducted a systematic review of 62 studies that examined functional status and quality of life in patients who underwent transcatheter aortic valve replacement (AVR) for their symptomatic severe aortic valve stenosis.  In 11,205 patients who underwent TAVR, a clinically meaningful improvement was seen in physical functional measures and disease-specific quality of life measures, whereas improvement in psychological measures or more general health measures were modest and inconsistent.  Given the dismal prognosis of severe aortic stenosis treated conservatively, it was clear that transcatheter AVR improved functional status and quality of life.  However, there was insufficient evidence that compares these patient-centered outcomes between transcatheter AVR and surgical AVR.
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Severe Aortic Stenosis: Flow-Gradient Patterns after Aortic Valve Replacement

MedicalResearch.com Interview with:
Mackram Eleid, MD
Division of Cardiovascular Diseases and Internal Medicine

MedicalResearch.com: What are the main findings of the study?

Dr. Eleid: Our study investigated the characteristics, outcomes and impact of aortic valve replacement in a large series of 1704 patients with severe aortic stenosis (aortic valve area < 1 cm2) and preserved ejection fraction (EF > 50%) according to the flow-gradient classification that incorporates both stroke volume index and mean aortic valve gradient.  The primary findings were that patients with low flow, low gradient AS have lower survival than other flow-gradient patterns (a 3.2-fold increase risk of mortality compared to normal flow, low gradient), and their survival is improved with aortic valve replacement.  Conversely, patients with normal flow and low gradient had a favorable survival with medical management, suggesting a less advanced stage of disease compared to the other groups.  Additionally, a novel observation from this study is that patients with low flow had a higher prevalence of atrial fibrillation and previous heart failure events compared to other groups.

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