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Valvular Disorders

Sub-clinical valve thrombosis in the setting of bioprosthetic aortic valves

25 Nov, 15 | by flee

Bioprosthetic aortic valves have played a critical role in improving both quality of life and prognosis in patients with severe aortic valve disease. Implanted either surgically (SAVR) or percutaneously (TAVI), they provide restoration of valve function without the need for anticoagulation as required with mechanical valves.  This study was the result of clinical evaluation of a patient with a stroke soon after TAVI.  This evaluation included CT imaging of the bioprosthetic valve which revealed restricted leaflet mobility and prompted further inquiry.  Using data from a TAVI randomized trial and 2 registries of patients with both TAVI and SAVR, the authors went on to evaluate 187 patients who underwent CT and echocardiographic imaging during the first 12 months after bioprosthetic valve implantation in the aortic position.  The authors found reduced leaflet motion was not uncommon with 40% of patients in the clinical trial and 13% in the two registries having findings of moderate to severe restriction in 1 or more valve leaflets.  Although the cause of restricted motion could not be determined definitively, imaging suggested thrombus at the base of the valve leaflets that impaired normal leaflet excursion.  The possibility that thrombus was the causal factors was further suggested by the lack of impaired leaflet motion in any patient who was anticoagulated with warfarin.  In addition, among patients with restricted leaflet motion, restoration of leaflet motion was found in 100% of patients who were subsequently started on warfarin as compared with 10% of patients not anticoagulated (P<0.001).  Interestingly, abnormalities in leaflet motion could not be seen on standard transthoracic echo imaging and there was no evidence of an increased gradient across valves with restricted leaflet motion by CT or TEE.  The clinical consequences of this finding remain unclear with no increase in stroke or TIA patients with restricted leaflet motion, although the sample size was small.


Using advanced imaging techniques, reduced motion of bioprosthetic aortic valves was commonly observed and suggestive of subclinical valve thrombosis.  The clinical consequences of this finding remain uncertain and further study is warranted to ascertain optimal imaging approaches and management of this finding.

Summarized by Hussain Contractor and Steven M. Bradley

Makkar RR, Fontana G, Jilaihawi H, Chakravarty T, Kofoed KF, de Backer O, Asch FM, Ruiz CE, Olsen NT, Trento A, Friedman J, Berman D, Cheng W, Kashif M, Jelnin V, Kliger CA, Guo H, Pichard AD, Weissman NJ, Kapadia S, Manasse E, Bhatt DL, Leon MB, Søndergaard L. Possible Subclinical Leaflet Thrombosis in Bioprosthetic Aortic Valves. N Engl J Med. 2015 Oct 5. [Epub ahead of print]

Long-Term Outcomes of Transcatheter Aortic Valve Replacement 

5 May, 15 | by Alistair Lindsay

The Placement of Aortic Transcatheter Valves (PARTNER) trial demonstrated that transcatheter aortic valve replacement (TAVR) for high-risk patients with aortic stenosis resulted in similar outcomes at 1, 2 and 3 years compared with surgical aortic valve replacement (SAVR). The present study reports the 5-year outcomes of this trial. The study enrolled 699 patients who were randomized to SAVR or TAVR (via a transfemoral or transapical approach). Overall, mean age was 84.1 years, 94% were NYHA Class 3 or 4, and the mean Society of Thoracic Surgeons Predicted Risk of Mortality at 30 days was 11.8%. At 5 years, there were no significant differences in mortality between groups (67.8% in the TAVR group versus 62.4% in the SAVR group; hazard ratio 1.04, 95% CI 0.86–1.24; p=0.76). more…

Clinical Outcomes at 1 Year Following Transcatheter Aortic Valve Replacement  

16 Apr, 15 | by Alistair Lindsay

To date, long-term outcome data following transcatheter aortic valve replacement (TAVR) has only been available from clinical trial data.  Evaluating long-term outcomes of TAVR in real-world use is important to ensure the anticipated benefits are observed in routine clinical practice.  Using data from the Society of Thoracic Surgeons/American College of Cardiology (STS/ACC) Transcatheter Valve therapies registry merged with Centers for Medicare & Medicaid Services administrative claims data, this study evaluated 1-year outcomes of mortality, stroke, and rehospitalization among 12,182 patients who underwent TAVR between November 2011 and June 2013.  In this cohort, the 1-year mortality rate 23.7%, the stroke rate was 4.1%, the rate of heart failure was 14.3%, and 1.4% had aortic valve reintervention.  A total of 53.2% were readmitted to the hospital within 1-year.    more…

Surgical Repair of Moderate Mitral Regurgitation at the Time of CABG Lacks Clear Benefit

17 Feb, 15 | by Alistair Lindsay

Ischemic mitral regurgitation (MR) is common and associated with poor outcomes among patients undergoing bypass surgery.  However, it remains unknown whether repair of ischemic MR concurrent to CABG leads to better patient outcomes.  To address this important clinical question, this multi-center study randomly assigned 301 patients with moderate ischemic MR to CABG alone or CABG plus mitral valve repair.  The primary end-point was the echocardiographic parameter of left ventricular end-systolic volume index (LVESVI) at 1-year, which is a measure of left ventricular remodeling and is a known predictor of poor outcomes. Secondary end-points included major adverse cardiac or cerebrovascular events and functional assessments using the Minnesota heart failure questionnaire. more…

Long-term outcomes of mechanical versus bioprosthetic aortic valve replacement in younger adults  

20 Dec, 14 | by Alistair Lindsay

Younger adults requiring aortic valve replacement often receive a mechanical valve given concerns over durability of bioprosthetic valves. However, prior studies have been underpowered to compare long-term survival implications of mechanical versus bioprosthetic valve replacement in younger adults. In this retrospective cohort from the New York Statewide Planning and Research Cooperative System (SPARCS) , 4253 patients age 50-69 receiving surgical aortic valve replacement (AVR) were studied to determine the relationship between valve type (bioprosthetic vs mechanical) and all-cause mortality. From this cohort, 1001 pairs of patient were matched on propensity scores for bioprosthetic valve replacement as determined from nonparsimonious hierarchical regression modeling accounting for clustering of patients within surgeons. In addition to assessing for adequacy of matching on propensity scores using statistical methods, 30-day complication rates were similar in the matched groups consistent with balanced operative risk. more…

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