Open access
1. Introduction
The management of aortic valve disease has undergone a dramatic transformation over the past 10 years. Without a doubt there has been significant developments in the diagnostic and management tools available to assess patients with aortic valve pathology. In addition to these tools are better and safer surgical techniques, especially with regards to anesthesia, myocardial protection, and peri-operative care, as well as the means in which patients can be risk-assessed to help guide decision-making. However, despite these advances, patients presenting with significant valvular disease are getting older and often will have substantial and more complex co-morbidities that place them at significant risk for challenging short- and long-term adverse outcomes. The goal of this text is to illustrate some of the challenges and controversies, with an emphasis on a surgical perspective, regarding the diagnosis and management of one of the most common forms of degenerative valve disease – aortic stenosis. While, by no means, is this a comprehensive review, it does provide a foundation and potential paradigm for how we evaluate, manage, and study valve disease both at a patient as well as a population level.
2. Background
Aortic stenosis is the most prevalent form of native valvular disease. Significant stenosis, as determined by the gradients across the valve and estimated orifice areas, are encountered in up to 2% of the population over 65 years old, 3% in those over 75 years old and 4% over 85 years old. Furthermore, over 100,000 people in the United States alone are diagnosed with severe aortic stenosis each year. Historically, the management of severe and critical aortic stenosis, especially in the context of symptoms such as chest pain, syncope, and shortness of breath, has focused on surgical intervention. However, the risks increase substantially with patients age and comorbidities [1].
Typically, severe or critical stenosis is manifested with the onset of symptoms such as shortness of breath. However, when patients start developing heart failure, chest pain, or syncope, their prognosis becomes worse than many cancers, including breast and colon. In fact, without intervention, the estimated survival in this population is less than 50% at two years [2].
3. Treatment options
It has been well established that the mortality difference between symptomatic aortic stenosis patients treated with surgery and those treated medically is one of the most striking mortality differences in all of medicine. In fact, it is argued that it is unethical to withhold therapy in symptomatic patients regardless of approach unless there are compelling contraindications. The percent survival of critical aortic stenosis patients is less than 20% at two years compared to a greater than 85% 4- to 5-year survival in those undergoing surgery [3]. A variety of tools have been developed over the years regarding risk assessment for surgery to aid in decision-making. One of the most commonly used is the Society of Thoracic Surgeons predicted risk of mortality calculator [4, 5]. Additional variables include a formal assessment of patient frailty, existing comorbidities and major organ system dysfunction, and technical or anatomical aspects of the procedure that may increase perioperative risks. Putting all of these variables together allows patients to be stratified as low, intermediate, high, and prohibitive risk. These tools are then used to help patients participate in shared decision-making regarding management options as guided by a Heart Team of cardiovascular specialists [6]. Historically, the options for treatment focused on surgery with a variety of biologic and mechanical valve choices – each with advantages and disadvantages, with trade-offs being either durability or the need for lifelong anticoagulation. The development over the past 10 to 15 years of catheter-based options, specifically transaortic valve replacement (TAVR) has resulted in a dramatic increase in therapies offered to patients who otherwise were prohibitive risk [7, 8]. Recent data has allowed for catheter-based therapies to be offered to lower risk populations [9]. However, despite the appeal of catheter-based therapies over conventional open-heart surgery, there are still many questions that need to be answered with regards to durability, paravalvular leaks, need for permanent pacemaker implantation, and the growing concerns surrounding both short- and long-term complications that are only slowly being definitively reported. Nevertheless, despite the evolving data and significant amount of industry-driven support stimulating the excitement over transcatheter therapies, combined with the significant costs associated with these based therapies, there are still concerns that surgery might still be the preferred approach for certain patients.
Some of the initial multi-center randomized trials that focused on high and extreme risk patients demonstrated a survival advantage which led to a considerable amount of enthusiasm regarding the potential for catheter-based valves as a viable option for patients who would otherwise die of complications related to their critical aortic stenosis. Following regulatory approval of these devices, additional studies in intermediate and lower risk patients were undertaken. While the selection criteria for intermediate risk patients was based upon their predicted risk of mortality, other significant comorbidities and baseline characteristics were considered in the decision-making. Again, despite the appeal of non-surgical options, the early data in the intermediate risk patient population demonstrated similar all-cause mortality and risk of disabling stroke of around 13 to 14% at two years [10]. These results suggested that catheter-based therapies were non-inferior to surgical approaches, and despite the similarities in outcomes, these findings have often been cited to imply that a non-surgical approach may be preferred by the patients and are even potentially superior with regards to both short- and long-term outcomes when compared to conventional surgery [11]. In fact, while surgery was associated with a period of recovery that impacted formal quality of life assessments, by six months, the objective assessment of quality of life was similar in the surgical and catheter-based patients. In addition, similar short- and long-term mortality and stroke risks were seen in low, intermediate, and higher risk patients, again illustrating that both approaches were similar with regards to patient outcomes. Nevertheless, there has been a significant appeal, for a variety of reasons, for trans-catheter therapies, and numerous studies have been undertaken to define which patient characteristics and comorbidities might be better suited for one therapy over the other. A review of 9500 intermediate risk patients enrolled in multiple studies showed no significant benefit of one therapy over another at one year [12]. Similar reviews were also performed in lower risk patients. Specifically looking at the mortality at two years in almost 3500 patients, there was no benefit to a trans-catheter approach over surgery, further emphasizing the concept of non-inferior outcomes [13]. In this meta-analysis, there were also similar outcomes with regards to procedure-related stroke. However, there was evidence of a potential 2-year survival advantage for patients undergoing surgery. This survival advantage was also seen in a meta-analysis of intermediate risk patients enrolled in 14 studies consisting of almost 4200 patients. All told, at three years, there appeared to be a significant survival advantage for the intermediate risk patients undergoing surgical aortic valve replacement when compared to trans-catheter therapies [14]. Despite these concerns regarding the long-term outcomes in patients undergoing catheter-based therapies, there have been several randomized multi-center studies exploring their potential role in lower risk patients. The early data has suggested non-inferior outcomes, although some suggest a potential small survival advantage in those undergoing catheter-based therapies with specific types of valves. However, these trials have been heavily criticized. For example, in the PARTNER-3 trial, there was some concern that, despite enrolling low risk patients only, some of the comorbidities and surgical procedures required for these patients implied an inherently much higher risk profile [15]. Furthermore, there was concern that many patients were excluded based upon anatomical considerations, and patient selection might have played a substantial role in reported outcomes favoring catheter-based therapies [16]. Other low risk trials validated some of the short-term outcome experiences that contributed to regulatory approval with low-risk patients. A fundamental consideration is that low risk is not synonymous with younger patients, and given some of the evolving concerns surrounding intermediate- and long-term survival differences, there are still substantial concerns about offering catheter-based therapies to patients who have a predicted life expectancy beyond several years. Unfortunately, this has not attenuated the astronomical growth of catheter-based therapies at the expense of surgery in a patient population that still, based upon best available evidence, might still benefit from a surgical approach.
The selection bias and concerns of the low-risk trials for TAVR have prompted investigators to report some of the real-world outcomes in similar patients. For example, registry data out of Israel looking at very low risk and low risk patients demonstrated a 10 to 15% two-year mortality, respectively [17]. These outcomes were substantially worse than similar two-year survival rates reported in contemporary surgical studies in which the reported mortality was almost half of those reported in similar TAVR patients [18]. It is unclear if patients are aware of the substantial risks of these procedures when they are making decisions or are being consented.
Clearly, there is still much to learn with regards to the risks, benefits, and patient selection for specific therapies used to treat aortic stenosis. Furthermore, as experiences evolve, especially with the rapid proliferation of transcatheter therapies, there are still many challenges and unanswered questions.
4. Evolving controversies
4.1 Stroke
There is a common misconception that trans-catheter therapies are inherently associated with fewer strokes. This is an observation that has not been demonstrated in many of the high-profile studies. Furthermore, there are growing concerns that the neurologic events that patients experience after trans-catheter therapies occur after the index hospitalization in which the procedure is performed. For example, one study exploring a Medicare database of over 44,000 patients suggested an 86% greater risk of ischemic stroke and a six-fold increase risk of hemorrhagic stroke after trans-catheter therapies when compared to conventional surgery, with many of the events occurring in subsequent readmissions to the hospital within the first year [19]. In fact, the 90-day readmission rate for neurologic events after TAVR was substantially higher than many other cardiac and non-cardiac procedures, including left ventricular assist device placement, cardiac catheterization, surgical aortic valve replacement, and coronary artery bypass procedures [20]. Clearly, the risk of neurologic events after catheter-based valvular interventions requires further objective review.
Such concerns have resulted in a substantial increase in the development and utilization of cerebral protection devices during TAVR. Despite the inherent appeal and considerable cost associated with these protection devices, definitive data demonstrating a clinical improvement and reduction in neurologic events is still lacking [21, 22]. Nevertheless, this is an area of tremendous research and development [23, 24].
4.2 Pacemaker rates
There is no doubt, as demonstrated in almost every major study of TAVR, that this procedure is associated with a much greater risk for needing a permanent pacemaker when compared to conventional surgery. While conduction abnormalities are not uncommon after valve surgery, there is growing concern that the need for a pacemaker after TAVR is neither trivial nor benign. Some large-scale studies suggest a four-fold increase in the need for permanent pacemaker after TAVR [25]. While the long-term consequences of needing a pacemaker are still unclear, especially since the short and long-term natural history of conduction problems after valve replacement is variable, there is evidence to suggest that the need for a pacemaker is associated with worse long-term survival in these patients [26]. Considering the growing emphasis on early discharge and the concern that some of the conduction abnormalities might be physiologically significant and not present until after the index hospitalization, the consequences of such events is still unclear [27].
4.3 Paravalvular leaks
Unlike surgical valve replacement in which the existing stenotic calcified valve is physically removed, TAVR inserts and expands against the existing valve. This fundamental difference in the two procedures can explain why TAVR is still associated with a significantly higher rate of paravalvular leaks – especially in those with eccentric valve pathology or bicuspid valves [28]. Again, the long-term significance of paravalvular leaks is incompletely defined, but without a doubt, those patients with at least moderate leaks have a much worse survival at 2 years than those with mild or less leaks. The PARTNER 2 study, as previously discussed above, demonstrated a 34% risk of mortality in patients with moderate to severe paravalvular leaks, when compared to the 13-14% risk in those with none, trace, or mild leaks [29]
4.4 Durability and cost
Durability and cost remain a considerable concern regarding catheter-based therapies. Although costs vary significantly depending on the intrinsic structure of a health-care system, conflicting evidence regarding the short- and long-term costs of different types of therapy for valvular disease exists. Without a doubt, a surgical valve is substantially less expensive than a catheter-based valve, but the overall costs of the hospitalization and short-term rehabilitation needs might be more. However, factoring in the needs for pacemakers, stroke management, and concomitant coronary disease, there is growing concern surrounding the real-world costs for catheter-based therapies – especially as an increasing number of patients with advanced comorbidities, age, and poor functional status are being treated prior to dying [30, 31].
4.5 Coronary artery interventions
Especially with patients who are older and have multiple comorbidities, the incidence of coronary artery disease further challenges clinical decision-making. Again, despite the appeal of catheter-based solutions to treat both obstructive coronary disease and aortic valve pathology, definitive data directing one therapeutic option over another is lacking. In fact, many of the initial studies exploring the outcomes of one approach over another specifically excluded concomitant coronary procedures or those patients with significant obstructive disease. Nevertheless, criticism of some of the more recent low risk trials is that the surgical patients had a much higher intrinsic risk profile because of the need for concomitant coronary revascularization. In addition, structural characteristics of artificial valves also raises concerns regarding difficulties in coronary access in patients with previous valve replacements (both surgical and TAVR) and further suggests the importance of complete revascularization at the time of definitive valve therapies. As mentioned, many studies specifically excluded patients with combined aortic stenosis and coronary artery disease, and current guidelines tend to favor surgery considering the limitations of the data [32, 33]. Preliminary data also suggests that patients undergoing coronary stenting prior to TAVR may have worse outcomes and increased need for re-interventions due to major adverse cardiac and cerebrovascular events [34, 35].
4.6 Repeat interventions
The area of aortic valve disease that probably is the most supportive of trans-catheter therapies is in patients that have had previous valve replacement, either with a previous surgical valve or a trans-catheter valve. Many patients underwent surgical replacement with a biologic valve, despite established guidelines and a potential survival advantage advocating the use of a mechanical valve under the promise that their next intervention would be a trans-catheter valve [36, 37]. While the appeal of this approach is undeniable and logical, the practical applications are still under considerable study. Conflicting data regarding the best approach for the management of a failing biologic valve is substantial. Even though repeat surgery is not without risks, many experienced centers can offer re-operative surgery with a risk profile similar to first-time valve replacement. Furthermore, there are concerns surrounding a reduction in the effective orifice areas and the risk for patient-prosthesis mismatch after placement of a TAVR inside of a previous surgical or trans-catheter valve.
4.7 Choice of valves
In the surgical era, the choice of valves consisted of tissue valves and mechanical valves. Mechanical valves required life-long anticoagulation and this was often unappealing to patients, despite studies demonstrating a long-term survival advantage. Tissue valves did not require long-term anticoagulation, but were associated with structural degeneration and the need for repeat interventions – often at significant risk as outlined above. Many different types of biologic valves exist – bovine, porcine, homographs, stentless, etc – and there is extensive literature generated over decades of experience regarding the advantages and disadvantages of each valve type. Much of the decision-making regarding the initial valve choice is now under debate with the development of catheter-based therapies that can be used for failing biologic valves. Since the concept (as mentioned above) of “valve-in-a-valve” has altered the natural history of the long-term outcomes associated with biologic valves, there is growing interest in their use in younger patients and in the use of those prosthetic valves with structural characteristics that might lend themselves to a more favorable scaffolding for future re-interventions. Concepts surrounding strut design and annular cracking (or fracking) to increase the annular size to allow for larger replacement valves are rapidly evolving areas of study [38]. Likewise, the choice of transcatheter valve design – annular, supra-annular, self- vs balloon-expanding -- and tissue characteristics are also areas of extensive clinical research and debate.
4.8 Indications for intervention
The guidelines for intervention on critical aortic stenosis have also been evolving to reflect the developments in therapy options. However, there is growing evidence to suggest that adverse, and potentially irreversible, structural changes in the myocardium occur prior to the development of symptoms. Even patients with very advanced disease can have minimal symptoms, and much research is being directed towards, as illustrated by the chapter on strain-rate assessment of valvular disease, more objective tools to assess the pathophysiologic consequences of valvular pathology. Tools such as cardiac magnetic resonance imaging, strain-rate, and stress-echocardiography are becoming more commonly used in complex clinical cases to help direct management decisions.
4.9 Other areas of debate
The list of potential controversial topics in the diagnosis and management of valvular disease is extensive and beyond the scope of a simple chapter or even text. Such areas only illustrate the complexity of valve disease and, especially in the context of newer options for therapy, how there are great opportunities to re-explore the options patients have for aortic valve interventions. Even the methods we have to guide therapies – such as the development of Heart Teams (similar to cancer tumor boards in which each patient’s clinical characteristics and pathologies are reviewed to make an optimal decision based upon expertise and best available data) and “shared decision making” (a concept in which the patient plays a substantial role in deciding how they want to be treated after weighing the pros/cons of the options as presented to them) – continue to evolve [39].
Other areas that only scratch the surface regarding the management of valve disease include:
Endocarditis
Native vs prosthetic valve
Early vs late surgical vs medical management
Re-operative options in the setting of substance abuse
Indications for left-sided vs right-sided valves
Aortic insufficiency
Timing of surgery
Role of catheter-based therapy
Bicuspid valve disease
Associated ascending aortic aneurysms and pathology
Impact of previous cardiac surgery
Special patient populations
End-stage renal disease – i.e. dialysis
Morbid obesity
Small/large aortic roots
Complex co-morbidities
“Younger” patients
Women of child-bearing age
Impact of other co-morbidities
Frailty
End-stage pathologies – i.e. liver, lung, cancers
Age
Role of anticoagulation/anti-platelet agents
Impact on short-term risk for stroke
Risk for tissue or valve degeneration/thickening
Interventions in asymptomatic patients
Impact of and options for concomitant cardiac pathologies
Atrial fibrillation
Obstructive coronary artery disease
Other valvular pathologies
Mitral, tricuspid
Aortic aneurysms
Evolving repair technologies
Prosthetic tissue and structural options
Bovine vs porcine vs non-biologic
Anti-calcification treatments
Stented vs non-stented
Stent material
5. Conclusions
The list of topics that can be reviewed is endless, clearly beyond the scope of a single text, and only serves to illustrates the importance of having a solid foundation in the existing literature, guidelines, and technologies as we move forward with regards to how we objectively assess and manage patient with aortic valve pathology. While patient preferences clearly should have a role, it is imperative that patients and their families be provided with accurate and objective data that take their personal characteristics into consideration so that their decisions can be properly guided with the goal of optimizing their opportunities for an ideal short- and long-term outcome. Hopefully, texts such as this along with multi-disciplinary Heart Teams can help improve these short- and long-term outcomes in terms of quality and quantity of life for those patients with significant valvular pathology.
Conflict of interest
Dr Firstenberg serves as a heart valve repair and replacement educational consultant for Medtronic plc. Dr Hanna reports no conflicts of interest or relevant disclosures in the context of the material presented in this chapter.
References
- 1.
Iung B, Baron G, Butchart EG, Delahaye F. Gohlke-Brwolf C, Levang OW, Tornos P, Vanoverschelde JL, Vermeer F, Boersma E, Ravaud P, Alec Vahanian. A prospective survey of patients with valvular heart disease in Europe: The Euro Heart Survey on Valvular Heart Disease. Eu Heart J. 2003;24:1231-43 - 2.
Lester SJ, Heilbron B, Gin K, Dodek A, Jue J. The natural history and rate of progression of aortic stenosis. Chest. 1998 Apr 1;113(4):1109-14 - 3.
Perera S, Wijesinghe N, Ly E, Devlin G, Pasupati S. Outcomes of patients with untreated severe aortic stenosis in real-world practice. NZ Med J. 2011 Nov 4;124(1345):40-8 - 4.
Thourani VH, Suri RM, Gunter RL, Sheng S, O’Brien SM, Ailawadi G, Szeto WY, Dewey TM, Guyton RA, Bavaria JE, Babaliaros V. Contemporary real-world outcomes of surgical aortic valve replacement in 141,905 low-risk, intermediate-risk, and high-risk patients. The Annals of thoracic surgery. 2015 Jan 1;99(1):55-61 - 5.
http://riskcalc.sts.org/stswebriskcalc/calculate - 6.
Holmes DR, Rich JB, Zoghbi WA, Mack MJ. The heart team of cardiovascular care. Journal of the American College of Cardiology. 2013 Mar 5;61(9):903-7 - 7.
Mack MJ, Leon MB, Smith CR, Miller DC, Moses JW, Tuzcu EM, Webb JG, Douglas PS, Anderson WN, Blackstone EH, Kodali SK. 5-year outcomes of transcatheter aortic valve replacement or surgical aortic valve replacement for high surgical risk patients with aortic stenosis (PARTNER 1): a randomised controlled trial. The Lancet. 2015 Jun 20;385(9986):2477-84 - 8.
Gleason TG, Reardon MJ, Popma JJ, Deeb GM, Yakubov SJ, Lee JS, Kleiman NS, Chetcuti S, Hermiller JB, Heiser J, Merhi W. 5-Year outcomes of self-expanding transcatheter versus surgical aortic valve replacement in high-risk patients. Journal of the American College of Cardiology. 2018 Dec 4;72(22):2687-96 - 9.
Popma JJ, Deeb GM, Yakubov SJ, Mumtaz M, Gada H, O’Hair D, Bajwa T, Heiser JC, Merhi W, Kleiman NS, Askew J. Transcatheter aortic-valve replacement with a self-expanding valve in low-risk patients. New England Journal of Medicine. 2019 May 2;380(18):1706-15 - 10.
Reardon MJ, Van Mieghem NM, Popma JJ, Kleiman NS, Søndergaard L, Mumtaz M, Adams DH, Deeb GM, Maini B, Gada H, Chetcuti S. Surgical or transcatheter aortic-valve replacement in intermediate-risk patients. New England Journal of Medicine. 2017 Apr 6;376(14):1321-31 - 11.
Søndergaard L, Popma JJ, Reardon MJ, Van Mieghem NM, Deeb GM, Kodali S, George I, Williams MR, Yakubov SJ, Kappetein AP, Serruys PW. Comparison of a complete percutaneous versus surgical approach to aortic valve replacement and revascularization in patients at intermediate surgical risk: results from the randomized SURTAVI trial. Circulation. 2019 Oct 15;140(16):1296-305 - 12.
Brennan JM, Thomas L, Cohen DJ, Shahian D, Wang A, Mack MJ, Holmes DR, Edwards FH, Frankel NZ, Baron SJ, Carroll J. Transcatheter versus surgical aortic valve replacement: propensity-matched comparison. Journal of the American College of Cardiology. 2017 Jul 25;70(4):439-50 - 13.
Witberg G, Lador A, Yahav D, Kornowski R. Transcatheter versus surgical aortic valve replacement in patients at low surgical risk: a meta-analysis of randomized trials and propensity score matched observational studies. Catheterization and Cardiovascular Interventions. 2018 Aug 1;92(2):408-16 - 14.
Takagi H, Mitta S, Ando T, ALICE (All-Literature Investigation of Cardiovascular Evidence) group. Long-term survival after transcatheter versus surgical aortic valve replacement for aortic stenosis: A meta-analysis of observational comparative studies with a propensity-score analysis. Catheterization and Cardiovascular Interventions. 2018 Aug 1;92(2):419-30 - 15.
Mack MJ, Leon MB, Thourani VH, Makkar R, Kodali SK, Russo M, Kapadia SR, Malaisrie SC, Cohen DJ, Pibarot P, Leipsic J. Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients. New England Journal of Medicine. 2019 May 2;380(18):1695-705 - 16.
Shahim B, Malaisrie SC, George I, Thourani V, Russo M, Biviano A, Mack M, Brown DL, Babaliaros V, Guyton R, Kodali S. TCT CONNECT-468 Postoperative Atrial Fibrillation or Flutter Following Transcatheter or Surgical Aortic Valve Replacement for Severe Aortic Stenosis in Patients at Low Surgical Risk: An Analysis From the PARTNER 3 Trial. Journal of the American College of Cardiology. 2020 Oct 27;76(17 Supplement S):B200- - 17.
Finkelstein A, Rozenbaum Z, Halkin A, Banai S, Bazan S, Barbash I, Segev A, Fefer P, Maor E, Danenberg H, Planner D. Outcomes of transcatheter aortic valve implantation in patients with low versus intermediate to high surgical risk. The American journal of cardiology. 2019 Feb 15;123(4):644-9 - 18.
Klautz RJ, Kappetein AP, Lange R, Dagenais F, Labrousse L, Bapat V, Moront M, Misfeld M, Zeng C, Sabik III JF, PERIGON Investigators. Safety, effectiveness and haemodynamic performance of a new stented aortic valve bioprosthesis. European Journal of Cardio-Thoracic Surgery. 2017 Sep 1;52(3):425-31 - 19.
Stein L, Thaler A, Liang JW, Tuhrim S, Dhamoon AS, Dhamoon MS. Intermediate-Term Risk of Stroke Following Cardiac Procedures in a Nationally Representative Data Set. Journal of the American Heart Association. 2017 Dec 2;6(12):e006900 - 20.
Stein LK, Thaler A, Liang JW, Tuhrim S, Dhamoon AS, Dhamoon MS. Intermediate Risk of Stroke Following Cardiac Procedures in a Nationally Representative Dataset. InANNALS OF NEUROLOGY 2017 Oct 1 (Vol. 82, pp. S49-S49). 111 RIVER ST, HOBOKEN 07030-5774, NJ USA: WILEY - 21.
Giustino G, Sorrentino S, Mehran R, Faggioni M, Dangas G. Cerebral embolic protection during TAVR: a clinical event meta-analysis. Journal of the American College of Cardiology. 2017 Jan 31;69(4):465-6 - 22.
Ndunda PM, Vindhyal MR, Muutu TM, Fanari Z. Clinical outcomes of sentinel cerebral protection system use during transcatheter aortic valve replacement: a systematic review and meta-analysis. Cardiovascular Revascularization Medicine. 2020 Jun 1;21(6):717-22 - 23.
Haussig S, Mangner N, Dwyer MG, Lehmkuhl L, Lücke C, Woitek F, Holzhey DM, Mohr FW, Gutberlet M, Zivadinov R, Schuler G. Effect of a cerebral protection device on brain lesions following transcatheter aortic valve implantation in patients with severe aortic stenosis: the CLEAN-TAVI randomized clinical trial. Jama. 2016 Aug 9;316(6):592-601 - 24.
Alkhouli M, Alqahtani F, Harris AH, Hohmann SF, Rihal CS. Early Experience With Cerebral Embolic Protection During Transcatheter Aortic Valve Replacement in the United States. JAMA internal medicine. 2020 May 1;180(5):783-4 - 25.
Subramani S, Arora L, Krishnan S, Hanada S, Sharma A, Ramakrishna H. Analysis of Conduction Abnormalities and Permanent Pacemaker Implantation After Transcatheter Aortic Valve Replacement. Journal of Cardiothoracic and Vascular Anesthesia. 2020 Apr 1;34(4):1082-93 - 26.
Fujita B, Schmidt T, Bleiziffer S, Bauer T, Beckmann A, Bekeredjian R, Möllmann H, Walther T, Landwehr S, Hamm C, Beyersdorf F. Impact of new pacemaker implantation following surgical and transcatheter aortic valve replacement on 1-year outcome. European Journal of Cardio-Thoracic Surgery. 2020 Jan 1;57(1):151-9 - 27.
Mazzella AJ, Hendrickson MJ, Arora S, Sanders M, Li Q, Vavalle JP, Gehi AK. Shifting Trends in Timing of Pacemaker Implantation After Transcatheter Aortic Valve Replacement. Cardiovascular Interventions. 2020 Nov 9 - 28.
Pollari F, Dell'Aquila AM, Söhn C, Marianowicz J, Wiehofsky P, Schwab J, Pauschinger M, Hitzl W, Fischlein T, Pfeiffer S. Risk factors for paravalvular leak after transcatheter aortic valve replacement. The Journal of thoracic and cardiovascular surgery. 2019 Apr 1;157(4):1406-15 - 29.
Leon MB, Smith CR, Mack MJ, Makkar RR, Svensson LG, Kodali SK, Thourani VH, Tuzcu EM, Miller DC, Herrmann HC, Doshi D. Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. New England Journal of Medicine. 2016 Apr 28;374(17):1609-20 - 30.
Armoiry X, Obadia JF, Iung B, Polazzi S, Duclos A. Clinical outcomes and direct costs after transcatheter aortic valve implantation in French centres: a longitudinal study of 1332 patients using a national database. Interactive cardiovascular and thoracic surgery. 2016 Dec 1;23(6):883-8 - 31.
Baron SJ, Wang K, House JA, Magnuson EA, Reynolds MR, Makkar R, Herrmann HC, Kodali S, Thourani VH, Kapadia S, Svensson L. Cost-effectiveness of transcatheter versus surgical aortic valve replacement in patients with severe aortic stenosis at intermediate risk: results from the PARTNER 2 trial. Circulation. 2019 Feb 12;139(7):877-88 - 32.
El-Haddad H, Resar J. Stenting the Snorkel: PCI of a Restenosed Left Main Stent Placed for Coronary Obstruction after Valve in Valve TAVR. Journal of Structural Heart Disease. 2019 Apr;5(2):48-51 - 33.
Voudris KV, Petropulos P, Karyofillis P, Charitakis K. Timing and Outcomes of PCI in the TAVR Era. Current treatment options in cardiovascular medicine. 2018 Mar 1;20(3):22 - 34.
Faroux L, Campelo-Parada F, Munoz-Garcia E, Nombela-Franco L, Fischer Q, Donaint P, Serra V, Veiga G, Gutiérrez E, Vilalta V, Alperi A. Procedural Characteristics and Late Outcomes of Percutaneous Coronary Intervention in the Workup Pre-TAVR. JACC: Cardiovascular Interventions. 2020 Oct 14 - 35.
Tarus A, Tinica G, Bacusca A, Artene B, Popa IV, Burlacu A. Coronary revascularization during treatment of severe aortic stenosis: A meta-analysis of the complete percutaneous approach (PCI plus TAVR) versus the complete surgical approach (CABG plus SAVR). Journal of Cardiac Surgery. 2020 Aug;35(8):2009-16 - 36.
Goldstone AB, Chiu P, Baiocchi M, Lingala B, Patrick WL, Fischbein MP, Woo YJ. Mechanical or biologic prostheses for aortic-valve and mitral-valve replacement. New England Journal of Medicine. 2017 Nov 9;377(19):1847-57 - 37.
Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Fleisher LA, Jneid H, Mack MJ, McLeod CJ, O’Gara PT, Rigolin VH. 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology. 2017 Jul 3;70(2):252-89 - 38.
James TM, Stamou SC, Rothenberg M, Nores MA. Transcatheter aortic valve in valve implantation with bioprosthetic valve fracture. Catheterization and Cardiovascular Interventions. 2019 May 1;93(6):1170-2 - 39.
Coylewright M, Forrest JK, McCabe JM, Nazif TM. TAVR in low-risk patients: FDA approval, the new NCD, and shared decision-making. Journal of the American College of Cardiology. 2020 Mar 17;75(10):1208-11