Should brain natriuretic peptides be measured in patients with aortic valve disease?

This editorial refers to ‘Relation of N-terminal pro B-typenatriuretic peptide to progression of aortic valve disease’by Weber et al., on page 1023 Close to 3% of the population over the age of 65 suffers fromsignificant aortic valve disease, a figure likely to rise inour aging population. The current guidelines reflect the ampleevidence supporting surgical intervention in symptomatic patients.¹However, optimal treatment of asymptomatic patients with severedisease remains undetermined. The risk of surgical interventionoutweighs the risk of sudden cardiac death in asymptomatic patientswith severe aortic     

Is an antithrombotic strategy after transcatheter aortic valve implantation clearer now?

Journal of Thrombosis and Thrombolysis -     

Frequency of congenitally bicuspid aortic valves in patients ≥80 years of age undergoing aortic valve replacement for aortic stenosis (with or without aortic regurgitation) and implications for transcatheter aortic valve implantation

The purpose of the present report was to determine the frequency of a congenitally bicuspid aortic valve in patients ≥80 years of age old with aortic stenosis (AS) severe enough to warrant aortic valve replacement. Transcatheter aortic valve implantation (TAVI) has traditionally been reserved for patients ≥80 years of age with severe AS involving a 3-cuspid aortic valve. Traditionally, AS involving a 2-cuspid aortic valve has been a contraindication to TAVI. We examined operatively excised stenotic aortic valves in 364 patients aged ≥80 years to determine the frequency of an underlying congenitally bicuspid aortic valve. Of the 347 octogenarians and 17 nonagenarians, 78 (22%) and 3 (18%) had stenotic congenitally bicuspid aortic valves, respectively. In conclusion, because the results of TAVI are less favorable in patients with stenotic congenitally bicuspid valves than in patients with stenotic tricuspid aortic valves, proper identification of the underlying aortic valve structure is important when considering TAVI as a therapeutic procedure for AS in older patients.     

Is balloon aortic valvuloplasty safe in patients with significant aortic valve regurgitation?

Objectives: To assess safety and effectiveness of balloon aortic valvuloplasty (BAV) in patients with symptomatic severe aortic stenosis (AS) and significant aortic regurgitation. Background: BAV is a palliative procedure that has possibly been underused in patients with symptomatic AS not suitable for surgical aortic valve replacement or transcatheter aortic valve implantation. Significant aortic regurgitation is commonly perceived as a contraindication to BAV. Methods: Among 416 consecutive patients undergoing BAV at our Institution, 73 patients showed moderate or severe AR before the procedure. Demographics and baseline characteristics, as well as in‐hospital clinical outcome, have been prospectively collected in a dedicated database. Transthoracic echocardiography was regularly performed in all patients undergoing BAV before the procedure and at hospital discharge. Results: Patients had a high‐risk profile, confirmed by advanced age (77.2 ± 11.8 years) and important comorbidity (logistic Euroscore 26.5 ± 16.3%). Advanced heart failure was present in 73.9%. Indication to BAV was cardiogenic shock in 9.6%, palliation in 31.5%, bridge in 58.9% of the patients. BAV was performed with standard retrograde approach. Aortic valve area increased from 0.62 ± 0.15 cm² at baseline to 0.83 ± 0.17 cm² before discharge (P < 0.001). The degree of AR was improved or unchanged in 65 patients (89%). In‐hospital mortality was 6.9%, mainly limited to terminal patients. Symptomatic status at discharge was improved in all surviving patients. Acute AR occurred in seven patients; in five of them it was successfully resolved in the catheterization laboratory. Conclusions: When clinically indicated, BAV can be safely performed in patients with combined aortic stenosis and significant aortic regurgitation. © 2011 Wiley Periodicals, Inc.     

Change in quality of life after transcatheter aortic valve implantation and aortic valve replacement surgery in Australian patients aged ≥ 75 years: the effects of EuroSCORE and patient operability

Objective To determine the extent to which differences in generic quality of life (QOL) between transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (AVR) patients explained by EuroSCORE and heart-team operability assessment. Methods A total of 146 high-risk patients with EuroSCORE > 6 and aged ≥ 75 years underwent TAVI (n = 80) or aortic valve replacement (n = 66) between February 2010 and July 2013. A total of 75 patients also completed preoperative and six month SF-12 QOL measures. Analyses examined incident major morbidity, compared six month QOL between groups adjusted for EuroSCORE and operability, and quantified rates of clinically significant QOL improvement and deterioration. Results The AVR group required longer ventilation (> 24 h) (TAVI 5.0% vs. AVR 20.6%, P = 0.004) and more units of red blood cells [TAVI 0 (0–1) vs. AVR 2 (0–3), P = 0.01]. New renal failure was higher in TAVI (TAVI 5.0% vs. AVR 0%, P = 0.06). TAVI patients reported significantly lower vitality (P = 0.01) by comparison to AVR patients, however these findings were no longer significant after adjustment for operability. In both procedures, clinically significant QOL improvement was common [range 25.0% (general health) – 62.9% (physical role)] whereas deterioration in QOL occurred less frequently [range 9.3% (physical role) – 33.3% (mental health)]. Conclusions Clinically significant improvement and deterioration in QOL was evident at six months in high risk elderly aortic valve replacement patients. Overall QOL did not differ between TAVI and AVR once operability was taken into consideration.     

Electrocardiographic evolution of interatrial conduction consistent with Bayés syndrome after transcatheter aortic valve implantation

Journal of Interventional Cardiac Electrophysiology -     

Comprehensive geriatric assessment in patients undergoing transcatheter aortic valve implantation–rationale and design of the European CGA-TAVI registry

PurposeAortic stenosis (AS) is the most common valvular abnormality in the elderly population. For inoperable patients or those at high-risk for surgery, transcatheter aortic valve implantation (TAVI) has become an alternative therapeutic option. The aim of the “Comprehensive geriatric assessment for transcatheter aortic valve implantation” (CGA-TAVI) registry is to evaluate the effectiveness of TAVI from the perspective of the geriatrician and to identify patient characteristics and indicators related to complications and clinical benefits for patients with symptomatic severe calcified degenerative AS undergoing TAVI.Materials and methodsThe CGA-TAVI registry is an international, multi-center, prospective, observational registry across Europe with consecutive patient enrolment. The registry will enrol up to 200 patients with AS undergoing TAVI, starting August 2013. CGA-TAVI has two co-primary objectives: (1) Establish predictive value of Comprehensive geriatric assessment (CGA) for mortality and/or hospitalization in TAVI patients. (2) Demonstrate CGA changes within 3 months after TAVI. Secondary objectives are: (1) Establish predictive value of CGA in TAVI patients for all-cause hospitalization, TAVI-related hospitalization, and nursing home admission. (2) Develop a comprehensive score for the assessment of TAVI patient prognosis.ConclusionsThe data obtained from the CGA-TAVI registry will supplement previous results to document the potential value of the effectiveness of TAVI from the perspective of geriatricians and will allow the assessment of the predictive value of CGA for mortality and/or hospitalization in elderly TAVI patients.     

A call to action - Geriatricians’ experience in treatment of aortic stenosis and involvement in transcatheter aortic valve implantation

Aortic stenosis (AS) represents a significant healthcare burden in the elderly population. For inoperable patients or those at high-risk for surgery, transcatheter aortic valve implantation (TAVI) has become an alternative therapeutic option. The recently conducted European Union Geriatric Medicine Society (EUGMS) TAVI survey found that the involvement of geriatricians in the management of patients undergoing TAVI is generally low. Because of the complexity and rapidly progressive nature of severe AS, a geriatrician should be involved because of the need for a comprehensive geriatric patient assessment that may ameliorate or delay disability, cognitive dysfunction or nutritional status and their impact on clinical outcomes. Therefore, the EUGMS is currently setting up a prospective, observational study, designed to evaluate the effectiveness of TAVI from the perspective of the geriatrician (Transcatheter Aortic Valve Implantation Registry with Comprehensive Geriatric Assessment, CGA-TAVI). CGA-TAVI will investigate the prognostic relevance of clinical, cognitive, functional, nutritional, and social parameters and is carried out using six standardized scales and information on medications and social support network. Taken together, there is considerable potential for increased involvement of geriatricians in the management of elderly patients with severe asymptomatic AS. The input of geriatricians is invaluable to informed decision-making related to the prognosis and risk status of frail and/or elderly patients. The EUGMS recommends that geriatricians should be involved at an early stage of patient management, and should have a substantial impact on decision-making, rehabilitation and long-term care of elderly patients with AS, requiring valve replacement therapy.