Predictors and outcomes of stroke after transcatheter aortic valve replacement.

OBJECTIVES: Stroke is a devastating complication of transcatheter aortic valve replacement (TAVR). Many studies have investigated risk factors for postoperative stroke, but reliable predictors are not yet well-established. The objective of this study was to further characterize the predictors and outcomes of stroke after TAVR. METHODS: This is a retrospective cohort study of 1022 patients who underwent TAVR at a single institution between 2012 and 2018. Multivariable logistic regression analysis was used to identify independent predictors of postoperative stroke and Kaplan-Meier method to compare 1-year survival in patients with and without postoperative stroke. RESULTS: Postoperatively, 36 patients experienced a stroke (3.5%) with most developing multiple (63.9%, N = 23), and often bilateral infarcts (50.0%, N = 18). Stroke patients more commonly had peripheral arterial disease (P = .032) and carotid stenosis (P = .013) and were less likely to receive predeployment balloon aortic valvuloplasty (P = .005). Alternative access approach (odds ratio [OR], 2.322; 95% confidence interval [CI]: 1.067-5.054) and history of transient ischemic attack (OR, 2.373; 95% CI: 1.026-5.489) were identified as independent predictors of postoperative stroke. Stroke patients more frequently developed postoperative complications, including prolonged ventilation (P < .001), major vascular complications (P < .001), and new-onset dialysis (P < .001). Operative mortality was greater in stroke patients (19.4% vs 3.7%; P < .001), and 1-year Kaplan-Meier estimates revealed worsened survival (log-rank P = .002). CONCLUSIONS: Alternative access approach and a history of transient ischemic attack emerged as independent predictors of postoperative stroke. Patients with stroke suffered more complications and had worse survival, underscoring the importance of characterizing the stroke risk in these patients.

Predictors and outcomes of patient-prosthesis mismatch after transcatheter aortic valve replacement.

BACKGROUND: Patient-prosthesis mismatch (PPM) has been shown to be associated with adverse outcomes after surgical aortic valve replacement. There is limited data on its risk and impact after transcatheter aortic valve replacement (TAVR), especially with the newer generation heart valves. OBJECTIVES: The objective of this study is to investigate the incidence, predictors, and clinical outcomes of PPM after TAVR. METHODS: This is a retrospective study of 991 consecutive patients who underwent TAVR procedure at a tertiary referral center, between April 2012 and February 2019. Patients were stratified by the presence or absence of PPM, defined as an effective orifice area/body surface area ratio ≤0.85 cm2 /m2 . Multivariable logistic regression analysis was used to determine independent predictors of PPM. Kaplan-Meier survival estimates were used to determine overall 5-year survival. RESULTS: PPM was encountered in 27.6% of patients. In multivariable analysis, age less than 70 years (P = .062), body mass index (BMI) more than 30 (P = .0057), history of atrial fibrillation (P = .0004), black race (P = .0078), and Sapien 3 sizes 20 and 23 mm (P < .0001)emerged as independent predictors of PPM. Sapien 3 valve size 20/23 mm was associated with higher risk of PPM compared to other valve types. Patients with PPM had comparable postoperative outcomes and overall 5-year survival. There was no significant difference in postoperative complications between patient groups. PPM was not associated with worse overall survival (56% for both PPM and no-PPM patients, log-rank P = .80). CONCLUSIONS: Younger age, atrial fibrillation, black race, higher BMI were predictors of PPM. Smaller sizes balloon-expandable valves had a higher risk of PPM.

Alternative Access Versus Transfemoral Transcatheter Aortic Valve Replacement in Nonagenarians.

OBJECTIVES: Previous studies suggest that alternative access (AA) such as transapical (TA) approach to transcatheter aortic valve replacement (TAVR) is inferior to transfemoral (TF) approach. However, there is a paucity of data characterizing these outcomes, and studies often do not consider transaortic (TAO) and transaxillary (TAX) TAVR approaches. Therefore, the purpose of this study was to compare the outcomes of nonagenarians undergoing AA-TAVR compared to TF-TAVR. METHODS: A concurrent cohort study of 148 consecutive nonagenarian patients (≥90 years old) undergoing TAVR from April 2012 to July 2017 was carried out. We stratified the patient cohort into two groups based on access approach: TF-TAVR (n = 112); and AA-TAVR (n = 36), which included TA (n = 24), TAX (n = 8), and TAO (n = 4) approaches. Preoperative, operative, and postoperative outcomes and 5-year actuarial survival rates were analyzed. RESULTS: Compared to TF-TAVR, patients undergoing AA-TAVR were more likely to require blood transfusions (28% vs 69%; P<.001) and readmission (16% vs 58%; P<.001). AA-TAVR also resulted in significantly higher rates of postoperative complications, such as stroke (1% vs 8%; P=.02) and atrial fibrillation (19% vs 36%; P=.03). There was no significant difference in aortic valve gradients (P>.05), operative mortality rate (6% vs 8%; P=.66), or actuarial 5-year survival rate (68% vs 44%, log-rank P=.10). CONCLUSION: There is a higher risk of adverse events following AA-TAVR compared with TF-TAVR. Therefore, TF-TAVR is recommended when feasible, with AA approach as a viable back-up option in nonagenarians.