483

John G. Webb, David A. Wood

Transcatheter aortic valve replacement (TAVR) is the new standard of care for patients with symptomatic aortic stenosis who are deemed “inoperable.” Webb and Wood argue that new data show that TAVR should also be the preferred alternative to surgical AVR in selected high-risk, but still operable, patients. Ongoing refinement of transcatheter valve systems, techniques, and patient selection are making TAVR an increasingly appealing option for a broader range of moderate-risk patients.

493

Lutz Buellesfeld, Stefan Stortecky, Dik Heg, Sven Hausen, Ralf Mueller, Peter Wenaweser, Thomas Pilgrim, Steffen Gloekler, Ahmed A. Khattab, Christoph Huber, Thierry Carrel, Balthasar Eberle, Bernhard Meier, Peter Boekstegers, Peter Jüni, Ulrich Gerckens, Eberhard Grube, Stephan Windecker

Transcatheter aortic valve implantation (TAVI) causes atrioventricular-conduction abnormalities requiring permanent pacemaker (PPM) implantation in up to 40% of patients treated with self-expanding prostheses. Buellesfeld and colleagues sought to determine if this affects post-TAVI clinical outcomes. Out of 353 patients, 28% required a new PPM, 14% had a prior PPM, and 59% did not have or require a PPM. At 12 months' follow-up, all-cause mortality was similar in all 3 groups at about 20%. Peri-procedural PPM implantation does not appear to adversely affect clinical outcomes among patients undergoing transfemoral TAVI.

502

Anna Sonia Petronio, Marco De Carlo, Francesco Bedogni, Francesco Maisano, Federica Ettori, Silvio Klugmann, Arnaldo Poli, Antonio Marzocchi, Gennaro Santoro, Massimo Napodano, Gian Paolo Ussia, Cristina Giannini, Nedy Brambilla, Antonio Colombo

Petronio and colleagues assessed the procedural and 2-year results of the subclavian approach for transcatheter aortic valve implantation (TAVI). Subclavian approach was used in 141 patients in the Italian CoreValve Registry who had unsuitable femoral artery anatomy and were compared to 141 patients who underwent a femoral approach. The 2 groups showed similar procedural success, major vascular complications, life-threatening bleedings, and the combined safety endpoint. The subclavian group showed lower rates of acute kidney injury stage 3 and of minor vascular complications at the 18-F sheath insertion site. These results shows that the subclavian approach for TAVI is safe and feasible, and suggest that subclavian access should be considered a valid option not only when the femoral approach is impossible, but also when it is difficult.

508

Rachel H. Mackey, Philip Greenland, David C. Goff, Jr, Donald Lloyd-Jones, Christopher T. Sibley, Samia Mora

Mackey and colleagues evaluated the independent associations of high-density lipoprotein cholesterol (HDL-C) and particle (HDL-P) concentrations with carotid intima-media thickness (cIMT) and incident coronary heart disease (CHD) in subjects enrolled in the MESA (Multi-Ethnic Study of Atherosclerosis) trial. HDL-C and HDL-P correlated with each other and inversely with low-density lipoprotein particle (LDL-P), cIMT, and the risk of CHD. In a multivariable model adjusting for LDL-P, HDL-C was no longer associated with cIMT or CHD, but HDL-P was. The authors speculate that more HDL-P may equal higher reverse cholesterol transport capacity or the benefits may be related to HDL's protein or other cargo (e.g., apolipoprotein A-I, paraoxonase-1, myeloperoxidase) rather than to its cholesterol cargo.

Editorial Comment: Emil M. deGoma, Daniel J. Rader, p.517

521

Andrew D. M. Grant, Nicholas G. Smedira, Randall C. Starling, Thomas H. Marwick

Grant and colleagues sought to determine if quantifying pre-operative right ventricle (RV) function would aid in predicting RV failure in patients undergoing left ventricular assist devices (LVAD) implantation. Clinical, hemodynamic, and echocardiographic data were collected on 117 patients prior to LVAD insertion including velocity vector imaging of RV free wall longitudinal strain. There was a significant difference in peak strain between patients with and without RV failure. A peak strain cutoff of −9.6% predicted RV failure with 76% specificity and 68% sensitivity and was incremental to the Michigan Risk Score. Measuring RV free wall peak longitudinal strain can help to identify patients at increased risk of RV failure after LVAD implantation.

Editorial Comment: John P. Boehmer, p.529

531

Luigi Di Biase, Pasquale Santangeli, Matteo Anselmino, Prasant Mohanty, Ilaria Salvetti, Sebastiano Gili, Rodney Horton, Javier E. Sanchez, Rong Bai, Sanghamitra Mohanty, Agnes Pump, Mauricio Cereceda Brantes, G. Joseph Gallinghouse, J. David Burkhardt, Federico Cesarani, Marco Scaglione, Andrea Natale, Fiorenzo Gaita

Di Biase and colleagues studied the left atrial appendage (LAA) shape by computed tomography (CT) and/or magnetic resonance imaging (MRI) to correlate different LAA morphologies with the risk of stroke or transient ischemia attack (TIA) in patients with atrial fibrillation (AF). LAAs were categorized into 4 different morphologies: Cactus, Chicken Wing, Windsock, and Cauliflower. Nearly one-half were classified as Chicken Wing with an obvious bend in the proximal or middle part of the dominant lobe, or folding back of the LAA anatomy. After controlling for CHADS₂ score and AF type in a multivariable logistic model, those with Chicken Wing morphology had a 79% lower risk of prior stroke/TIA. These results suggest that LAA morphology influences the risk of stroke in patients with AF and may play a role in guiding anticoagulation strategies of patients with a low-intermediate CHADS₂ score.

539

Babar Parvez, Joseph Vaglio, Shane Rowan, Raafia Muhammad, Gayle Kucera, Tanya Stubblefield, Shannon Carter, Dan Roden, Dawood Darbar

Recent genome-wide association studies have identified 3 loci, on chromosomes 4q25 that associate with either typical or lone atrial fibrillation (AF). Parvez and colleagues hypothesized that these loci may alter the efficacy of antiarrhythmic drugs (AADs) used to treat AF. Patients had their AAD chosen without knowledge of their genetic profile. Successful rhythm control was defined as the patient remaining on the same AAD therapy for a minimum of 6 months with ≥75% reduction in symptomatic AF burden. In the discovery cohort, one of the loci was significantly associated with successful rhythm control, while clinical factors were not. Similar findings were found in a validation cohort. These results suggest that this polymorphism modulates response to AAD therapy and points to a potential role for stratification of therapeutic approaches by genotype.

Editorial Comment: James P. Daubert, Geoffrey S. Pitt, p.546

548

Matthew R. Reynolds, Elizabeth A. Magnuson, Kaijun Wang, Vinod H. Thourani, Mathew Williams, Alan Zajarias, Charanjit S. Rihal, David L. Brown, Craig R. Smith, Martin B. Leon, David J. Cohen, on behalf of the PARTNER Trial Investigators

Reynolds and colleagues compared health status and quality-of-life outcomes for patients with severe aortic stenosis (AS) and high surgical risk randomized to either transcatheter or surgical aortic valve replacement (TAVR or SAVR). Health status was assessed at baseline, 1, 6, and 12 months using the Kansas City Cardiomyopathy Questionnaire (KCCQ). The KCCQ summary score improved more rapidly with TAVR, but was similar for the 2 groups at 6 and 12 months. Further analysis showed that subjects treated with a transfemoral (TF) approach had significant health status benefits at 1 month, whereas patients treated via the transapical (TA) approach had no benefit over SAVR at any timepoint. These results confirm the benefits of TAVR via the TF approach over SAVR, but the lack of benefit with the TA approach warrants caution and further investigation.