Search

Patients with severe aortic stenosis and considered at high surgical risk or inoperable, and not eligible for a randomized clinical trial evaluating percutaneous aortic valve replacement (PAVR), were studied. Many of the patients referred to the study did not meet the inclusion criteria and/or had conditions listed in the exclusion criteria. These patients were then deferred to other treatment modalities. The study cohort consisted of 285 patients with severe aortic stenosis referred to participate in a clinical trial of PAVR. Patients were screened for eligibility on the basis of the protocol inclusion and exclusion criteria and deferred to other treatment modalities if they did not meet the enrollment criteria. Those patients were followed clinically by telephone contact or office visits. Of the 285 patients referred for PAVR, 216 (75.8%) were not included. The leading reasons for lack of eligibility were significant peripheral vascular disease in 50 (23.1%), Society of Thoracic Surgeons score <10% in 48 (22.9%), aortic valve area >0.8 cm2 in 30 (13.9%), significant coronary artery disease in 25 (11.6%), and renal failure in 22 (10.2%). Sixty-nine of these patients (31.9%) were treated medically, 102 (47.2%) with balloon aortic valvuloplasty, and 45 (20.9%) with surgical aortic valve replacement. Major baseline characteristics were similar. Society of Thoracic Surgeons scores were lower in the surgical group compared with the medical and balloon aortic valvuloplasty groups (10.2 ± 2.5 vs 12.8 ± 3.3 vs 13.7 ± 3.3, respectively, p <0.001). During a median follow-up period of 175.5 days (range 55.7 to 344.75), the mortality rate was higher in the balloon aortic valvuloplasty group compared with the medical and surgical aortic valve replacement groups (46 [45.1%] vs 22 [31.9%] vs 10 [22.2%], respectively, p = 0.01). In conclusion, high-risk patients with severe aortic stenosis who are deferred from PAVR often do poorly and incur high mortality rates, especially when treated with balloon valvuloplasty or medical therapy, while a loss of quality of life is apparent in those treated surgically. [Copyright &y& Elsevier]

We sought to determine the outcome with undersized drug-eluting stents for percutaneous coronary intervention of saphenous vein graft lesions. Using intravascular ultrasound guidance, 209 saphenous vein graft lesions were treated with drug-eluting stents (153 sirolimus-eluting and 56 paclitaxel-eluting stents). The lesions were divided into 3 groups according to the ratio of the stent diameter to the average intravascular ultrasound reference lumen diameter: group I, <0.89; group II, 0.9 to 1.0; and group III, >1.0. Angiographic no-reflow was defined as a Thrombolysis In Myocardial Infarction flow grade of 0, 1, and 2 after percutaneous coronary intervention. Plaque intrusion was defined as tissue extrusion through the stent struts. Stent malapposition was defined as one or more stent struts that had clearly separated from the vessel wall with evidence of blood speckles behind the strut. No significant differences were found in the use of distal protection devices (group I, 44%; group II, 35%; and group III, 36%; p = 0.5); and no significant differences were found in the incidence of stent malapposition among the 3 groups (group I, 21%; group II, 42%; and group III, 52%; p = 0.001). The plaque intrusion area (group I, 0.13 ± 0.30 mm2; group II, 0.25 ± 0.42 mm2; and group III, 0.31 ± 0.40 mm2; p = 0.018) and plaque intrusion volume (group I, 0.25 ± 0.68 mm3; group II, 0.40 ± 0.68 mm3; and group III, 0.75 ± 1.34 mm3; p = 0.007) were smallest in group I. The plaque intrusion area and plaque intrusion volume correlated with the ratio of the stent diameter to the average intravascular ultrasound reference lumen diameter (r = 0.278, p <0.001 and r = 0.283, p <0.001, respectively). The incidence of a creatine kinase-MB elevation >3 times normal was 6% in group I, 9% in group II, and 19% in group III (p = 0.025). No significant differences were found in the incidence of 1-year target lesion revascularization (group I, 13%; group II, 9%; and group III, 15%; p = 0.5) or target vessel revascularization (group I, 13%; group II, 13%; and group III, 15%; p = 0.9) among the 3 groups. In conclusion, the use of undersized drug-eluting stents to treat patients with saphenous vein graft lesions is associated with a reduction in the frequency of post-percutaneous coronary intervention creatine kinase-MB elevation without an increase in 1-year events. [Copyright &y& Elsevier]

Continued controversy surrounds the optimal therapeutic approach to the patient who does not undergo percutaneous coronary intervention (PCI) early during acute myocardial infarction, when ischemic myocardium could still be salvaged, and who presents days to weeks after the acute event with persistent total occlusion of the infarct-related coronary artery. The Occluded Artery Trial (OAT) demonstrated no measurable effect of PCI on outcome. There were trends, however, for more frequent reinfarctions and a higher estimated 4-year cumulative primary event rate. Because patient selection included only patients with 1- or 2-vessel coronary disease, and because interventionalists were permitted to perform PCI on the noninfarct-related arteries, >85% of patients in the intervention group had no coronary arteries with significant obstructions after PCI, a situation that would cause the functional regression of existing collaterals. If subsequent plaque rupture and total occlusion of any of the 3 coronary arteries occurred (expected in 5% to 15% of patients with acute coronary syndromes over the first 1 to 2 years), the impaired collateral flow immediately after new acute occlusion would predispose to greater myocardial injury and therefore greater patient risk, which could explain the negative effects of the OAT study, and which raises the disturbing possibility that complete revascularization in patients with recent acute coronary syndromes could possibly lead to greater risks in the following 1 to 2 years in those patients who experience recurrent acute coronary occlusion. Conversely, late opening of the culprit artery in patients with multivessel coronary disease, without all arteries being patent, may favorably alter late outcomes. In conclusion, the therapeutic implications of the OAT study apply to a specific patient cohort; whether late opening of the culprit artery improves or impairs outcome appears critically to depend on the specific cohort treated. [Copyright &y& Elsevier]

Two hundred eighty-four consecutive patients with 438 native coronary artery stenoses were enrolled prospectively in a study of intravascular ultrasound (IVUS)-guided provisional percutaneous transluminal coronary angioplasty (PTCA): (1) IVUS-guided, aggressive lesion-site media-to-media balloon sizing, (2) IVUS assessment of residual lumen dimensions to identify optimal PTCA results (minimum lumen area > or =65% of the average of the proximal and distal reference lumen areas or > or =6.0 mm2 and no major dissection), and (3) liberal stent crossover. Overall, 206 stenoses in 134 patients were treated with PTCA alone. Reasons for crossover were flow-limiting or lumen compromising dissections in 28% of patients or a suboptimal IVUS minimum lumen area in 72% of patients. Sixty-three stenoses (27%) were treated with Gianturco-Roubin stents and 169 (73%) with Palmaz-Schatz stents. The clinical success rate and major in-hospital complication rates were similar in the optimal PTCA and stent crossover groups. At 1 year, 42 patients (15%) with 53 stenoses (12%) underwent revascularization: 8% of stenoses in the PTCA group and 16% in the stent crossover group. In approximately half of the patients treated using an IVUS guided aggressive PTCA strategy, stent implantation could be avoided without sacrificing an increase in acute complications or late clinical outcome. This provides an alternative strategy for interventionalists less inclined to use routine elective stenting. [ABSTRACT FROM AUTHOR]

Intravascular ultrasound (IVUS) detects target lesion calcium twice as often as does coronary angiography. Target lesions in smaller vessels are thought to be more calcified than target lesions in large vessels. This study determined whether the presence and magnitude of target lesion calcium is related to angiographic reference lumen size. Preintervention IVUS imaging and coronary angiography were performed to study 1,454 non-aortoostial native vessel lesions in 1,342 patients. Target lesions and reference segments were evaluated according to previously published methods and are presented as mean +/- 1 SD. By angiography, 37% of lesions contained calcium, and 68% of calcium-containing lesions were classified as moderately calcified, and 32% as severely calcified. There was no relation between angiographic reference lumen size and angiographic calcium detection (p = 0.7066) or classification (none/mild vs moderate vs severe, p = 0.8135). By IVUS, 73% of lesions contained calcium. There was a consistent relation between decreasing angiographic reference lumen size and increasing IVUS lesion-associated calcium: the presence of any calcium (p = 0.0122), arc of calcium (p = 0.002), percent of lesions with an arc of calcium > 180 degrees (p = 0.0018), length of calcium (p < 0.0001), presence of any superficial calcium (p < 0.0001), arc of superficial calcium (p < 0.0001), percent of lesions with an arc of superficial calcium > 180 degrees (p = 0.0021), and length of superficial calcium (p < 0.0001). This was especially true for arteries with an angiographic reference lumen dimension < 2.00 mm. There is a distinct relation between decreasing angiographic reference lumen size and increasing lesion calcium, most striking in vessels < 2.00 mm. This increased target lesion calcium in small vessels is not seen angiographically. [ABSTRACT FROM AUTHOR]

Stent area assessed by intravascular ultrasound is a strong predictor of late outcome after percutaneous coronary intervention. Because sirolimus-eluting stents (SESs) prevent intimal regrowth within the stent, achieving a larger final stent area might no longer be noteworthy; therefore, the investigators sought to determine the relevance and impact of the final stent area with SESs. [Copyright &y& Elsevier]

The incidence, correlates, and prognostic implications of pulmonary hypertension (PH) are unclear in patients with severe aortic stenosis (AS). We studied 509 patients with severe AS evaluated for transcatheter aortic valve implantation (TAVI). Patients were divided into groups based on pulmonary artery systolic pressure (PASP): group I, 161 (31.6%) with PASP <40 mm Hg; group II, 175 (34.3%) with PASP 40 to 59 mm Hg; and group III, 173 (33.9%) with PASP ≥60 mm Hg. Group III patients were more symptomatic and had higher creatinine levels and higher left ventricular end-diastolic pressure. Transpulmonary gradient was >12 mm Hg in 17 patients (10.5%), 31 patients (17.7%), and 80 patients (46.2%) in groups I through III, respectively. In a median follow-up of 202 days (73 to 446) mortality rates were 35 (21.7%), 69 (39.3%), and 85 (49.1%) in groups I through III, respectively (p <0.001). Immediately after TAVI, in patients with PASP >40 mm Hg there was significant decrease in PASP (63.1 ± 16.2 to 48.8 ± 12.4 mm Hg, p <0.0001), which remained at 1 year (50.1 ± 13.1 mm Hg, p = 0.04). After surgical aortic valve replacement there was a significant immediate decrease in PASP (66.1 ± 16.3 to 44.7 ± 14.2 mm Hg, p <0.0001), which persisted at 3 to 12 months (44.8 ± 20.1 mm Hg, p <0.001). In patients who underwent balloon aortic valvuloplasty, PASP decreased immediately after the procedure (63.2 ± 14.8 to 51.8 ± 17.1 mm Hg, p <0.0001), yet at 3 to 12 months pressure returned to baseline levels (57.4 ± 17.0 mm Hg, p = 0.29). In conclusion, patients with severe AS have a high prevalence of PH, and in patients with severe AS increased PASP is associated with increased mortality. Surgical aortic valve replacement and TAVI are effective treatments for these patients and result in a significant PASP decrease. [ABSTRACT FROM AUTHOR]

This study evaluated the clinical, intravascular ultrasound (IVUS), and angiographic determinants of the coronary flow reserve (CFR) as measured by guidewire Doppler velocimetry. Using standard methodology, 86 consecutive patients were studied before intervention (n = 73 patients, including the assessment of intermediate stenoses) and/or after intervention (n = 39 patients, including after percutaneous transluminal coronary angioplasty (PTCA) in 27 and post-Palmaz-Schatz stent placement + high-pressure adjunct PTCA in 12). Only 5 patients were studied before intervention, post-PTCA, and poststent. Univariate and multivariate clinical, quantitative coronary angiography (QCA), and IVUS correlates of the CFR were evaluated. There was a linear relation between CFR and IVUS minimum lumen cross-sectional area (CSA): r = 0.771, p <0.0001 for the overall cohort; r = 0.831, p <0.0001 before intervention; r = 0.514, p = 0.0061 post-PTCA; and r = 0.623, p = 0.0306 poststent placement. Overall, an IVUS minimum lumen CSA of > or = 4.0 mm2 had a diagnostic accuracy of 89% in identifying a CFR of > or = 2.0. This diagnostic accuracy increased slightly to 92% when only the preintervention observations were considered. Using multivariate linear regression analysis, the independent determinants of the CFR in the overall cohort of 112 observations were IVUS minimum lumen CSA (p <0.0001), angiographic lesion length (p = 0.0101), and diabetes mellitus (p = 0.0371): r2 = 0.6224. When the subset of preintervention observations were analyzed separately, the independent determinants of the CFR were minimum lumen CSA (p <0.0001) and angiographic lesion length (p = 0.0095); r2 = 0.7176. Thus, the major determinants of the CFR in patients with coronary artery disease are lumen compromise (which is best assessed by the IVUS measurement of the minimum lumen CSA) and lesion length. A minimum lumen CSA > or = 4.0 mm2 has a high diagnostic accuracy in predicting a CFR > or = 2.0, especially before intervention. [ABSTRACT FROM AUTHOR]

The incidence of aortic regurgitation (AR) after transcatheter aortic valve replacement (TAVR) in a self-expanding and a balloon-expandable system is controversial. This study aimed to examine the incidence and severity of post-TAVR AR with the CoreValve (CV) versus the Edwards XT Valve (XT). Baseline, procedural, and postprocedural inhospital outcomes were compared. The primary end point was the incidence of post-TAVR AR of any severity, assessed with a transthoracic echocardiogram, in the CV versus XT groups. A multivariate logistic regression analysis was completed to evaluate for correlates of the primary end point. The secondary end points included the change in severity of AR at 30-day and 1-year follow-up. A total of 223 consecutive patients (53% men, mean age 82 years) who had transfemoral TAVR with either a CV (n = 119) or XT (n = 104) were evaluated. The rates of post-TAVR AR in the groups were similar, and there was no evidence of more-than-moderate AR in either group. There were significant differences in the rates of intraprocedural balloon postdilation with the CV (17.1%) versus XT valve (5.8%; p = 0.009) and in the rates of intraprocedural implantation of a second valve-in-valve prosthesis with the CV (9.9%) versus XT valve (2.2%; p = 0.036). There were no significant differences in inhospital safety outcomes between the 2 groups. In conclusion, the incidence of post-TAVR AR is similar between the CV and the XT valve when performed by experienced operators using optimal intraprocedural strategies, as deemed appropriate, to mitigate the severity of AR. [ABSTRACT FROM AUTHOR]

The impact of the specific etiology of mitral regurgitation (MR) on outcomes in the transcatheter aortic valve replacement (TAVR) population is unknown. This study aimed to evaluate the longitudinal changes in functional versus organic MR after TAVR in addition to their impact on survival. Consecutive patients who underwent TAVR from May 2007 to May 2015 who had baseline significant (moderate or greater) MR were included. Transthoracic echocardiography was used to evaluate the cohort at baseline, post-procedure, 30-day, 6-month, and 1-year follow-up. The primary outcomes included mortality at 30 days and 1 year. Longitudinal, mixed-model regression analyses were performed to assess the differences in the magnitude of longitudinal changes of MR, left ventricular (LV) ejection fraction, and New York Heart Association functional class. Seventy patients (44% men, mean 83 years) with moderate or greater MR at baseline (30 functional vs 40 organic) were included, with the functional group having a statistically significant mean younger age and higher rates of previous coronary artery bypass grafting. Kaplan-Meier cumulative mortality rates were similar: 30 days (10% vs 17.5%, unadjusted log-ranked p = 0.413) and 1 year (29.4% vs 23.2%, unadjusted log-ranked p = 0.746) in the functional versus organic MR groups, respectively. There were greater degrees of short- and long-term improvement in MR severity (slope difference p = 0.0008), LV ejection fraction (slope difference p = 0.0009), and New York Heart Association class (slope difference p = 0.0054) in the functional versus organic group. In conclusion, patients with significant functional versus organic MR who underwent TAVR have similar short- and long-term survival; nevertheless, those with a functional origin are more likely to have significant improvements in MR severity, LV-positive remodeling, and functional class. These findings may help strategize therapies for MR in patients with combined aortic and mitral valve disease who are undergoing TAVR. [ABSTRACT FROM AUTHOR]

Although metallic coronary stents significantly reduce angina pectoris compared with optimal medical therapy, angina after percutaneous coronary intervention (PCI) remains frequent. We, therefore, sought to compare the incidence of any angina during the 1 year after PCI among the spectrum of commercially available metallic stents. Metallic stent type was classified as bare metal stent, Cypher, Taxus Express, Xience V, Promus Element, and Resolute. The primary end point was patient-reported angina within 1 year of PCI. Multivariable logistic regression was performed to assess the independent association of stent type with any angina at 1 year. Overall, 8,804 patients were queried in regard to angina symptoms; 32.3% experienced angina at some point in the first year after PCI. Major adverse cardiovascular events, a composite of all-cause mortality, target vessel revascularization, and Q-wave myocardial infarction, increased with angina severity: 6.8% for patients without angina, 10.0% for patients with class 1 or 2 angina, and 19.7% for patients with class 3 or 4 angina (p <0.001 for trend). After multivariable adjustment, there was no significant association between stent type and angina at 1 year after PCI. Baseline Canadian Cardiovascular Society class 3 or 4 angina, history of coronary artery bypass grafting, and history of PCI were associated with a higher likelihood of angina at 1 year; increasing age, male gender, presentation with acute coronary syndrome, and higher stented length were associated with less angina. In conclusion, metallic stent type is not associated with the occurrence of angina at up to 1 year after PCI. [ABSTRACT FROM AUTHOR]

Left-sided cardiac remodeling in patients with severe aortic stenosis (AS) was associated with improved outcome; however, there are scarce data on remodeling process after transcatheter aortic valve implantation (TAVI). We sought to describe the remodeling process in patients with severe AS who underwent TAVI. Echocardiographic data were systematically collected at baseline, 30 days, 6 months, and 1 year, from a cohort of 333 patients who underwent TAVI. Patients were categorized according to left ventricular mass index (LVMi) and relative wall thickness (RWT) to the following geometries: (1) normal; (2) concentric remodeling; (3) concentric hypertrophy; and (4) eccentric hypertrophy. Reverse remodeling (partial or complete) was defined as normalization of LVMi and/or RWT and adverse remodeling as an increase in LVMi and/or RWT. The longitudinal change in LVMi and left atrial diameter index (LADi) was assessed using mixed models. Reverse LV remodeling at 1-year was observed in 24% of patients with available echo at follow-up, whereas 17% of patients had adverse remodeling at 1-year follow-up. This was especially noted in patients with normal geometry at baseline. Interestingly, LV reverse remodeling was not accompanied by a reduction in left atrial diameter. In conclusion, TAVI reverse ventricular remodeling and LV hypertrophy induced by aortic stenosis; however, this reversal is incomplete in most patients at 1-year and not followed by change in left atrial dimensions. Whether this favorable remodeling may impact clinical outcome needs to be further elucidated. [ABSTRACT FROM AUTHOR]

Limited amount of data suggest that patients with aortic stenosis and pulmonary hypertension (PH) who undergo transcatheter aortic valve replacement (TAVR) experience decrease in PH postprocedure. Inconsistent use of systolic pulmonary artery pressure cut-off values in previous studies limits our ability to drawmeaningful conclusions regarding the prognostic role of PH in assessment of TAVR candidates. A total of 415 consecutive patients who underwent TAVR were included in the present study. Two groups were compared based on receiveroperating characteristics curve analysis for the best SPAP value to predict outcome, yielding 2 study groups of no/mild PH (≤50mm Hg; n = 172, 41%) versusmoderate/severe PH (>50mm Hg; n=243, 59%). Demographics and co-morbidities were comparable between the 2 groups; however, right-sided cardiac failure (35% vs 19.8%, p=0.02) andmitral regurgitation (18.4% vs 8.6%, p = 0.007) were more frequent in patients with moderate/severe PH. Procedural characteristics and complications were comparable between the groups. Although there was an early overall decrease in SPAP postprocedure, only 26% of moderate/severe patients with PH experienced a significant decrease in SPAP (>10 mm Hg). The 30-day (14.5% vs 7.4%, p = 0.02) and 1-year mortality (30.8% vs 21%, p = 0.02) was higher in moderate/severe patients with PH. In multivariate analysis, systolic pulmonary artery pressure and chronic lung disease were identified as independent predictors for mortality at 1 year. PH is a frequent co-morbidity in patients with severe aortic stenosis who underwent TAVR. Significantly elevated pulmonary artery pressures at baseline may serve as a poor prognostic factor when performing preprocedural assessment of the patients. [ABSTRACT FROM AUTHOR]

Risk assessment for transcatheter aortic valve replacement (TAVR) patients is challenging, and surgical scores do not optimally correlate with outcome. The aim of this study was to assess the correlation between serum albumin and survival of patients with symptomatic severe aortic stenosis undergoing TAVR. Patients with severe aortic stenosis who underwent TAVR were categorized into 2 groups according to low and normal preprocedural serum albumin (<3.5 and ≥3.5 g/dl, respectively). The all-cause mortality rates at hospital discharge, at 30-day and 1-year follow-up were compared across the groups. Additionally, a Cox proportional-hazards model was generated to assess the independent effect of serum albumin at 1-year follow-up. Among 567 consecutive patients who underwent TAVR, 476 (84%) had documented preprocedural serum albumin measurements. Of these, 50% had low serum albumin levels, and 50% had normal serum albumin levels. Baseline and procedural characteristics, including age, gender, and transapical access, were similar among the groups. Prevalence of left ventricular ejection fraction <40% was higher in patients with low albumin (29% vs 20%, p = 0.02), and risk assessment according to Society of Thoracic Surgeons score tended to be higher in the low-albumin group (10 ± 4.7 vs 9.4 ± 4.4, p = 0.09). Patients presenting with low albumin had higher in-hospital mortality (11% vs 5%), as well as at 30-day (12% vs 6%, p = 0.01) and 1-year (29% vs 19%, p = 0.02) follow-up. Serum albumin was independently associated with 1-year mortality (adjusted hazard ratio per 0.1 g/dl decrease 1.64, 95% confidence interval 2.50 to 1.75, p = 0.02), along with body mass index <20 kg/m2 (hazard ratio 1.89, 95% confidence interval 3.33 to 1.75, p = 0.03). In conclusion, preprocedural serum albumin level and low body mass index are independently associated with mortality in patients who undergo TAVR. Patients with severe aortic stenosis and low albumin levels should undergo careful evaluation before and after TAVR. [ABSTRACT FROM AUTHOR]

Baseline anemia is associated with transfusions and increased risk of mortality in patients who underwent cardiac surgery and percutaneous coronary intervention. The impact of blood transfusions in anemic patients who underwent transcatheter aortic valve implantation (TAVI) remains unclear. All patients who underwent transfemoral TAVI at our institution were retrospectively included. We determined the effect of blood transfusions on short- and long-term mortality and its interaction with baseline hemoglobin levels and bleeding complications. Additionally, we evaluated baseline hemoglobin effect on mortality. A total of 332 patients were included. All patients (99%) except 2 (1%) met the definition for anemia. Of the 332 patients, 124 (37%) received a blood transfusion and 208 (63%) did not. Blood transfusions were associated with increased in-hospital (p <0.001), 30-day (p <0.001), and 1-year (28% vs 13%, p = 0.001) mortality; however, after a landmark analysis, the effect of blood transfusion on mortality was only seen within 30 days of the procedure (p = 0.001). The increased risk of mortality associated with blood transfusion was present after multivariate adjustment at 30 days (hazard ratio 3.59 [1.04 to 12.4]; p = 0.04). Major vascular complications were a correlate for short- and long-term death. In contrast, baseline hemoglobin level and bleeding complications were not independently associated with mortality. The p value for interaction was not significant between transfusion and hemoglobin level and for transfusion and bleeding complication and transfusion and major vascular complication. In conclusion, the presence of anemia in patients who underwent TAVI does not affect mortality. Transfusion is a correlate of all-cause mortality in this patient population and should be used with caution. [ABSTRACT FROM AUTHOR]

Patients with severe aortic stenosis and no obstructed coronary arteries are reported to have reduced coronary flow. Doppler evaluation of proximal coronary flow is feasible using transesophageal echocardiography. The present study aimed to assess the change in coronary flow in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI). The left main coronary artery was visualized using transesophageal echocardiography in 90 patients undergoing TAVI using the Edwards SAPIEN valve. The peak systolic and diastolic velocities of the coronary flow and the time-velocity integral were obtained before and after TAVI using pulse-wave Doppler. Mean aortic gradients decreased from 47.1 ± 15.7 mm Hg before TAVI to 3.6 ± 2.6 mm Hg after TAVI (p <0.001). The aortic valve area increased from 0.58 ± 0.17 to 1.99 ± 0.35 cm2 (p <0.001). The cardiac output increased from 3.4 ± 1.1 to 3.8 ± 1.0 L/min (p <0.001). Left ventricular end-diastolic pressure (LVEDP) decreased from 19.8 ± 5.4 to 17.3 ± 4.1 mm Hg (p <0.001). The following coronary flow parameters increased significantly after TAVI: peak systolic velocity 24.2 ± 9.3 to 30.5 ± 14.9 cm/s (p <0.001), peak diastolic velocity 49.8 ± 16.9 to 53.7 ± 22.3 cm/s (p = 0.04), total velocity-time integral 26.7 ± 10.5 to 29.7 ± 14.1 cm (p = 0.002), and systolic velocity-time integral 6.1 ± 3.7 to 7.7 ± 5.0 cm (p = 0.001). Diastolic time-velocity integral increased from 20.6 ± 8.7 to 22.0 ± 10.1 cm (p = 0.04). Total velocity-time integral increased >10% in 43 patients (47.2%). Pearson's correlation coefficient revealed the change in LVEDP as the best correlate of change in coronary flow (R = --0.41, p = 0.003). In conclusion, TAVI resulted in a significant increase in coronary flow. The change in coronary flow was associated mostly with a decrease in LVEDP. [ABSTRACT FROM AUTHOR]

Premature antiplatelet therapy discontinuation (ATD) after drug-eluting stent (DES) implantation is known to predict stent thrombosis (ST). However, recent data suggest that a shorter antiplatelet therapy duration is safe with newer generation DESs. The study aimed to compare the impact of early and late clopidogrel ATDs on ST in a real-world registry of first- and second-generation DES use. A total of 6,236 patients who underwent DES implantation were analyzed retrospectively: 4,217 received first-generation DESs (sirolimus- and paclitaxel-eluting stents) and 2,019 received second-generation DESs (everolimus-eluting stents). Within each DES cohort, patients were categorized into timing of clopidogrel discontinuation within 1 year: early (<3 months), late (3 to 12 months), and continued. ST rates and clinical outcomes at 1 year were analyzed. There were 341 patients (8.1%) in the first-generation DES group and 126 patients (6.2%) in the second-generation DES group who discontinued clopidogrel within the first year. Definite and probable ST rates were 3.8% for early ATD, 2.5% for late ATD, and 0.5% for continued (p [ 0.001) in the first-generation DES cohort, whereas there were no definite or probable ST events in early and late ATDs and 0.5% for continued in the second-generation DES cohort. Major adverse cardiac event rates were 9.9% for early ATD, 5.6% for late ATD, and 0.9% for continued (p <0.001) in the first-generation DES cohort and 5.5% for early ATD, 7.4% for late ATD, and 1.5% for continued (p <0.001) in the second-generation DES cohort. In conclusion, ATD within the first year is associated with increased ST events with firstgeneration DESs, whereas ATD appears safe with second-generation DESs with regard to ST. However, ATD is associated with greater mortality and major adverse cardiac events in both first- and second-generation DESs. Thus, this study supports ATD if required based on physician discretion with the use of second-generation DESs but cannot rule out potential benefit for longer duration of dual antiplatelet therapy even when secondgeneration DESs are used. [ABSTRACT FROM AUTHOR]

Transcatheter aortic valve implantation (TAVI) is associated with improved left ventricular (LV) function in patients with aortic stenosis (AS) and LV dysfunction; however, the outcome after TAVI of patients with low left ventricular ejection fraction (LVEF) is unclear. This study aimed to characterize the baseline, procedural, and long-term outcomes of patients with low LVEF undergoing TAVI and to assess the prognostic utility of pre-TAVI balloon aortic valvuloplasty (BAV) and dobutamine stress echocardiography (DSE) to predict TAVI benefits. Consecutive patients with symptomatic severe AS who underwent TAVI from 2007 to 2013 were analyzed. Two groups were compared: normal or near normal LV function (LVEF >45%) and LVEF £45% at baseline. In total, 371 patients were analyzed; 272 (73%) had preserved LVEF and 99 (27%) had low LVEF. Patients with low LVEF had higher Society of Thoracic Surgeons score and EuroSCORE. Short- and longterm mortality was similar between groups (1-year rate: 22.2% vs 22.4%, p [ 0.79). Of the patients with low LVEF, 24% demonstrated improvement (‡10%) in LVEF at 30 days; patients with improvement had lower mortality at 1 year than those without (8% vs 27%, p = 0.06). Contractile reserve in DSE did not predict LVEF recovery in patients with low LVEF but did predict lower mortality. LVEF recovery after BAV predicted greater LVEF improvement after TAVI. In conclusion, patients with severe AS and impaired LV function benefit from TAVI and have comparable procedural outcomes compared with patients with preserved LVEF. Both DSE and BAV provide complementary data with regard to recovery of LVEF and mortality, both periprocedural and late after TAVI. [ABSTRACT FROM AUTHOR]

Re-operation after coronary artery bypass grafting (CABG) is associated with increased risk for morbidity and mortality. Transcatheter aortic valve implantation (TAVI) is an alternative for patients with aortic stenosis, but the outcomes of patients with a history of CABG are unknown. The aim of this study was to explore the association between previous CABG and the outcome of patients undergoing TAVI. Out of 372 consecutive patients who underwent TAVI from 2007 to 2013, 122 (32.8%) had previous CABG, whereas 250 (67.2%) did not. A comparison was made between groups. Subgroup analysis compared patients with and without previous CABG in 3 patient subsets: inoperable, operable, and those who underwent transapical TAVI. Patients with previous CABG were younger (81.99 ± 6.78 vs 84.81 ± 7.06 years, respectively, p <0.001). These patients also had more high-risk features (e.g., peripheral vascular disease, previous myocardial infarction, past cerebrovascular disease, and lower average left ventricular ejection fraction (p <0.05 for all). Procedural aspects were mostly similar between groups. No disparities in mortality rates at 1 year were noted (22.1% vs 21.6%, respectively, p[0.91). Subgroup analyses yielded similar outcomes for all 3 groups. In conclusion, although patients with previous CABG present with more high-risk features, they share similar short- and long-term outcomes with patients without previous CABG, irrespective of their surgical risk. This includes patients who underwent transapical access. TAVI in patients with previous CABG is safe and does not confer a significant risk for adverse outcome. [ABSTRACT FROM AUTHOR]

In patients with aortic stenosis who cannot have surgery, transcatheter aortic valve replacement using the Edwards SAPIEN valve has been shown to improve survival rate and is approved for commercial use in the United States. This study aims to assess the clinical profile, procedural characteristics, and in-hospital complications in patients treated with a commercial SAPIEN valve outside the clinical trial context. We retrospectively analyzed 69 consecutive patients who underwent transcatheter aortic valve replacement with a commercial SAPIEN valve compared with 55 Placement of AoRTic traNscathetER valves (PARTNER) trial patients from cohort B enrolled in the same institution by the same Heart Team. Compared with the commercial group, patients in the PARTNER cohort B had higher mean Society of Thoracic Surgeons score (10 ± 5 vs 9 ± 4, p[0.04) and a lower rate of peripheral arterial disease (19% vs 44%, p[0.004). Most patients in the commercial group had the procedure under conscious sedation (83% vs 66%, p [ 0.03). Planned surgical cut down for vascular access was rare in the commercial group (1.4% vs 46%, p <0.001). The overall rates of major vascular complications, life-threatening or major bleeding, and blood transfusions were lower in commercial group (7.2% vs 27%, p [ 0.003; 2.9% vs 16%, p [ 0.01; and 28% vs 60%, p <0.001, respectively). In-hospital all-cause mortality (5.8% vs 9.1%, p [ 0.51) and stroke rates (7.2% vs 14.5%, p [ 0.19) were not statistically different between groups. The median length of hospitalization (p <0.001) and postprocedural length of stay (p [ 0.01) was shorter in the commercial group. In conclusion, transfemoral commercial use of the Edwards SAPIEN valve for inoperable patients shows similar in-hospital mortality and stroke rates compared with PARTNER cohort B. The refinements in the procedure such as more conscious sedation, experience of the operators, and careful vascular planning in the commercial group led to lesser vascular and bleeding complications and shorter length of stay. [ABSTRACT FROM AUTHOR]

The safety and efficacy outcomes of stent overlap with second-generation drug-eluting stents (DES) have not been well established. This study aimed to compare the 1-year clinical outcomes of overlapping everolimus-eluting stents (EES) with those of overlapping firstgeneration DES. This retrospective analysis included 350 patients treated with overlapping EES (169 patients with 237 lesions), sirolimus-eluting stents (SES, 102 patients with 252 lesions), or paclitaxel-eluting stents (PES, 79 patients with 182 lesions). End points were major adverse cardiovascular events (MACE: defined as the composite of death, myocardial infarction, or target lesion revascularization), target vessel revascularization, and definite stent thrombosis at 1 year. During a follow-up of 1 year, overall MACE occurred in 6.5% of EES-, 16.8% of SES-, and 10.1% of PES-treated patients (p [0.026). Myocardial infarction was lowest in the EES group versus SES and PES groups (0 vs 1.0% vs 2.5%, respectively; p [ 0.080), and mortality was similar (3.6% vs 9.0% vs 5.1%, p [ 0.162). The EES patients showed a trend toward lower rates of 1-year target lesion revascularization (3.1% vs 8.2% vs 6.5%, p [ 0.181) and target vessel revascularization (3.7% vs 9.1% vs 11.7%, p [ 0.051) compared with the SES- and PES-treated patients. The cumulative incidence of definite stent thrombosis was lowest in the EES group (0 for EES vs 3.9% for SES vs 2.5% for PES, p [ 0.014). In conclusion, stent overlap with EES versus first-generation DES was associated with lower rates of MACE and stent thrombosis. Our results suggest that the use of EES when deploying overlapping stents is effective and safe. [ABSTRACT FROM AUTHOR]

Brain natriuretic peptide (BNP) is a marker of systolic and diastolic dysfunction and a strong predictor of mortality in heart failure patients. The present study aimed to assess the relationship of BNP with aortic stenosis (AS) severity and prognosis. The cohort comprised 289 high-risk patients with severe AS who were referred for transcatheter aortic valve implantation. Patients were divided into tertiles based on BNP level: I (n = 96); II (n = 95), and III (n = 98). Group III patients were more symptomatic, had higher Society of Thoracic Surgeons and Euro SCORE scores, and had a greater prevalence of renal failure, atrial fibrillation, and previous myocardial infarction; lower ejection fraction and cardiac output; and higher pulmonary pressure and left ventricular end diastolic pressure. The degree of AS did not differ among the 3 groups. Stepwise forward multiple regression analysis identifies ejection fraction and pulmonary artery systolic pressure as independent correlates with plasma BNP. Mortality rates during a median follow-up of 319 days (range 110 to 655) were significantly lower in Group I compared with Groups II and III, p <0.001. After multivariable adjustment, the strongest correlates for mortality were renal failure (hazard ratio 1.44, p = 0.05) and medical/balloon aortic valvuloplasty (HR 2.2, p <0.001). Mean BNP decreased immediately after balloon aortic valvuloplasty from 1,595 ± 1,229 to 1,252 ± 1,076, p = 0.001 yet increased to 1,609 ± 1,264, p = 0.9 at 1 to 12 months. After surgical aortic valve replacement, there was a nonsignificant, immediate decrease in BNP level from 928 ± 1,221 to 896 ± 1,217, p = 0.77, continuing up to 12 months 533 ± 213, p = 0.08. After transcatheter aortic valve implantation, there was no significant decrease in BNP immediately after the procedure; however, at 1-year followup, the mean BNP level decreased significantly from 568 ± 582 to 301 ± 266 pg/dl, p=0.03. In conclusion, a high BNP level in high-risk patients with severe AS is not an independent marker for higher mortality. BNP level does not appear to be significantly associated with the degree of AS severity but does reflect heart failure status. [ABSTRACT FROM AUTHOR]

Second-generation everolimus-eluting stents (EESs) have demonstrated superiority in efficacy and safety compared with first-generation drug-eluting stents (DESs) in the treatment of native coronary artery lesions. The present study evaluated and compared the safety and efficacy of EESs and first-generation DESs in saphenous vein graft lesions. The EES group consisted of 88 patients with 96 lesions, and the first-generation DES group consisted of 243 patients with 317 lesions (sirolimus-eluting stents, n [ 212; paclitaxeleluting stents, n [ 105). The end points included target lesion revascularization, target vessel revascularization, major adverse cardiovascular events (composite of all-cause death, myocardial infarction, and target vessel revascularization), and definite stent thrombosis at 2 years. The groups had similar baseline characteristics and graft ages (128.1 ± 77.5 vs 132.4 ± 90.8 months, p [ 0.686). The EES group had more type C lesions and less embolic protection device use. The peak postprocedure values of creatinine kinase-MB and troponin I were similar between the 2 groups. Overall, major adverse cardiovascular events occurred in 18.2% of EES patients and 35.0% of first-generation DES patients (p [ 0.003), mainly driven by a lower target vessel revascularization rate (6.8% vs 24.5%, p <0.001). The target lesion revascularization rate was lower in the EES group (1.1% vs 11.6%, p [ 0.005). Stent thrombosis was low and similar between the 2 groups (0% vs 0.8%, p [ 1.000). On multivariate analysis, the type of DES implanted and graft age were the only independent predictors of major adverse cardiovascular events. In conclusion, the superiority of EESs compared with first-generation DESs shown in native artery lesions has been extended to saphenous vein graft lesions and should be considered as the DES of choice for this lesion type. [ABSTRACT FROM AUTHOR]

The incidence and prognostic implication of myocardial injury after transcatheter aortic valve replacement (TAVR) have not been consistently studied. We aimed to assess the incidence and extent of myocardial injury after TAVR performed using transfemoral and transapical approaches. The clinical data from patients with aortic stenosis who underwent TAVR were retrospectively analyzed. The myocardial necrosis markers cardiac troponinI and creatine kinase (CK)-MB were assessed during hospitalization. Of the 150 TAVR patients, 95% and 50% had an abnormally elevated cardiac troponin I and CK-MB level, respectively. The transapical patients had significantly greater elevations of both cardiac troponin I (13.8 ± 14.0 vs 2.5 ± 5.8 ng/ml, p <0.001) and CK-MB (28.4 ± 24.2 vs 7.4 ± 8.6 ng/ ml, p ≼0.001). On receiver operating curve analysis, postprocedural CK-MB (twofold increase) had high predictive power for 30-day mortality (area under the curve 0.85, p <0.001). Patients with high CK-MB levels had greater rates of postprocedural kidney injury (22% vs 6%, p = 0.026), in-hospital (22% vs 0%, p <0.001), 30-day (27% vs 1.5%, p <0.001), and 1-year mortality (41% vs 18%, p = 0.01). Baseline renal failure and no β-blocker treatment on admission were independent predictors of an elevated postprocedural CK-MB level. In conclusion, a cardiac biomarker increase after TAVR was common and more frequent among transapical access patients. A twofold increase (>7 ng/ml) in CK-MB after transfemoral TAVR was a surrogate for poor long-term outcomes. [ABSTRACT FROM AUTHOR]

percutaneous coronary intervention (PCI). The aim of this study was to determine whether there are differences in correlates between genders for these long-term adverse outcomes in patients with acute coronary syndromes. Gender differences were evaluated in the clinical outcomes of 6,929 consecutive patients with acute coronary syndromes from a large, contemporary PCI registry. Rates of major adverse cardiovascular events, defined as all-cause mortality, myocardial infarction, and target lesion revascularization at 1-year follow-up, are reported. Independent correlates of adverse outcomes were identified using multivariate proportional-hazards regression analysis. Women were older (p <0.001); had a higher prevalence of diabetes mellitus (p <0.001), systemic hypertension (p <0.001), chronic renal insufficiency (p = 0.02), peripheral arterial disease (p <0.001), and congestive heart failure (p <0.001); had lower body surface areas (p <0.001); and had higher body mass indexes (p <0.001). Acute coronary syndrome presentation in women tended to be unstable angina pectoris with Canadian Cardiovascular Society class III and IV symptoms, whereas men had more acute myocardial infarctions. At 1 year, the unadjusted rates of all-cause mortality (10.7% vs 7.5%, p <0.001) and major adverse cardiovascular events (16.4% vs 12.7%, p <0.001) were higher in women. There was a stark difference between the genders in independent correlates of mortality and major adverse cardiovascular events at 1 year. Moreover, the traditional correlates did not have the same impact in women as in men. In conclusion, although there are differences in clinical outcomes after PCI for women compared with men, there are different correlates for these adverse outcomes. These gender-based differences should be taken into account when women undergo contemporary PCI. [ABSTRACT FROM AUTHOR]

Although second-generation everolimus-eluting stents (EESs) have demonstrated superiority over first-generation paclitaxel-eluting stents for a broad subset of patients and lesions, it is unclear whether the same applies to sirolimus-eluting stents (SESs). The present study compared the long-term clinical outcomes between EESs and SESs in patients with small coronary artery disease. A cohort of 643 patients treated with EESs (220 patients with 245 lesions) or SESs (423 patients with 523 lesions) in small vessel lesions (defined as those receiving stents ⩽2.5 mm) were retrospectively analyzed. The end points included target lesion revascularization, target vessel revascularization, major adverse cardiovascular events (all-cause death, myocardial infarction, or target lesion revascularization), and definite stent thrombosis at 1 year of follow-up. The baseline characteristics were generally similar between the 2 groups, except that more systemic hypertension was seen in the EES group and more patients had a family history of coronary artery disease in the SES group. The 1-year target lesion revascularization (5.6% vs 4.8%, p [ 0.68) and target vessel revascularization (5.6% vs 7.6%, p [ 0.33) rates showed no significant differences between the EES and SES groups. Overall major adverse cardiovascular events occurred in 9.1% of the EES- and 8.6% of SES-treated patients (p [ 0.83). This similar major adverse cardiovascular events rate remained after adjustment. The rate of stent thrombosis was 0% in the EES group and 1.2% in the SES group (p[0.17). In conclusion, EESs demonstrated comparable clinical outcomes to those of SESs in small vessel interventions. The absence of stent thrombosis among patients treated with EESs suggests a good safety profile for this second-generation drug-eluting stent, which should be carefully studied in a larger series of patients with small vessel disease. [ABSTRACT FROM AUTHOR]

Patients with acute coronary syndrome undergoing percutaneous coronary intervention (PCI) commonly receive a loading dose of either clopidogrel or prasugrel, in addition to aspirin. The present study aimed to assess the safety of reloading prasugrel in patients who had initially received a loading dose of clopidogrel compared to prasugrel loading alone. The study included a cohort of 606 consecutive patients with acute coronary syndrome who had received a 60-mg loading dose of prasugrel before PCI. These patients were then categorized into clopidogrel preloading (300 or 600 mg) followed by prasugrel reloading (CP-load group, n [ 90) and prasugrel loading only (P-load group, n [ 516). Both groups received a 10-mg maintenance dose of prasugrel after PCI. The primary end point was in-hospital Thrombolysis In Myocardial Infarction-defined major bleeding. The secondary end points were other in-hospital bleeding complications and major cardiovascular events. Patients in the CPload group compared to the P-load group were younger, with lower rates of cardiovascular risk factors. Significantly more patients in the CP-load group presented with biomarkerpositive myocardial infarction (80.0% vs 30.6%, p £0.001) and cardiogenic shock (5.6% vs 1.4%, p [ 0.022). No significant differences (p [ NS) were seen in Thrombolysis In Myocardial Infarction major bleeding (2.6% vs 2.8%), Thrombolysis In Myocardial Infarction major or minor bleeding (12.2% vs 7.0%), the need for blood transfusion (2.6% vs 2.1%), and vascular complications (1.3% vs 2.0%) between groups. The CP-load group experienced more in-hospital major adverse cardiac events (5.6% vs 1.6%, p [ 0.031), urgent coronary artery bypass grafting (3.3% vs 0.2%, p [ 0.011), and longer hospital and intensive care unit stays. In conclusion, preloading with clopidogrel should not be prohibitive to reloading with prasugrel in patients presenting with acute coronary syndrome and undergoing PCI with respect to bleeding and vascular complications. [ABSTRACT FROM AUTHOR]

The randomized TRial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet InhibitioN with PrasugreleThrombolysis In Myocardial Infarction (TRITONTIMI) 38 trial compared prasugrel and clopidogrel in patients with acute coronary syndrome undergoing percutaneous coronary intervention (PCI). Patients treated with prasugrel had fewer ischemic events but more procedure-related bleeding. In the present study, we aimed to determine the effect of bivalirudin on bleeding in patients treated with prasugrel. A total of 692 patients with consecutive acute coronary syndrome underwent PCI with stent implantation and were anticoagulated with bivalirudin. The patients were divided into 2 groups according to the antiplatelet regimen (clopidogrel or prasugrel) chosen during or just after PCI. The bleeding complications during hospitalization were tabulated. Ischemic events were analyzed during hospitalization and at 30 days. Prasugrel was used in 96 patients (13.9%) and clopidogrel in 596 (86.1%). The clinical and procedural characteristics were similar, although the clopidogrel patients more often reported systemic hypertension (p = 0.01), previous PCI (p <0.001), and chronic renal insufficiency (p = 0.05). During hospitalization, the bleeding and ischemic complication rates were similar and low in both groups (major in-hospital complications 4.2% for clopidogrel vs 2.1% for prasugrel, p = 0.6; Thrombolysis In Myocardial Infarction major bleeding 2.5% vs 2.1%, p = 1.00; Thrombolysis In Myocardial Infarction minor bleeding 4.2% vs 5.2%, p = 0.6). At 30 days, no differences were found in ischemic events between both groups (target vessel revascularization/major adverse cardiac events 5.4% vs 2.1%, p = 0.2). In conclusion, prasugrel, when given after bivalirudin as the intraprocedural antithrombin agent for patients with acute coronary syndrome undergoing PCI, is as safe and effective as clopidogrel. [ABSTRACT FROM AUTHOR]

Drug-eluting stents have shown promising clinical results in the treatment of coronary artery disease, including in women. Studies with first-generation drug-eluting stents, however, have reported higher rates of stent thrombosis (ST). The aim of this study was to evaluate the safety and efficacy of second-generation everolimus-eluting stents (EES) versus first-generation sirolimus-eluting stents (SES) in women. The study included 1,649 women; 1,152 (70%) received SES and 497 (30%) received EES. In-hospital and 1-, 6-, and 12-month clinical outcomes were analyzed and compared. Correlates of major adverse cardiac events and ST were identified. Baseline clinical characteristics were similar between stent types, although more peripheral vascular disease and family history of coronary artery disease were seen in the SES group, while more unstable angina pectoris at initial diagnosis was more prevalent in the EES group. The EES group had more type C and distal lesions. There was a higher rate of target vessel revascularization and major adverse cardiac events in the SES group (14.7% vs 10.8%, p = 0.04) at 1 year. ST tended to be higher in the SES group (1.5% vs 0.4%, p=0.06) at 6 and 12 months. After adjustment, multivariate analysis indicated that the EES group was less likely to have target vessel revascularization and major adverse cardiac events (hazard ratio 0.67, 95% confidence interval 0.47 to 0.95, p = 0.024) and had lower rates of ST (hazard ratio 0.09, 95% confidence interval 0.01 to 0.70, p = 0.022) at 1 year. In conclusion, contemporary use of EES in women is associated with improvement in efficacy and safety profiles compared to SES; however, a large randomized trial is needed to confirm this conclusion. [ABSTRACT FROM AUTHOR]

Disturbances in atrioventricular conduction and the additional need for a permanent pacemaker are recognized complications after transcatheter aortic valve replacement (TAVR). We analyzed the incidence of postprocedural conduction disorders and the need for permanent pacemaker implantation in patients undergoing TAVR with the Edwards SAPIEN valve. In 125 consecutive patients with symptomatic, severe aortic stenosis undergoing TAVR, a standard 12-lead electrocardiogram was obtained before and serially after the procedure. The cohort was divided into 2 groups with regard to the post-TAVR appearance of conduction disturbances, defined as left bundle branch block, right bundle branch block, fascicular hemiblock, atrioventricular block, and the need for a permanent pacemaker. The patients with and without conduction disturbances were compared. After TAVR, 19 patients (15.2%) met the study definition of a “new conduction defect” and 5 patients (4%) required a permanent pacemaker because of an advanced atrioventricular block. New left bundle branch block appeared in 5 patients (4%) and left anterior hemiblock in 9 (7.2%). No new right bundle branch block or left posterior hemiblock was observed. Although most baseline, echocardiographic, and procedural characteristics were equally distributed, the patients with new conduction disturbances more often had diabetes mellitus and peripheral vascular disease. Also, they more often were taking an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker, and the procedure was performed more often with apical access (12 [63.2%] vs 7 with femoral access [36.8%], p = 0.002). In conclusion, although the incidence of conduction disturbances was high after TAVR using the Edwards SAPIEN valve, with a significant increase in the rate of left bundle branch block and left anterior hemiblock, the need for permanent pacemaker implantation after TAVR with this valve remained low. [ABSTRACT FROM AUTHOR]