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ObjectivesThe TRI-SCORE reliably predicts in-hospital mortality after isolated tricuspid valve surgery (ITVS) on native valve but has not been tested in the setting of redo interventions. We aimed to evaluate the predictive value of the TRI-SCORE for in-hospital mortality in patients with redo ITVS and to compare its accuracy with conventional surgical risk scores.MethodsUsing a mandatory administrative database, we identified all consecutive adult patients who underwent a redo ITVS at 12 French tertiary centres between 2007 and 2017. Baseline characteristics and outcomes were collected from chart review and surgical scores were calculated.ResultsWe identified 70 patients who underwent a redo ITVS (54±15 years, 63% female). Prior intervention was a tricuspid valve repair in 51% and a replacement in 49%, and was combined with another surgery in 41%. A tricuspid valve replacement was performed in all patients for the redo surgery. Overall, in-hospital mortality and major postoperative complication rates were 10% and 34%, respectively. The TRI-SCORE was the only surgical risk score associated with in-hospital mortality (p=0.005). The area under the receiver operating characteristic curve for the TRI-SCORE was 0.83, much higher than for the logistic EuroSCORE (0.58) or EuroSCORE II (0.61). The TRI-SCORE was also associated with major postoperative complication rates and survival free of readmissions for heart failure.ConclusionRedo ITVS was rarely performed and was associated with an overall high in-hospital mortality and morbidity, but hiding important individual disparities. The TRI-SCORE accurately predicted in-hospital mortality after redo ITVS and may guide clinical decision-making process (www.tri-score.com).

Calcific aortic stenosis is a prevalent and worrisome healthcare problem. The therapeutic approach in asymptomatic aortic stenosis is not well established. We argue that the natural history of this disease is based on old incomplete studies with many limitations. Likewise, studies suggesting that replacement, either surgical or percutaneous, improves prognosis in asymptomatic patients with severe aortic stenosis have important drawbacks and do not support this strategy as the treatment of choice. Despite the lack of evidence, some groups recommend early valve replacement in patients with severe asymptomatic aortic stenosis. There are five ongoing randomised trials which will shed light on this topic. Our conclusion is that unless a randomised study changes the evidence, valve replacement cannot be recommended in asymptomatic patients with severe aortic stenosis.

The severity of stenosis or regurgitation, the presence of symptoms and the consequences on the left ventricle are the main drivers of decision-making for the management of valvular diseases in current guidelines.1 2 Interventions are generally considered in severe valvular diseases and most publications focus therefore on severe lesions, although more attention is now paid on moderate valvular disease, in particular regarding aortic stenosis. The originality of the paper by Taylor et al 3 is to also analyse the prognostic impact of the least severe valvular heart disease, that is, mild valvular disease, as well as calcific valve lesions without functional effect on the same valve, that is, aortic sclerosis and mitral annular calcification (MAC). Separating functional and anatomical valvular lesions is challenging since there is a close interaction between valve function and anatomy. As an illustration, the quantification of calcium burden using the calcium score is now recommended to assess aortic stenosis severity, which is complementary to echocardiography.1 2 Nevertheless, the definitions used in the paper by Taylor et al allow for separate assessment of the prognostic impact of the severity of valvular disease and of the extent of calcific valve lesion. Mild valvular disease and anatomical lesions without functional consequences can be studied only by using systematic echocardiographic screening, which is an important feature of the OxValve cohort. Although this is not current recommended practice, a reliable detection of valvular disease requires systematic echocardiography, with only 10% of valvular disease detected by cardiac auscultation. This is particularly true for mild valvular disease and calcific valve lesions, which are …

Atrial fibrillation (AF) is frequent in patients with rheumatic mitral stenosis (MS). Pressure overload leads to marked structural and electrical remodelling of left atrium. The frequency of persistent AF increases with age and paroxysmal, asymptomatic, AF seems even more frequent. The occurrence of AF worsens the haemodynamic tolerance of MS and markedly increases the risk of thromboembolic events. AF has a negative impact on the natural history of MS and on its outcome after commissurotomy. The respective indications of rhythm and rate control should be adapted to patient characteristics, particularly the consequences of MS, and take into account the high risk of recurrence of AF. Oral anticoagulant therapy is mandatory when AF complicates MS, regardless of its severity and CHA2DS2-VASc score. Non-vitamin K antagonists oral anticoagulants are not recommended in moderate-to-severe MS due to the lack of data. Percutaneous mitral commissurotomy does not appear to prevent the occurrence of AF in MS but should be considered as the first-line therapy when AF is associated with severe symptomatic MS, followed by the discussion of cardioversion or ablation. AF ablation should be considered in patients with mitral disease requiring intervention, but the ideal timing and techniques are difficult to determine due to the lack of appropriate specific randomised trials in patients with MS.

In this issue of Heart , Cahill et al report an analysis of the OxValve cohort assessing the prevalence, presentation and outcome of atrioventricular valve regurgitations.1 The strength of the OxValve cohort is that it was prospectively designed to specifically study heart valve disease using systematic echocardiographic examination in an unselected population aged 65 years or more in a community setting. Echocardiography is the only means to reliably assess the prevalence of heart valve disease since auscultation correctly identifies only around 10% of patients with heart valve disease.2 Unbiased assessment of the prevalence and characteristics of patients with heart valve disease needs to be performed in a community setting, as illustrated by differences between the OxValve and the hospital database cohorts. Moreover, contemporary guideline-based criteria were used in the OxValve cohort for the quantification of the severity of regurgitations and the identification of their mechanisms. Such detailed analyses were not performed in the rare previous population-based studies on the epidemiology of heart valve disease. The collection of detailed and standardised echocardiographic data in a large population-based study is therefore highly relevant in the field of heart valve disease. The unadjusted prevalence of moderate or severe mitral or tricuspid regurgitation was estimated at 2.0% in subjects aged 65–75 years and 7.7% in those aged ≥75 years. This considerable increase in the prevalence …

The term non-valvular atrial fibrillation (NVAF) has become popular with the development of non-vitamin K antagonists (VKA) novel oral anticoagulants (NOAC), or direct oral anticoagulants (DOAC). Randomised trials evaluating NOACs in atrial fibrillation (AF) targeted NVAF since thromboembolic risk was presumed to be higher, and possibly to involve different mechanisms, in patients with valvular heart disease (VHD). However, it is acknowledged that the definition of NVAF is not uniform. Exclusion criteria for valvular AF differed between trials on NOACs with regard to the type and severity of native VHD and the type of valve prostheses (table 1).1–7 The availability of subgroup analyses now allows for a better risk assessment and ascertainment of indications of NOACs in patients with VHD.1 4 6 7 View this table: Table 1 Identifying patients with ‘Nonvalvular AF’ With increasing life expectancy, the epidemic of VHD is becoming more prevalent. Simultaneously, transcatheter aortic valve implantation (TAVI) has emerged as an alternative therapy for patients with significant VHD and the ideal antithrombotic regimen for these patients has not yet been firmly established. We review here the issues of anticoagulation in VHD, focusing on patients with AF, in the light of recent 2017 American Heart Association (AHA)/American College of Cardiology (ACC) and European Society of Cardiology (ESC)/European Association of Cardio-Thoracic Surgery (EACTS) guidelines on VHD (table 2).8 9 View this table: Table 2 Management of atrial fibrillation in patients with valvular heart disease Anticoagulation is mainly required in aortic valve diseases in the presence of AF and conventional treatment uses VKA. In AHA/ACC guidelines, anticoagulation is indicated in patients with a CHA2DS2-VASc score ≥2 while no score threshold is mentioned in ESC/EACTS guidelines.8 9 Following subgroup analyses from randomised trials on NOACs,10 their use for the prevention of AF is now a IIa recommendation in AHA/ACC and …

Surgery for aortic stenosis in patients with thoracic radiation therapy is associated with high morbi-mortality. Trans-catheter aortic valve implantation (TAVI) represents an alternative but has never been studied in this population. We aimed to compare outcomes in radiation and matched control patients undergoing TAVI and to identify predictive factors of survival.Between 2006 and 2011, 288 consecutive patients underwent TAVI in our institution, of whom 26 had previous chest radiation. They were matched 1:1 for age, sex and TAVI approach with controls.In both groups, median age was 73 years, 50% of patients were male and 15% had a transapical approach. Procedural success was 88% in the radiation group versus 100% in controls (p0.001) and 30-day survival was 92% in both groups. Five-year survival was 33%±10% in the radiation group and 42%±11% in controls (p=0.26). In radiation patients, the main cause of death was respiratory insufficiency in 40%. We identified four independent predictive factors of death in the radiation group: extracardiac arteriopathy (p=0.002) and the absence of β-blocker therapy (p=0.005) as preprocedural variables, and infectious complications (p=0.009) and a higher peak creatinine level (p=0.009) as postprocedural variables. In the radiation group, 89% of survivors were in New York Heart Association class I-II at last follow-up.Patients in the radiation group displayed high mortality rates although not significantly different from the controls. Respiratory failure was the main cause of death, emphasising the need for a careful pulmonary evaluation. Finally, we show a sustained improvement in functional results after TAVI in this population.

Learning objectives In this review, we will discuss the current knowledge of heart valve disease (HVD) epidemiology, how it has changed over time and possible future trends. There are large differences in HVD epidemiology between high-income and low-income countries and across different forms of HVD. The majority of morbidity and mortality attributable to HVD worldwide is due to rheumatic heart disease (RHD), which is most commonly seen in low-income countries. In high-income countries, the greatest burden of HVD referred to hospital is due to calcific aortic valve disease (CAVD). Although prevalence of HVD is low compared with coronary heart disease, the requirement for long-term follow-up, and significant investigation and treatment costs, means that the impact of HVD on healthcare systems is disproportionately large. The strong association between HVD and age, combined with the rapid ageing of populations worldwide, means that HVD has been described as the ‘next cardiac epidemic’.1 ### Current knowledge Acute rheumatic fever (ARF) occurs a number of weeks after Streptococcus pyogenes (group A streptococcus) infection, usually in children. ARF leads to valve inflammation through molecular mimicry between the streptococcal M protein and cardiac proteins such as myosin and vimentin, although it is likely that other mechanisms are also involved.2 The requirements for ARF to lead to chronic RHD are not yet fully established but are likely to be related to repeated episodes of often subclinical secondary infection, leading to progressive valve fibrosis and self-sustaining valve inflammation. Those with repeated infections are more likely to progress to chronic RHD, and extended antibiotic prophylaxis is recommended for those with a …

The spectrum of valvular heart diseases (VHDs) has evolved during the past decades in the developed countries. However, there are few epidemiological data on VHD and large contemporary population-based studies are lacking. In this issue of the journal, Andell et al present the findings of a nationwide study in Sweden that includes a population of about 10 million people.1 The authors used nationwide registers to identify all patients with first diagnosis of VHD at Swedish hospitals between 2003 and 2010. The cases diagnosed in the years 2000, 2001 and 2002 were excluded, therefore allowing to estimate the incidence rates of VHDs. The incidence of each VHD was then stratified for age and sex. Andell et al should be commended for this elegant and important study that provides a contemporary and comprehensive portrait of the epidemiology spectrum of VHD within a large European country.1 Previous epidemiology studies on VHD included either representative samples2 or primary care series recruited locally3 and the majority of these studies reported only prevalence rates. Incidence rates have been previously reported for aortic stenosis (AS)4 5 but the present study is the first to report incidence rates for the different VHDs. Over the 8-year period of the present study conducted in the Swedish population, a new diagnosis of VHD was identified in close to 77 000 persons.1 The overall incidence of VHD was 63.9 per 100 000 person-years and the most common disease was AS (47%) , followed by mitral regurgitation (MR) (24%) and aortic regurgitation (AR) (18%) (figure 1). In the vast majority (68.9%) of the cases, the VHDs were diagnosed in subjects aged ≥65 years, except for pulmonary valve disease whose incidence peaked in newborns. Half of the persons with AS also had atherosclerotic vascular disease, which provides further support to the commonality …

Objectives In the general population, planned caesarean section is thought to be safer in high-risk situations as it avoids the greater risk of an emergency caesarean section. Only limited data exist on the optimal mode of delivery in women with structural heart disease. We investigated the relationship between mode of delivery and pregnancy outcome in women with preexisting heart disease. Methods The Registry on Pregnancy and Cardiac Disease is an on-going, global, prospective observational registry of women with structural heart disease. We report on 1262 deliveries, between January 2007 and June 2011. Results The caesarean section was planned in 393 women (31%): 172 (44%) for cardiac and 221 (56%) for obstetric reasons of whom 53 delivered by emergency caesarean section. Vaginal delivery was planned in 869 (69%) women, of whom 726 (84%) actually delivered vaginally and 143 (16%) had an emergency caesarean section. Perinatal mortality(1.1 vs 2.7, p=0.14) and low apgar score (11.9 vs 10.1, p=0.45) were not significantly different in women who had a caesarean section or vaginal delivery; gestational age(37 vs 38 weeks p=0.003) and birth weight (3073 vs 2870 g p

Objective Decision making for intervention in symptomatic aortic stenosis should balance the risks of surgery and of transcatheter aortic valve implantation (TAVI). We identified the factors associated with early mortality after TAVI and aimed to develop and validate a simple risk score. Methods A population of 3833 consecutive patients was randomly split into two cohorts comprising 2552 and 1281 patients, used respectively to develop and validate a scoring system predicting 30-day or in-hospital mortality. Results TAVI was performed using the Edwards Sapien prosthesis in 2551 (66.8%) patients and the Medtronic Corevalve in 1270 (33.2%). Approach was transfemoral in 2801 (73.4%) patients, transapical in 678 (17.8%), subclavian in 219 (5.7%) and other in 117 (3.1%). Early mortality was 10.0% (382 patients). A multivariate logistic model identified the following predictive factors of early mortality: age ≥90 years, body mass index 2 , New York Heart Association class IV, pulmonary hypertension, critical haemodynamic state, ≥2 pulmonary oedemas during the last year, respiratory insufficiency, dialysis and transapical or other (transaortic and transcarotid) approaches. A 21-point predictive score was derived. C-index was 0.67 for the score in the development cohort and 0.59 in the validation cohort. There was a good concordance between predicted and observed 30-day mortality rates in the development and validation cohorts. Conclusions Early mortality after TAVI is mainly related to age, the severity of symptoms, comorbidities and transapical approach. A simple score can be used to predict early mortality after TAVI. The moderate discrimination is however a limitation for the accurate identification of high-risk patients.

The first guidelines of the European Society of Cardiology (ESC) on the diagnosis and treatment of aortic diseases have recently been released.1 Guidelines are particularly needed in this field characterised by a diversity of aetiologies, lesions and locations, and potentially severe complications. Over the last years, there has been growing knowledge concerning the diagnostic performance of different imaging modalities and the natural history of aortic diseases. Besides surgery, endovascular interventions have widened the range of therapeutic options. Although randomised trials are scarce in this field, indications for intervention take into account recent information on the natural history and the results of interventions. ESC guidelines cover the wide spectrum of thoracic and abdominal aortic diseases; however, we will focus here on the two most frequent presentations of thoracic aortic disease, that is, acute aortic syndromes (AAS) and thoracic aortic aneurysms (TAA), referring to corresponding recommendations from the American guidelines.2 Imaging plays a key role in the diagnosis, pre-therapeutic evaluation and follow-up of aortic diseases.3 Both ESC and American guidelines consistently highlight the need for appropriate techniques and standards for measurements and reporting. Unlike the American guidelines, the ESC guidelines recommend analysis of the entire aorta at first diagnosis using CT or MRI. The choice between techniques should be based on their performance, but also on their local availability and feasibility according to the context (eg, in emergency) and on their potential to cause harm, particularly due to radiation or renal function. Therefore, MRI is preferred over CT in young patients. The consistency between the findings of different investigations should be checked, particularly when measurements or evolutive trends have an impact on decision making for intervention. The term AAS encompasses a variety of anatomic diseases that are characterised by tears of the intima and media. Whatever the lesion, AAS …

Objective We analysed long-term results of percutaneous mitral commissurotomy (PMC) performed because of mitral restenosis after previous commissurotomy. Design Follow-up of a prospective cohort. Setting Tertiary university hospital. Patients We studied 163 consecutive patients who underwent PMC because of restenosis occurring 16±8 years after previous commissurotomy (closed-heart in 121, open-heart in 30 and PMC in 12). Mean age was 48±14 years; 62 patients (38%) had valve calcification. Restenosis was due to bicommissural fusion in all cases. Intervention PMC using a single or double balloon in 80 patients and the Inoue balloon in 83. Results Good immediate results (IR) (valve area ≥1.5 cm2 with MR≤2/4) were obtained in 135 pts (83%). 20-year rates were 27.9±4.7% for cardiovascular survival without mitral surgery and 14.8±3.9% for good functional results (cardiovascular survival without reintervention on the mitral valve and in New York Heart Association (NYHA) class I or II). After good IR, 20-year rates were 33.2±5.5% for cardiovascular survival without surgery and 17.9±4.7% for good functional results. After good IR, multivariate predictive factors of poor late functional results were higher NYHA class (p=0.01), atrial fibrillation (p=0.0002) and higher mean mitral gradient after PMC (p=0.004). Conclusions In patients with restenosis after mitral commissurotomy, PMC provides good IR in most cases. After good IR, one patient out of three remains free from surgery and one out of five has good functional results at 20 years. These findings support the use of PMC after previous commissurotomy, particularly in selected patients with few symptoms and in sinus rhythm.

Objective Previous studies suggested an independent prognostic value of B-type natriuretic peptide (BNP) in aortic valve stenosis (AS) but were impeded by small sample sizes and inclusion of relatively selected young patients. We aimed to evaluate the relationship among N-terminal fragment of proBNP (Nt-proBNP), AS severity, symptoms and outcome in a large cohort of elderly patients with AS. Design Observational cohort study, COhorte Francaise de Retrecissement Aortique du Sujet Age (clinicalTrial.gov number-[NCT00338676][1]) and GENEtique du Retrecissement Aortique (clinicalTrial.gov number-[NCT00647088][2]). Setting Single-centre study. Patients Patients older than 70 years with at least mild AS. Interventions None. Measurements A comprehensive clinical, biological and echocardiographic evaluation was performed at study entry. Asymptomatic patients were prospectively followed on a 6-months basis and AS-related events (sudden death, congestive heart failure or new onset of AS-related symptoms) collected. Results We prospectively enrolled 361 patients (79±6 years, 230 severe AS). Nt-proBNP increased with the grade of AS severity and the NYHA class (all p

Aortic stenosis (AS) is the consequence of active valve remodelling, which can be easily diagnosed, but for which no preventive strategy is available. It is the most common valve disease in Western countries, where its prevalence increases with age, reaching about 3% after the age of 75. The burden of AS is high and is expected to double within the next 50 years. Surgery is recommended in patients with severe symptomatic AS. In practice, however, surgery is often denied to the elderly owing to extensive comorbidities or 'frailty' and, as a consequence, decision-making is not always consistent with risk-benefit analysis. These findings highlight the need for less invasive approaches in high-risk patients and account for the rapid development of transcatheter aortic valve implantation (TAVI). Preliminary analyses suggest that in-hospital costs of TAVI compare favourably with the costs of surgery. Cost-effectiveness analyses are needed but should be interpreted with caution, given the discrepancies in analyses concerning surgery.

Measurement of the degree of aortic valve calcification (AVC) using electron beam computed tomography (EBCT) is an accurate and complementary method to transthoracic echocardiography (TTE) for assessment of the severity of aortic stenosis (AS). Whether threshold values of AVC obtained with EBCT could be extrapolated to multislice computed tomography (MSCT) was unclear and AVC diagnostic value in patients with low ejection fraction (EF) has never been specifically evaluated.Patients with mild to severe AS underwent prospectively within 1 week MSCT and TTE. Severe AS was defined as an aortic valve area (AVA) of less than 1 cm(2). In 179 patients with EF greater than 40% (validation set), the relationship between AVC and AVA was evaluated. The best threshold of AVC for the diagnosis of severe AS was then evaluated in a second subset (testing set) of 49 patients with low EF (≤40%). In this subgroup, AS severity was defined based on mean gradient, natural history or dobutamine stress echocardiography.Correlation between AVC and AVA was good (r=-0.63, p0.0001). A threshold of 1651 arbitrary units (AU) provided 82% sensitivity, 80% specificity, 88% negative-predictive value and 70% positive-predictive value. In the testing set (patients with low EF), this threshold correctly differentiated patients with severe AS from non-severe AS in all but three cases. These three patients had an AVC score close to the threshold (1206, 1436 and 1797 AU).In this large series of patients with a wide range of AS, AVC was shown to be well correlated to AVA and may be a useful adjunct for the evaluation of AS severity especially in difficult cases such as patients with low EF.

The difficulties in achieving stable international normalised ratios (INRs) are a common concern in clinical practice and have been related to thromboembolic and bleeding risks in a number of clinical trials in patients with atrial fibrillation.1 The paper by Grzymala-Lubanski and colleagues fills an important gap since it provides an in-depth analysis of the clinical impact of warfarin treatment quality in the specific population of patients with mechanical heart valve prostheses, who are at particular risk of thromboembolism and bleeding.2 The time in therapeutic range (TTR) of 72% in the paper by Grzymala-Lubanski and colleagues is consistent with trials performed in atrial fibrillation. However, adherence to treatment is often better in clinical trials than in real life. In addition, this analysis was based on INR management by the Auricula network which uses a computerised dosing system allowing for good INR stability. In Sweden, TTR rates were among the highest in recent international clinical trials on atrial fibrillation. Therefore, it is likely that warfarin treatment quality is less satisfactory in other countries than in Sweden. The relationship between warfarin treatment quality and outcome has seldom been studied in the specific subgroup of patients with mechanical heart valve prostheses. A study published in 2002 found a strong relationship between poor INR stability and all-cause mortality in 1272 patients and this remained significant in multivariable analysis.3 The strength of the paper by Grzymala-Lubanski and colleagues is to confirm and expand these findings in a much larger patient sample and in a contemporary setting with regard to the type of prosthesis and target INRs. The quality of the SWEDEHEART registry is widely acknowledged and the prospective collection of clinical events through the Auricula network ensures …

Percutaneous balloon mitral valvuloplasty is now the treatment of choice for many patients with symptomatic mitral stenosis Applications are expanding to include several categories of patients previously considered ineligible for the procedure. Commissural fusion is now recognised as the principal pathology underlying mitral stenosis, and commissural splitting underlies successful interventional treatment. Although the technique of surgical commissurotomy was first described as early as 1948,1 percutaneous commissurotomy became a feasible option with the advent of the Inoue balloon in 1984.2 Percutaneous balloon mitral valvuloplasty (PBMV) is now the treatment of choice for many patients with symptomatic mitral stenosis. Numerous large series have reported excellent short, medium, and long term outcome3–7 with a low incidence of serious complications.8 Furthermore, randomised trials comparing balloon valvuloplasty with the surgical alternatives of open or closed commissurotomy have demonstrated equivalent outcome,9,10 although patients treated using the percutaneous approach enjoy the advantages of reduced procedural morbidity and mortality and a short hospital stay. Specific advantages of the Inoue balloon in comparison with other percutaneous techniques include a lower risk of complications (particularly left ventricular perforation which is more frequent using double balloon techniques), easier manoeuvrability, its slender profile (creating a smaller defect in the interatrial septum), its self positioning characteristics, short inflation–deflation cycle, and capacity to permit gradually increasing successive balloon inflation sizes, which allow the operator to terminate the procedure when commissural splitting is achieved or when there is an increase in the severity of mitral regurgitation. Disadvantages include circumferential application of pressure during balloon inflation, occasionally resulting in paracommissural tears, especially in degenerate, calcified valves. In developing nations, the application of PBMV is frequently limited on account of the high cost of the Inoue balloon. The development of a percutaneous metallic valvulotome, which can be autoclaved after each …

The association of coronary artery disease with heart valve disease is frequently encountered and it can be expected that this association will become more common because of the evolution in the epidemiology of valvar diseases. Degenerative lesions are now the most frequent cause of valve disease in western countries and they frequently occur in old patients, who are also at higher risk for atherosclerotic disease. The association of calcified aortic stenosis and coronary heart disease is the main problem, because it is the most frequently encountered association and because it raises specific questions, particularly in regard to the detection and management of both pathologies. Despite many reports in the literature, recently published guidelines point out the fact that concern remains regarding the optimal strategies for diagnosis and treatment of coronary artery disease in patients with valve disease.1 ### Frequency of coronary artery disease in patients with calcified aortic stenosis The frequency of coronary artery disease in patients with calcified aortic stenosis can be correctly assessed only in studies comprising systematic coronary angiography, regardless of the symptoms. The frequency of associated coronary disease varies according to the characteristics of the population involved, in particular age and, to a lesser degree, the geographic origin. Series of patients with calcific aortic stenosis whose mean age is between 60 and 70 years reported 30–50% of associated significant coronary artery disease (at least one stenosis > 50% or 70% of vessel diameter). Coronary artery disease has been reported in more than 50% of patients aged ⩾ 70 years2 and, of patients aged ⩾ 80 years, in 65% in series from the USA3 and 41% in a British series.4 Series published in the 1960s and '70s led certain authors to suggest that aortic stenosis could have a protective role against coronary atherosclerosis. This was in fact probably only the consequence of a selection bias in series in …

In their Heart paper, Hassell et al 1 present an original analysis of four studies comparing single and dual antiplatelet therapy after transcatheter aortic valve implantation (TAVI). There was no difference in the primary endpoint of net adverse clinical and cerebral events combining 30-day rates of mortality, acute coronary syndrome, stroke and major bleeding. However, there was a strong trend, although not statistically significant, towards less major or life-threatening bleeding at 30 days in patients receiving aspirin alone as compared with those treated using the usual combination of aspirin and clopidogrel early after TAVI. These findings challenge current recommendations and may contribute to improving patient outcome after TAVI. Guidelines consistently recommend dual antiplatelet therapy during 3–6 months after TAVI followed by single antiplatelet therapy (table 1).2–5 This relies mainly on the extrapolation of antithrombotic regimens following coronary stenting. However, despite the common presence of a metallic stent, coronary stenting and TAVI differ by a number of features which may influence thrombus formation, in particular vessel diameter, environment (atheromatous plaques or calcified aortic leaflets), presence of prosthetic leaflets and the frequency of associated atrial fibrillation. View this table: Table 1 Current recommendations for antithrombotic therapy after transcatheter aortic valve implantation (TAVI) or surgical bioprosthetic valve replacement Recommended antithrombotic regimens markedly differ between TAVI and surgical aortic valve replacement (AVR) using a bioprosthesis. Anticoagulant therapy was initially recommended during the first 3 months following bioprosthetic AVR, which corresponds to the time delay for endothelialisation of the sewing ring. However, this rationale was challenged by series suggesting that antiplatelet therapy alone may have a better risk:benefit profile.2 This led to changes in ESC/EACTS and American Heart Association/American …