Impact of coronary artery disease in patients undergoing transcatheter aortic valve replacement: Insights from the FRANCE-2 registry.

BACKGROUND: Coronary artery disease (CAD) is common in patients undergoing transcatheter aortic valve replacement (TAVR). However, the impact of CAD distribution before TAVR on short- and long-term prognosis remains unclear. HYPOTHESIS: We hypothesized that the long-term clinical impact differs according to CAD distribution in patients undergoing TAVR using the FRench Aortic National CoreValve and Edwards (FRANCE-2) registry. METHODS: FRANCE-2 is a national French registry including all consecutive TAVR performed between 2010 and 2012 in 34 centers. Three-year mortality was assessed in relation to CAD status. CAD was defined as at least 1 coronary stenosis >50%. RESULTS: A total of 4201 patients were enrolled in the registry. For the present analysis, we excluded patients with a history of coronary artery bypass. CAD was reported in 1252 patients (30%). Half of the patients presented with coronary multivessel disease. CAD extent was associated with an increase in cardiovascular risk profile and in logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) (from 19.3% ± 12.8% to 21.9% ± 13.5%, P < 0.001). Mortality at 30 days and 3 years was 9% and 44%, respectively, in the overall population. In multivariate analyses, neither the presence nor the extent of CAD was associated with mortality at 3 years (presence of CAD, hazard ratio [HR]: 0.90; 95% confidence interval [CI]: 0.78-1.07). A significant lesion of the left anterior descending (LAD) was associated with higher 3-year mortality (HR: 1.42; 95% CI: 1.10-1.87). CONCLUSIONS: CAD is not associated with decreased short- and long-term survival in patients undergoing TAVR. The potential deleterious effect of LAD disease on long-term survival and the need for revascularization before or at the time of TAVR should be validated in a randomized control trial.

Percutaneous Patent Foramen Ovale (PFO) closure in young patients with both cryptogenic brain infarction and PFO associated with Atrial Septal Aneurysm (ASA).

BACKGROUND: To assess the safety and efficacy of percutaneous patent foramen ovale (PFO) closure for the prevention of recurrent stroke in high-risk patients. METHODS AND RESULTS: Between January 2002 and March 2005, 40 patients (65% female), mean (SD) age 43 (10) years were identified using the following inclusion criteria: <60 years, recent brain infarction (<3 months), combination of PFO plus atrial septal aneurysm (ASA) and exclusion of any other thromboembolic cause. Percutaneous PFO closure was performed under general anaesthesia and under the guidance of transoesophageal echocardiography (TEE). Aspirin and clopidogrel were given for three months after PFO closure, followed by aspirin alone. Neurological examination was performed every three months. RESULTS: PFO closure was successful in all patients, using all devices: INTRASEPT in 34 cases, STARFlex in 5 cases and AMPLATZER in one case. At day one, transthoracic echocardiography (TTE) excluded malpositioning of the device or pericardial effusion. At 6 months, TTE and TEE confirmed satisfactory implantation of the device, with no spontaneous shunt. No device related thrombi was observed. Mean patient follow-up was 17+/-7 months (range 12-38) and was 100% complete. No patients suffered from recurrent stroke (neither transient ischaemic attack nor brain infarction). CONCLUSION: This preliminary experience is encouraging for PFO closure with a 0% risk of stroke recurrence rate in a high-risk subset of patients (< 60 years, recent cryptogenic stroke, PFO plus ASA) and is safe using the current technology. Larger series with longer follow-up and randomised studies are still necessary in this setting before the completion of guidelines.