Von Willebrand Factor Activity Association With Outcomes After Transcatheter Edge-to-Edge Mitral Valve Repair.

Background: Residual mitral regurgitation (MR) is associated with worse outcomes after transcatheter edge-to-edge mitral valve repair (TEER). Shear stress induced by MR leads to altered von Willebrand factor activity (vWF:Act) and increased closure time with adenosine diphosphate (CT-ADP). Objectives: The purpose of this study was to investigate the use of CT-ADP to monitor MR during TEER and the association between the vWF, residual MR, and clinical events post-TEER. Methods: Sixty-five patients undergoing TEER were enrolled. CT-ADP was measured at baseline, after each clip deployment, 1 hour and 24 hours post-TEER. CT-ADP values were related to vWF:Act/vWF antigen (vWF:Ag) ratio at the same time points, and MR severity was assessed by echocardiography at 1 month. Combined events of all-cause mortality and heart failure hospitalizations were evaluated at 1 year. Results: At 1 month, 32 (49%) patients had residual MR > mild (of those, 14% had MR > moderate). There was no significant change in CT-ADP values during the procedure. However, CT-ADP significantly decreased 1-hour post-TEER (P < 0.001). Patients with corrected MR demonstrated an increase in vWF:Act/vWF:Ag ratio 1-hour post-TEER. Elevated baseline vWF:Act/vWF:Ag ratio and the periprocedural percentage changes of the vWF:Act/vWF:Ag ratio (1 hour post-TEER - baseline values) were associated with the combined clinical outcome. Conclusions: CT-ADP evolution in time was not quick enough to provide real-time monitoring of MR severity during TEER. However, vWF:Act/vWF:Ag ratio at baseline and its variations following the procedure were associated with clinical outcomes. Those findings will need external validation.

Coronary Revascularization in Patients Undergoing Transcatheter Aortic Valve Replacement.

Concomitant coronary artery disease (CAD) is highly prevalent among patients with severe aortic stenosis (AS). Historically, surgical aortic valve replacement with coronary artery bypass grafting was the only treatment option for patients with severe AS and significant CAD. The rapid expansion of transcatheter aortic valve replacement has led to significant paradigm shifts in the treatment of severe AS and has raised new questions regarding the optimal management of CAD in these patients. We review the evidence regarding management of concomitant CAD in severe AS patients, specifically focusing on issues surrounding transcatheter aortic valve replacement. In the absence of robust evidence supporting specific treatment strategies, decisions regarding coronary revascularization in severe AS should be individualized and made within the context of a multidisciplinary heart team.

Impact of Coronary Artery Disease Severity Assessed With the SYNTAX Score on Outcomes Following Transcatheter Aortic Valve Replacement.

BACKGROUND: The influence of coronary artery disease (CAD) on clinical and echocardiographic outcomes after transcatheter aortic valve replacement (TAVR) is still controversial. We sought to evaluate the impact of CAD severity as measured by the SYNTAX score (SS) on patients undergoing TAVR. METHODS AND RESULTS: A total of 377 patients who underwent TAVR in 2 high-volume centers in North America were included in our retrospective analysis. A blinded angiographic core laboratory calculated the SS on all available coronary angiograms with the use of quantitative coronary analysis. Patients were stratified into 4 groups: (1) no CAD (SS=0); (2) low SS (SS between 1 and 22); (3) intermediate SS (SS between 23 and 32); and (4) high SS (SS ≥33). Patients who had undergone percutaneous coronary intervention within 6 months prior to TAVR were separated into 2 categories based on their residual SS (<8 and ≥8). Patients with previous coronary artery bypass grafting (CABG) were divided into 2 groups: (1) low CABG SS and (2) high CABG SS. The primary end point was a composite of all-cause mortality, myocardial infarction, and stroke. At 30 days and 1 year, both the presence and the severity of CAD had no impact on the rate of the combined primary end point and on all-cause mortality, cardiovascular mortality, and myocardial infarction. Patients with less complete revascularization (residual SS ≥8 versus residual SS <8 and low CABG SS versus high CABG SS, had similar rates of the combined primary end point, all-cause mortality, cardiovascular mortality, MI, and stroke, at both 30 days and 1 year. CONCLUSIONS: In our core laboratory-validated study, neither the severity of CAD nor completeness of revascularization after percutaneous coronary intervention or CABG were associated with clinical outcomes after TAVR, at both 30 days and 1 year.