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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThis article discusses variables that put patients who are undergoing aortic valve replacement at increased risk; the impact of these factors on morbidity and mortality; and the validity of standardized risk algorithms. Additional topics include aortic valve technology, mitral valve technology, and decision-making strategies in patients with advanced valvular disease.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Techniques \u0026amp; Devices\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EValvular Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EPrevention \u0026amp; Screening\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EAssessing Risk\u003C\/h2\u003E\n         \u003Cp id=\u0022p-2\u0022\u003EBlase A. Carabello, MD, Baylor College of Medicine, Houston, Texas, USA, discussed variables that put patients who are undergoing aortic valve replacement at increased risk (eg, coronary heart disease, renal failure, liver and lung disease, and porcelain aorta); the impact of these factors on morbidity and mortality; and the validity of standardized risk algorithms.\u003C\/p\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EThe European System for Cardiac Operative Evaluation (EuroSCORE) [\u003Ca href=\u0022http:\/\/www.euroscore.org\/\u0022\u003Ehttp:\/\/www.euroscore.org\/\u003C\/a\u003E] and the Society of Thoracic Surgeons (STS) score [\u003Ca href=\u0022http:\/\/www.sts.org\/quality-research-patient-safety\/quality\/quality-performance-measures\u0022\u003Ehttp:\/\/www.sts.org\/quality-research-patient-safety\/quality\/quality-performance-measures\u003C\/a\u003E] [Roqes F et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2003; Edwards FH et al. \u003Cem\u003EAnn Thorac Surg\u003C\/em\u003E 1997] are used widely for the evaluation of procedural risk in cardiac surgery [\u003Ca href=\u0022http:\/\/209.220.160.181\/STSWebRiskCalc261\/de.aspx\u0022\u003Ehttp:\/\/209.220.160.181\/STSWebRiskCalc261\/de.aspx\u003C\/a\u003E].\u003C\/p\u003E\n         \u003Cp id=\u0022p-4\u0022\u003EDr. Carabello discussed bias in the STS database (weighted toward coronary artery bypass grafting) and recent modifications in its scoring system for valvular heart disease. Risk factors not only include renal and lung function, number of surgeries, and whether the patient has coronary artery disease but also a host of unmeasured variables, such as frailty, depression, the clinician\u0027s overall impression, and the success rate of the team that is selected to perform the operation.\u003C\/p\u003E\n         \u003Cp id=\u0022p-5\u0022\u003EIn that noncardiac comorbidities can outweigh risks that are associated with cardiac issues and that all risk is individual, it is in the patient\u0027s best interests to have his or her case reviewed by a joint cardiology-cardiac surgery team to determine which therapy is best for each patient.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EAortic Valve Technology\u003C\/h2\u003E\n         \u003Cp id=\u0022p-6\u0022\u003ETechnological advances in aortic valves, delivery systems, and techniques have improved outcomes, reduced length of hospital stays, and confirmed all preclinical expectations in an increasingly broad spectrum of patients. A presentation by Helene Eltchaninoff, MD, Charles Nicolle Hospital, Rouen, France, reviewed aortic valve technology.\u003C\/p\u003E\n         \u003Cp id=\u0022p-7\u0022\u003EDr. Eltchaninoff discussed transcatheter aortic valve implantation (TAVI) valves, delivery systems, and techniques from Edwards Lifesciences since 2004, comparing the company\u0027s earlier SAPIEN\u2122 transfemoral and transapical 23- and 26-mm valves with the RetroFlex delivery system to its SAPIEN XT\u2122, which is currently being used in Europe with improved Novaflex transfemoral and Ascendra 2 transapical delivery systems.\u003C\/p\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EThere are approximately 500 TAVI centers in Europe and some 50,000 patients worldwide. Expanded clinical indications will be determined by improvements in transcatheter valves and delivery systems, new imaging technologies and embolic protection devices, upcoming registries, controlled trials in specific subsets of patients, and assessment of valve and platform durability.\u003C\/p\u003E\n         \u003Cp id=\u0022p-9\u0022\u003EOutcomes of TAVI in high-risk and inoperable patients have been reported in a number of registries and have confirmed the results of the pivotal PARTNER-US Trial. TAVI has recently been approved by the United States Food and Drug Administration for use in nonsurgical patients. Patients must enroll and be followed long term within the new STS\/ACC TVT Registry [\u003Ca href=\u0022https:\/\/www.ncdr.com\/TVT\/Home\/Default.aspx\u0022\u003Ehttps:\/\/www.ncdr.com\/TVT\/Home\/Default.aspx\u003C\/a\u003E].\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EMitral Valve Technology\u003C\/h2\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EDonald D. Glower, MD, Duke University Medical Center, Durham, North Carolina, USA, discussed the evolution of mitral valve technology\u2014from closed commissurotomy in 1948 to percutaneous replacement in 2010.\u003C\/p\u003E\n         \u003Cp id=\u0022p-11\u0022\u003EBetter imaging and advances in robotic technology have improved patient appeal and advanced the standard of care. In imaging, 3- and 4-dimensional ultrasonographic capabilities have overcome limitations of current methods with automatic modeling, semiautomatic generation of the location of the mitral annulus, and improved visualization and understanding of mitral valve behavior [Schneider RJ et al. \u003Cem\u003EMed Image Comput Comput Assist Interv\u003C\/em\u003E 2011].\u003C\/p\u003E\n         \u003Cp id=\u0022p-12\u0022\u003EIn Europe and the United States [Casselman FP et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2007], less-invasive procedures include mitral valve repair under direct vision through a right minithoracotomy [Seeburger J et al. \u003Cem\u003EEur J Cardiothorac Surg\u003C\/em\u003E 2008] and a total endoscopic approach through a 3\u20134-cm incision [Casselman FP et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2003]. These techniques compete with the robotic approach, and currently, there is no indication that the robotic technique is any better or worse than the others or that it is more reproducible [Trento A. \u003Cem\u003EMayo Clin Proc\u003C\/em\u003E 2011].\u003C\/p\u003E\n         \u003Cp id=\u0022p-13\u0022\u003EFuture mitral valve technology will likely be less invasive, attract new patients, have increased initial costs, be directed toward higher-risk patients, and have a longer learning curve.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-4\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EDecision-Making in Patients With Advanced Valvular Disease\u003C\/h2\u003E\n         \u003Cp id=\u0022p-14\u0022\u003ERobert O. Bonow, MD, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA, discussed factors that weigh into decision-making in the treatment of advanced valve disease with aortic stenosis (AS) and mitral regurgitation (MR).\u003C\/p\u003E\n         \u003Cp id=\u0022p-15\u0022\u003EExercise testing can help identify patients who might benefit from early valve repair or replacement. In addition, stress echocardiography has emerged as an important component of stress testing in patients with valvular heart disease [Picano E et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2009].\u003C\/p\u003E\n         \u003Cp id=\u0022p-16\u0022\u003EIn challenging patients with MR, new data show that correction with the MitraClip in nonresponders to cardiac resynchronization therapy improves symptoms and promotes reverse remodeling [Auricchio A et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2011].\u003C\/p\u003E\n         \u003Cp id=\u0022p-17\u0022\u003EThe PARTNER Trial [\u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT00530894\u0026amp;atom=%2Fspmdc%2F11%2F15%2F22.atom\u0022\u003ENCT00530894\u003C\/a\u003E] indicated that in high-risk patients with severe AS, transcatheter and surgical procedures for aortic valve replacement are associated with similar rates of survival at 1 year, although there were important differences in periprocedural risks [Smith CR et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2011].\u003C\/p\u003E\n         \u003Cp id=\u0022p-18\u0022\u003EThe rates of death from any cause were 3.4% in the transcatheter group and 6.5% in the surgical group at 30 days (p=0.07) and 24.2% and 26.8%, respectively, at 1 year (p=0.44), with a reduction of 2.6 percentage points in the transcatheter group (upper limit of the 95% CI, 3.0 percentage points; predefined margin, 7.5 percentage points; p=0.001 for noninferiority). The rates of major stroke were 3.8% in the transcatheter group and 2.1% in the surgical group at 30 days (p=0.20) and 5.1% and 2.4%, respectively, at 1 year (p=0.07).\u003C\/p\u003E\n         \u003Cp id=\u0022p-19\u0022\u003EAt 30 days, major vascular complications were significantly more frequent with transcatheter replacement (11.0% vs 3.2%; p\u0026lt;0.001); adverse events that were more frequent after surgical replacement included major bleeding (9.3% vs 19.5%; p\u0026lt;0.001) and new-onset atrial fibrillation (8.6% vs 16.0%; p=0.006). More patients who were undergoing transcatheter replacement had an improvement in symptoms at 30 days, but by 1 year, there was no significant between-group difference.\u003C\/p\u003E\n         \u003Cp id=\u0022p-20\u0022\u003EIn severely ill patients with AS who were considered to be at too high a risk for surgical aortic valve replacement (SAVR), the PARTNER B Study showed that TAVI, compared with standard therapy, significantly reduced the rates of death from any cause (30.7% vs 50.7%; HR, 0.55; 95% CI, 0.40 to 0.74; p\u0026lt;0.001) and repeat hospitalization and cardiac symptoms (42.5% vs 71.6%; HR, 0.46; 95% CI, 0.35 to 0.59; p\u0026lt;0.001) [Leon MB et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2010]. However, there was a higher incidence of major stroke (5.0% vs 1.1%; p=0.06) and major vascular events (16.2% vs 1.1%; p\u0026lt;0.001). Two-year follow-up data, recently reported at TCT in 2011, confirmed these earlier observations. see the peer-reviewed summary here: \u003Ca href=\u0022http:\/\/www.nxtbook.com\/nxtbooks\/md_conference_express\/tct2011\/#\/0\u0022\u003Ehttp:\/\/www.nxtbook.com\/nxtbooks\/md_conference_express\/tct2011\/#\/0\u003C\/a\u003E.\u003C\/p\u003E\n         \u003Cp id=\u0022p-21\u0022\u003EIn patients with severe AS and depressed left ventricular systolic function (LVEF \u226450%), TAVI is associated with better LVEF recovery compared with SAVR [Clavel MA et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2010]. Long-term follow-up of this important surrogate outcome and the study of whether it remains an important predictor of clinical outcomes in TAVI patients are ongoing.\u003C\/p\u003E\n         \u003Cp id=\u0022p-22\u0022\u003EIn advanced valve disease with aortic stenosis, TAVI represents a transformative technology with enormous potential, but its broad application also presents issues of patient selection, cost-effectiveness, and the need for dedicated, expert heart valve centers. For the majority of patients, SAVR represents the standard, with proven safety and durability. However, too many patients are not referred for surgery, and of those that are, the ones who are at highest risk should be treated at centers of excellence.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2011 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/11\/15\/22.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzmvj2\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}