• Heart Failure
• Interventional Techniques & Devices
• Cardiology Clinical Trials
• Valvular Disease

• Cardiology & Cardiovascular Medicine
• Heart Failure
• Interventional Techniques & Devices
• Cardiology Clinical Trials
• Valvular Disease

Brian T. Bethea, MD, Tenet Florida Region, Florida, USA, discussed advanced treatments for heart failure (HF) and severe aortic stenosis (SAS). Patients with advanced HF require special intervention, including left ventricular assist device (LVAD) implantation. Studies of the HeartMate II LVAD reported 79% to 90% rates of survival to transplant, recovery, or ongoing device support at 180 days [John R et al. Ann Thorac Surg 2011; Starling RC et al. J Am Coll Cardiol 2011; Pagani FD et al. J Am Coll Cardiol 2009; Miller LW et al. N Engl J Med 2007] and 58% to 63% 2-year survival [Park SJ et al. Circ Heart Fail 2012; Slaughter MS et al. N Engl J Med 2009].

The Heartware Bridge to Transplant trial reported 82% survival at 2 years, with 34% still on the device, 40% transplanted, and 8% recovered [Strueber M et al. J Am Coll Cardiol 2011].

Recent LVAD improvements include decreased size and increased durability. Next-generation LVADs include the HeartMate III, HeartMate X, and HeartMate FILVAS.

SAS is life-threatening, and it progresses rapidly. In the PARTNER trial, 50% of inoperable patients died within 1 year [Leon MB et al. N Engl J Med 2010]. The 2014 Valvular Heart Disease guidelines recommend valve replacement for most patients with SAS promptly after symptom onset [Nishimura RA et al. J Am Coll Cardiol 2014]. Surgical aortic valve replacement (SAVR) is recommended for low- to moderate- and high-risk patients; transcatheter aortic valve replacement (TAVR) is recommended for high- and greater-risk patients.

The PARTNER trial evaluated TAVR versus SAVR in high-risk operable SAS patients (cohort A) [Smith CR et al. N Engl J Med 2011] and TAVR versus standard therapy in inoperable SAS patients (cohort B) [Leon MB et al. N Engl J Med 2010]. At 1 year, all-cause mortality in cohort A was 24.3% versus 26.8% in the TAVR and SAVR arms, respectively (p = .001 for noninferiority). Symptom improvement and hemodynamic performance were similar in both groups. There was no significant difference in stroke rates despite increased periprocedural events after TAVR at 30 days or 1 year; rates of all neurologic events were higher in the TAVR group at 30 days and 1 year (p = .04, both). In cohort B, TAVR versus standard therapy patients had a 25% absolute mortality reduction. Major vascular complications and major bleeding were more significant in the TAVR group at 30 days and 1 year (p < .001, all).

The CoreValve pivotal trial had superior 1-year all-cause mortality with TAVR (14.2%) versus SAVR (19.1%; p = .04) [Popma et al. N Engl J Med 2014]. Several next-generation valve systems are under development.

Dr. Bethea stressed the importance of a multidisciplinary approach to the treatment of HF and SAS patients, using a “shared care model” [Dickstein K et al. Eur Heart J 2008].

• © 2014 MD Conference Express®