JACC in a Flash

This month, JACC in a Flash brings a roundup of the simultaneous publications in the JACC Journals presented at TCT Connect 2020, and more from across the family of journals, including JACC: Clinical Electrophysiology and JACC: CardioOncology.

JACC Journals Research Explores New Interventional Algorithms, Therapies, More

Several novel interventional studies presented during TCT 2020 were simultaneously published in JACC Journals. Research included an automated algorithm for pre-PCI physiological results; an assessment of PCI patients in the work-up pre-TAVR; transcatheter mitral valve repair (TMVr) in patients with cardiogenic shock and mitral regurgitation (MR); early outcomes of the Cephea valve in patients with severe primary MR; assessment of accessory renal arteries (ARAs) as a target for renal denervation; and TAVR with the LOTUS Edge System.

JACC: Cardiovascular Interventions

According to a study simultaneously published in JACC: Cardiovascular Interventions, by Seung Hun Lee, MD, PhD, et al., an automated algorithm using pre-PCI fractional flow reserve (FFR) pullback curve may be able to predict post-PCI physiological results.

"Incorporating an automated algorithm of dFFR(t)/dt might provide additional information to further refine proper target lesion selection in the pre-PCI phase," the authors conclude.


Sebastian Völz, MD, PhD, and Elmir Omerovic, MD, PhD, note in a related editorial comment that "future studies designed for the assessment of relevant clinical endpoints are necessary to ultimately evaluate the feasibility and clinical benefit of pre-PCI physiological response assessment."

Lee SH, Shin D, Lee JM, et al. JACC Cardiovasc Interv 2020;Oct 14:[Epub ahead of print].


Cardiology Magazine Image

Research by Laurent Faroux, MD, et al., simultaneously published in JACC: Cardiovascular Interventions, looked at 1,197 patients who had PCI in the work-up pre-TAVR.

Results showed these patients "frequently exhibited complex coronary lesions and multivessel disease."


After a median follow-up of two years, 444 patients (37.1%) presented a major adverse cardiovascular and cerebrovascular event, "with incomplete revascularization determining an increased risk."

According to Cindy L. Grines, MD, FACC, and Pradyumna E. Tummala, MD, FACC, in a related editorial comment, "whether revascularization before TAVR is necessary is still uncertain."

Faroux L, Campelo-Parada F, Munoz-Garci E, et al. JACC Cardiovasc Interv 2020;Oct 14:[Epub ahead of print].


Cardiology Magazine Image

A study by Richard G. Jung, BSc, et al., simultaneously published in JACC: Cardiovascular Interventions, evaluated the outcome of TMVr in 141 patients across 14 institutions with cardiogenic shock and moderate to severe or severe MR.

According to the authors "TMVr may improve short- and intermediate-term mortality in high-risk patients with cardiogenic shock and moderate to severe MR."


Philipp Lurz, MD, PhD, and Christian Besler, MD, note in a related editorial comment, "the findings by Jung et al., are encouraging and should stimulate more intense research in the field, but there is still a long way to go.

Let's hope TMVr finally finds a role in [cardiogenic shock] management, in the interest of our patients."

Jung RG, Simard T, Kovach C, et al. JACC Cardiovasc Interv 2020;Oct 14:[Epub ahead of print].


Cardiology Magazine Image

Novel research by Alberto Alperi, MD, et al., simultaneously published in JACC: Cardiovascular Interventions, found that "the transfemoral delivery of a purposely designed mitral prosthesis (Cephea valve) was safe and feasible in prohibitive risk patients."

The researchers looked at three patients with severe primary MR (two women, mean age 79 years) at prohibitive surgical risk.


Alperi et al., found that at six-month follow-up, "valve performance was sustained, and clinical outcomes improved."

Moving forward, they add "the confirmation of these initial results, including a larger number of patients, could potentially open the door to a new therapeutic alternative in patients with severe MR, most likely including those with [mitral annular calcification] features."

Alperi A, Dagenais F, del Val D, et al. JACC Cardiovasc Interv 2020;13:2427-37.


Cardiology Magazine Image

Yu Sato, MD, et al., looked at 7,287 nerves from 14 accessory renal arteries (ARAs) and nine dominant renal arteries (DRAs) to assess the importance of ARA as a target for renal denervation.

The research, simultaneously published in JACC: Cardiovascular Interventions, showed that ARAs showed a smaller number of nerves than DRAs, however, these results were dependent on the size of the ARA.


"Ablation especially in large ARAs may allow for more complete denervation with the potential of further reducing blood pressure," the authors conclude.

Sato Y, Kawakami R, Jinnouchi H, et al. JACC Cardiovasc Interv 2020;Oct 14:[Epub ahead of print].


Cardiology Magazine Image

A study of 286 patients undergoing TAVR with the LOTUS Edge System conducted by Xavier Armario, MD, et al., was simultaneously published in JACC: Cardiovascular Interventions.

Results showed that short-term safety and efficacy was "satisfactory," in addition to "favorable hemodynamic data, and very low rates of paravalvular leak in an anatomically complex cohort."


The authors add that new permanent pacemaker implantation remained high – 25.9% among all patients and 30.8% among permanent pacemaker-naïve patients.

The authors conclude that "Further study will evaluate if increasing operator experience with the device and new implantation technique can reduce the incidence of [permanent pacemaker] implantation."

Armario X, Rosseel L, Kharbanda R, et al. JACC Cardiovasc Interv 2020;Oct 14:[Epub ahead of print].


PROSPECT ABSORB: PCI vs. GDMT For Angiographically Mild Lesions With Large Plaque Burden?

Cardiology Magazine Image

PCI of angiographically mild lesions with large plaque burden was safe, substantially enlarged the follow-up minimum lumen area (MLA), and was associated with favorable long-term clinical outcomes, according to findings from the PROSPECT ABSORB trial presented during TCT 2020 and simultaneously published in the Journal of the American College of Cardiology.

The study used three-vessel imaging and a combination IVUS and near-infrared spectroscopy (NIRS) catheter in 898 patients presenting with myocardial infarction following successful PCI of all flow-limiting coronary lesions.

Those patients with an angiographically nonobstructive stenosis not intended for PCI but with IVUS plaque burden ≥65% (n=192) were randomized to treatment of the lesion with either a bioresorbable vascular scaffold (BVS) plus guideline-directed medical therapy (GDMT) or GDMT alone.


The primary powered effectiveness endpoint was the IVUS-derived MLA at the protocol-driven 25-month follow-up. The primary safety endpoint was randomized target lesion failure at 24 months and the secondary clinical effectiveness endpoint was randomized lesion-related major adverse cardiac events (MACE) at latest follow-up.

Results showed the median angiographic diameter stenosis of the randomized lesions was 41.6%, while the NIRS-IVUS median plaque burden was 73.7%. The median MLA was 2.9 mm2, and median maximum lipid plaque content was 33.4%. Angiographic follow-up at 25 months was completed in 167 patients.

The follow-up MLA in BVS-treated lesions was 6.9±2.6 mm2 compared with 3.0±1.0 mm2 in those treated with GDMT alone. Researchers also noted that the rates of target lesion failure at 24 months were similar across both groups. Randomized lesion-related MACE occurred in 4.3% of patients in the BVS-treated group compared with 10.7% in the GDMT-alone group (p=0.12).

Among the limitations to the study: it was not powered for clinical outcomes, and the present PCI results only apply to the first generation everolimus-eluting Absorb BVS. "Whether the results would be superior with a thinner-strut BVS or a contemporary metallic DES is unknown," said Gregg W. Stone, MD, FACC.

However, Stone and colleagues note the "the favorable randomized lesion-related MACE rates observed after BVS treatment compared with GDMT alone warrants the performance of an adequately powered randomized trial to determine whether PCI treatment of focal vulnerable plaques improves patient outcomes."

But they add, that "until such a study, PCI of nonischemic lesions, even those with high-risk morphologic features, cannot be routinely recommended."

The PROSPECT ABSORB study was embedded in the PROSPECT II study, also presented at TCT 2020.

Stone GW, Maehara A, Ali ZA, et al. J Am Coll Cardiol 2020;Oct 14:[Epub ahead of print].


VT Substrate Ablation During Stable Rhythm Safe, Effective?

Cardiology Magazine Image

In patients with structural heart disease (SHD) undergoing a first ablation for scar-related ventricular tachycardia (VT), during sinus rhythm without VT induction, there was a low rate of procedure-related complications and early mortality, according to a study published in a special issue of JACC: Clinical Electrophysiology focused on VT.

The prospective, observational study conducted at six centers in Spain by Juan Fernandez-Armenta, MD, PhD, et al., examined the safety and short- and long-term outcomes of VT substrate ablation during stable rhythm (sinus or paced), using scar dechanneling, in patients with SHD and sustained monomorphic VT documented by ECG or ICD recording.


A total of 412 consecutive patients (92% men, mean age 64 years) were studied; two-thirds had ischemic cardiomyopathy, nearly 14% had arrhythmogenic right ventricular cardiomyopathy and the remainder had nonischemic cardiomyopathy.

In the six months preceding the ablation, patients had a median of four VT episodes, and 32.3% had arrhythmic storm or incessant VT. Preprocedural imaging was obtained in 61% of patients, and epicardial access was performed in 31%.

The results showed that after substrate-guided ablation, 74% of patients had no inducible VT with the entire procedure completed during stable rhythm. Procedure-related complication rate was 6.5%, including one death (0.2%). Only four patients (0.97%) had complications related to hemodynamic decompensation.

At one year, the primary endpoint of ventricular arrhythmia-free survival was 82.5% after one procedure and 87.8% after n procedures. Early 30-day mortality after first VT ablation was 1.7%. Overall survival was 95.8% at one year and 88.6% at three years.

Independent predictors of overall survival based on multivariable analysis were age ≥70 years (hazard ratio [HR], 4.95; p<0.001), chronic obstructive pulmonary disease (HR, 2.37; p=0.008), left ventricular ejection fraction <30% (HR, 2.43; p=0.002), and incomplete substrate ablation (HR, 2.37; p=0.026).

The authors add that VT ablation based on substrate elimination during stable rhythm is safe and effective and has reproducible results and that hemodynamic decompensation was uncommon, with a low rate of early mortality and procedure-related complications. However, they conclude that randomized studies will be needed to assess the safety and efficacy of this strategy.

In an accompanying editorial comment, John Sapp, MD, writes, "Induction of VT at the outset of a procedure may provide further physiologic information, but its role has diminished to permitting more aggressive concentration of ablative effort on targets with higher specificity, and is particularly useful for hemodynamically tolerated VT."

He adds that "the observations by Fernandez-Armenta, et al., provide reassurance that omitting initial induction is safe and reasonable for most patients. Induction testing at the end of a procedure remains useful for identification of residual substrate and to estimate prognosis when it appears clinically safe to do so."

Fernandez-Armenta J, Soto-Iglesias D, Silva E, et al. J Am Coll Cardiol 2020;76:1435-48.


SENECA Evaluates Safety, Feasibility of allo-MSC in AIC Patients

Cardiology Magazine Image

Transendocardial injection of allogeneic mesenchymal stromal cells (allo-MSCs) may be safe and feasible in patients with anthracycline-induced cardiomyopathy (AIC), according to findings from the SENECA trial presented during the Heart Failure Society of America Virtual Annual Scientific Meeting 2020 and simultaneously published in JACC: CardioOncology.

Importantly, the trial also demonstrates that cardiac CMR may be effectively used in heart failure patients despite the high prevalence of devices.

In this first-in-human study of its kind, Roberto Bolli, MD, et al., assessed 37 cancer survivors with chronic AIC – six patients enrolled in an open-label, lead-in phase and 31 patients randomized 1:1 – who received 1 x 108 allo-MSCs or vehicle transendocardially.

The primary objectives were safety and feasibility, and the secondary objectives included cardiac function and structure measured by CMR, functional capacity, quality of life and biomarkers.


Results showed that a total of 97% of patients underwent successful study product injections and all allo-MSC-assigned patients received the target dose of cells. Follow-up visits were well-attended (92%) with successful collection of endpoints in 94% at the one-year visit.

Although 58% of patients had non-CMR compatible devices, CMR endpoints were successfully collected in 84% of patients imaged at one year, and no new tumors were reported.

In terms of clinical outcomes, no significant differences were seen between allo-MSC and vehicle groups.

As for efficacy, allo-MSC therapy was associated with a significant improvement in quality of life, consistent with previous studies of MSC therapy in ischemic heart failure. A borderline significant difference was found in exercise tolerance measured by the 6-minute walk test, favoring the allo-MSC group.

"This phase 1 study met its primary objectives by demonstrating that allo-MSCs are well-tolerated, that they could be delivered as planned and that the outcome measures could be collected successfully," the authors conclude.

"Our exploratory evaluation of efficacy endpoints will be important to design phase 2 and 3 studies. Taken together, these results provide the necessary groundwork for future larger studies focused on efficacy of cell therapy in AIC patients."

Bolli R, Perin EC, Willerson JT, et al. JACC CardioOnc 2020;Epub DOI: 10.1016/j.jaccao.2020.09.001.


Is Female Advantage Reduced Following MI

Cardiology Magazine Image

Women generally have a lower risk of myocardial infarction (MI), coronary heart disease (CHD), heart failure and all-cause mortality than men, however, this female advantage may be reduced following an MI, according to a study published in the Journal of the American College of Cardiology.

Sanne A.E. Peters, PhD, et al., analyzed data for 171,897 women and 167,993 men ages 21 or older with health insurance in the U.S. who were hospitalized for MI in 2015 or 2016. These patients were frequency matched by age and year to 687,588 women and 671,972 men without CHD.


Results showed that age-standardized rates of MI per 1,000 person-years in patients without CHD were 4.5 in women and 5.6 in men, and 60.2 in women and 59.8 in men with MI. CHD rates were lower in patients without CHD (6.3 in women vs. 10.7 in men) than in patients with MI (84.5 in women vs. 99.3 in men). All-cause mortality rates were lower in patients without CHD (63.7 in women vs. 59.0 in men) than patients with MI (311.6 in women vs. 284.5 in men).

"This study highlighted the importance of lowering the risk for recurrent events among both women and men following a MI," the authors conclude.

In an accompanying editorial comment, Nanette K. Wenger, MD, MACC, notes that "[over] the decades, women have been substantially underrepresented in the diagnostic and therapeutic randomized clinical trials of coronary heart disease, resulting in a far less robust evidence base for women than for men."

Wenger highlights how this disparity still exists, "[despite] serial recommendations for sex-based analyses for information regarding women." Among her recommendations for remediation is "the appreciation by women and their health care team members that the female heart is vulnerable to coronary heart disease, with advocacy for a heart-healthy lifestyle," and more.

Peters SAE, Colantonio LD, Chen L, et al. J Am Coll Cardiol 2020;76:1751-60.


Sacubitril/Valsartan Safe, Effective in Reducing CV Death, HF Hosptalization in HFrEF

Cardiology Magazine Image

Sacubitril/valsartan may be an effective and safe therapy for reducing risk of cardiovascular death or heart failure (HF) hospitalization and improving quality of life in patients with HF with reduced ejection fraction (HFrEF) compared with enalapril, according to a state-of-the-art review published in JACC: Heart Failure.

Kieran F. Docherty, MBCHB, et al., review how neprilysin inhibition works; the clinical benefits of sacubitril/valsartan vs. renin-angiotensin aldosterone system blockade alone; the safety of sacubitril/valsartan; sacubitril/valsartan across the HF spectrum; and practical considerations with sacubitril/valsartan.


The authors also provide a practical and evidence-based approach to the clinical integration of sacubitril/valsartan in patients with HFrEF.

"In the last [five] years, sacubitril/valsartan has been established as a cornerstone component of comprehensive disease-modifying medical therapy in the management of chronic HFrEF," write the authors.

"The next [five] years should see its wider implementation in practice and potential expansion of its therapeutic indications."

Docherty KF, Vaduganathan M, Solomon SD, McMurray JJV. JACC Heart Fail 2020;8:800-10.


LDL-C Exposure at Younger Age and Greater Future CV Risk

Cardiology Magazine Image

An individual's risk of future cardiovascular events may depend both on cumulative exposure to LDL-C concentration and, independently, on the time course of LDL-C accumulation, according to a study published in the Journal of the American College of Cardiology.

Michael J. Domanski, MD, FACC, and Valentin Fuster, MD, PhD, MACC, et al., developed a risk model to determine the risk of future cardiovascular events that looks at the area under the LDL-C curve vs. age curve and the time course of area accumulation.


The researchers used data of 4,958 asymptomatic adults ages 18 to 30 years who were enrolled in the CARDIA study between 1985 and 1986 to test the model. Age 40 was used as the beginning of follow-up for cardiovascular events.

The primary outcome was a composite of nonfatal coronary heart disease, stroke, transient ischemic attack, heart failure hospitalization, cardiac revascularization, peripheral arterial disease intervention or cardiovascular death.

The mean age of surviving participants was 55.8 years (range, 46.5-66.3 years). In a median of 16 years of follow-up after age 40 years, 275 participants experienced an incident cardiovascular event.

After adjusting for sex, race and risk factors, both the area under the LDL-C curve vs. age curve (hazard ratio [HR], 1.053; p<0.0001 per 100 mg/dL x years) and the time course of area accumulation, or slope of LDL-C curve, (HR, 0.797 per mg/dL/year; p=0.045) were significantly associated with risk of a cardiovascular disease event.

The median age of the first cardiovascular event was 49.4 years (range, 40-60 years), and the rate of cardiovascular events was 3.1% at age 50 and 7.8% at age 60.

According to the researchers, the study suggests that incident cardiovascular event risk depends on prior exposure to LDL-C and time course of area accumulation.

The findings "suggest that clinical trials of lowering LDL-C in young, even teenage, populations might show a major reduction in [cardiovascular disease] incidence compared to risk reduction started later," they note.

They conclude the "same area accumulated at younger age, compared to older age, resulted in greater risk increase, emphasizing the importance of optimal LDL-C control starting early in life."

The "unresolved tension raised by this study is that while elevated LDL-C early in life is prognostically important, the ultimate trial to prove that early treatment is superior to our current strategy is impossible to perform, at least with conventional approaches," Michael D. Shapiro, DO, MCR, FACC, and Deepak L. Bhatt, MD, MPH, FACC, write in an accompanying editorial comment.

They add that "perhaps the most important issues to focus upon" include the amount of evidence needed to initiate long-term lipid-lowering treatment in young individuals with hypercholesterolemia and whether society has "the appetite to start low-intensity therapy in large swaths of young, healthy individuals even if robust randomized trial evidence does not support this approach."

Domanski MJ, Tian X, Wu CO, et al. J Am Coll Cardiol 2020;76:1507-16.


Active Myocardial Inflammation Major Predictor of Recurrent VT After Ablation

Cardiology Magazine Image

Active myocardial inflammation may be a powerful predictor of recurrent ventricular tachycardia (VT) following catheter ablation, according to a study published in the Journal of the American College of Cardiology.

Giovanni Peretto, MD, et al., assessed 125 consecutive patients with myocarditis undergoing VT ablation to describe results and identify factors associated with arrhythmia recurrences. Before ablation, disease stage was evaluated to identify active vs. previous myocarditis. The primary study endpoint was the assessment of VT recurrences by 12-month.

Results showed that all patients had a history of myocarditis diagnosed by endomyocardial biopsy (59%) and/or CMR (90%), as well multiple episodes of drug-refractory VTs.


The authors found that multimodal preprocedural staging identified 47 patients with active myocarditis (38%) and 78 patients with previous myocarditis (62%). All patients had low-voltage areas on electroanatomical mapping (97% epicardial or endoepicardial); of them, 25 (20%) had wide border zone.

VT recurrences were documented in 25 patients (20%) by 12 months, and in 43 (34%) by last follow-up. On multivariable analysis, active myocarditis stage was found to be the only predictor of VT recurrences by 12 months, whereas both active myocarditis stage and wide border zone were associated with arrhythmia recurrences anytime during follow-up.

No VT episodes were found after re-do ablation was performed in 23 patients during previous myocarditis stage.

"Further research is necessary to confirm our findings and describe the morphological and functional characteristics of the border zone," the authors conclude. "As mapping and ablation techniques are in constant evolution, future studies are needed to assess the role of VT mapping-guided ablation, as compared with a substrate-based approach."

In a related editorial comment, Kalyanam Shivkumar, MD, PhD, FACC, and Duc H. Do, MD, FACC, note that "multicenter studies to capture a larger and more generalizable patient sample are necessary to better understand the utility of different diagnostic algorithms and treatment modalities."

However, they add that, "unless a concerted effort is made to look for inflammation, it will remain overlooked and underrecognized, to the detriment of these patients. Thus, it is wise to look carefully at the heart before choosing an ablation catheter for interventions."

Peretto G, Sala S, Basso C, et al. J Am Coll Cardiol 2020;76:1644-56.


Procedural MI Rates, Outcomes Vary Based on MI Definition

Cardiology Magazine Image

Procedural myocardial infarction (PMI) rates during PCI and CABG and outcomes post PMI vary according to MI definition, according to two studies published in the Journal of the American College of Cardiology.

In an analysis of data from the EXCEL trial, John Gregson, PhD, et al., compared rates and prognostic implications of PMI during PCI and CABG, based on the prespecified protocol definition of PMI (PMIProt) vs. the Third Universal Definition of Myocardial Infarction (UDMI). The study's primary outcome was cardiovascular mortality.

The study consisted of 1,835 patients from the EXCEL trial: 935 underwent PCI and 923 underwent CABG. PMIProt occurred in 34 patients (3.6%) after PCI and 56 patients (6.1%) after CABG (difference, –2.4%; p=0.015).


Based on the Third UDMI definition, PMI occurred in 37 PCI patients (4.0%) and 20 CABG patients (2.2%) (difference 1.8%; p=0.025). Both definitions were associated with five-year cardiovascular mortality (adjusted hazard ratio [HR], 2.18 for PMIProt vs. 2.87 for Third UDMI).

According to the researchers, the consistent hazard after PCI and CABG supports the EXCEL trial's use of PMIProt and its conclusions that PCI and CABG provide similar three- and five-year rates of major adverse cardiovascular events for revascularization of patients with left main coronary artery disease.

The researchers conclude that additional research is needed to "determine whether alternative PMI definitions have even higher diagnostic accuracy and greater prognostic utility than those assessed in the present analysis."

In another study, Hironori Hara, MD, et al., used data from the SYNTAX Extended Survival trial to examine PMI rates, based on five different definitions, and their association with 10-year all-cause mortality and impact on composite endpoint of major cardiac or cerebrovascular events at five years in the original trial.

The researchers used PMI definitions from the SYNTAX, ISCHEMIA and EXCEL trials; the Fourth UDMI; and the SCAI definition. The researchers looked at 1,652 patients (91.8%) from the SYNTAX Extended Survival trial, including 857 patients who received PCI and 795 who received CABG.

Based on SYNTAX and Fourth UDMI definitions, the results showed PMI rates of 2.7% and 3%, respectively, for PCI vs. 2.4% and 2.1%, respectively, for CABG. According to the ISCHEMIA definition, the PMI rate was 6% for PCI and 8.8% for CABG. Using the SCAI and EXCEL definitions, PMI rates were 5.7% for PCI vs. 16.5% for CABG.

There was a stronger PMI-associated mortality based on the SYNTAX and Fourth UDMI definitions vs. EXCEL or SCAI definitions. In addition, most PMI events based on the ISCHEMIA, SCAI and EXCEL definitions were driven by CK-MB >10-times the upper limit of normal. Regardless of the definition used, PMI following PCI was associated with all-cause 10-year mortality, whereas PMI after CABG was associated with mortality for one year.

The researchers conclude that PMI rates are "highly dependent on their definition." Given the different outcomes based on PMI definition, the authors note that researchers and clinicians "need to be aware of the tremendous impact of the actual definition of PMI on global outcome" and that "large patient-level data will be required to ascertain the impact of PMI on mortality."

"There might need to be acceptance that the same procedural MI definition cannot be fit to both" PCI and CABG Donald E. Cutlip, MD, FACC, writes in an accompanying editorial comment. He notes the SYNTAX trials support use of the UDMI definition following CABG but not PCI and that biomarking thresholds also are clinically meaningful.

"If we cannot find definitions that fit these purposes, then perhaps it is time to remove [PMI] from primary composite endpoints," he concludes.

Gregson J, Stone GW, Ben-Yehuda O, et al. J Am Coll Cardiol 2020;76:1609-21.
Hara H, Serruys PW, Takahashi K, et al. J Am Coll Cardiol 2020;76:1622-39.


Valvular AFib Increases Risk of CV Death, Stroke in TAVR

Cardiology Magazine Image

In patients undergoing TAVR, the presence of valvular atrial fibrillation (AFib) increased the risk for cardiovascular death or disabling stroke compared with patients without AFib or nonvalvular AFib, according to a study published in JACC: Cardiovascular Interventions.

Taishi Okuno, MD, et al., performed a retrospective analysis of a prospective registry to assess the impact of valvular and nonvalvular AFib in patients undergoing TAVR. The primary endpoint was a composite of cardiovascular death or disabling stroke at one year after TAVR.

Of the 1,472 patients undergoing TAVR between August 2007 and June 2018, 465 patients (31.6%) had AFib (nonvalvular in 376 patients [25.5%] and valvular in 89 patients [6%]). AFib scores were comparable between patients with nonvalvular and valvular AFib.


Researchers found the primary endpoint occurred in 9.3% of patients without AFib, in 14.5% of patients with nonvalvular AFib and in 24.2% of patients with valvular AFib. The rate of the composite of cardiovascular death or disabling stroke was higher in patients with valvular AFib.

"The present findings may have implications for risk stratification in patients undergoing TAVR," write the authors.

"Although both [AFib] and mitral stenosis are recognized to increase the risk for adverse clinical outcomes in TAVR candidates, the present study is the first to appreciate the combined effect of the [two] factors. The identification of valvular [AFib] may refine the estimated risk for adverse clinical outcomes in patients undergoing TAVR."

"[The] coexistence of [AFib] with the different presentations of valvular heart disease deserves more attention," write Bernard Iung, MD, and Vincent Algalarrondo, MD, PhD, in an accompanying editorial comment.

"In addition to the obvious impact on the thromboembolic risk and the inherent indications for anticoagulant therapy, more studies are needed to ascertain the relationship between [AFib] types and aortic stenosis, thereby improving our decision-making for interventions in both diseases."

Okuno T, Hagemeyer D, Brugger N, et al. JACC Cardiovasc Interv 2020;13:2124-33.


Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Diabetes and Cardiometabolic Disease, Dyslipidemia, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Pericardial Disease, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Sports and Exercise Cardiology, Stable Ischemic Heart Disease, Valvular Heart Disease, Vascular Medicine, Anticoagulation Management and ACS, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and CHD and Pediatrics, Cardiac Surgery and Heart Failure, Cardiac Surgery and SIHD, Cardiac Surgery and VHD, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Imaging, CHD and Pediatrics and Interventions, CHD and Pediatrics and Prevention, Acute Heart Failure, Pulmonary Hypertension, Interventions and ACS, Interventions and Imaging, Interventions and Structural Heart Disease, Interventions and Vascular Medicine, Angiography, Nuclear Imaging, Hypertension, Sleep Apnea, Sports and Exercise and Congenital Heart Disease and Pediatric Cardiology, Sports and Exercise and ECG and Stress Testing, Sports and Exercise and Imaging, Chronic Angina

Keywords: ACC Publications, Cardiology Magazine, Acute Coronary Syndrome, Anticoagulants, Arrhythmias, Cardiac, Cardiac Surgical Procedures, Metabolic Syndrome, Angina, Stable, Heart Defects, Congenital, Dyslipidemias, Geriatrics, Heart Failure, Angiography, Diagnostic Imaging, Pericarditis, Secondary Prevention, Hypertension, Pulmonary, Sleep Apnea Syndromes, Sports, Exercise Test, Heart Valve Diseases, Aneurysm

< Back to Listings