Dhaval Kolte

Background: There are uncertainties regarding long‐term outcomes of low‐flow, low‐gradient (LFLG) severe aortic stenosis (AS) following transcatheter aortic valve replacement (TAVR). This study investigates long‐term outcomes of TAVR for high‐gradient (HG), classical LFLG, and paradoxical LFLG AS. Methods: We systematically searched PubMed, Embase, Scopus, and Cochrane Library databases until January 2025 for studies comparing HG, classical LFLG, and paradoxical LFLG AS outcomes following TAVR. The primary outcome was all‐cause mortality, analyzed using reconstructed individual patient data meta‐analysis. Secondary outcomes included cardiovascular mortality, heart failure hospitalization, acute kidney injury, bleeding events, stroke, myocardial infarction, permanent pacemaker implantation, and echocardiographic outcomes, analyzed using multivariate meta‐analysis. Results: We included 19 observational studies comprising 20 493 patients who underwent TAVR for severe AS. Time‐to‐event meta‐analysis indicated a higher risk of 5‐year all‐cause mortality in patients with classical and paradoxical LFLG AS compared with HG AS (hazard ratio [HR], 1.92 [95% CI, 1.62–2.27] and HR, 1.20 [95% CI, 1.07–1.34], respectively). Multivariate meta‐analysis indicated an increased risk of cardiovascular mortality in patients with LFLG versus HG AS (classical LFLG HR, 1.94 [95% CI, 1.74–2.16]; paradoxical LFLG HR, 1.40 [95% CI, 1.25–1.57]). Classical and paradoxical LFLG AS were also associated with a higher risk of heart failure hospitalization (HR, 4.12 [95% CI, 2.16–7.83]; HR, 1.80 [95% CI, 1.14–2.85], respectively) compared with HG AS. Conclusions: Classical and paradoxical LFLG AS were associated with higher all‐cause and cardiovascular mortality following TAVR compared with HG AS. Future studies are needed to determine strategies to improve outcomes following TAVR in patients with LFLG AS.

BACKGROUND: It remains unclear whether drug-coated balloons (DCBs) and drug-eluting stents are comparable in the treatment of coronary artery disease (CAD) and whether limus versus paclitaxel DCBs yield similar clinical outcomes. We aimed to assess the clinical efficacy of limus and paclitaxel DCBs in patients with CAD through a network meta-analysis. METHODS: We comprehensively searched multiple databases for randomized controlled trials comparing the following 4 strategies: limus DCB, paclitaxel DCB, second-generation or newer drug-eluting stent, and plain old balloon angioplasty. The primary outcome was trial-defined major adverse cardiovascular events (MACEs), typically a composite of death, myocardial infarction, or target lesion revascularization. Secondary outcomes included individual components of MACE. We performed subgroup analyses for in-stent restenosis, small-vessel (<3 mm) CAD, and other de novo CAD, such as large vessel and ST-segment–elevation myocardial infarction. RESULTS: We identified 39 randomized controlled trials including 10 219 patients. There was no significant difference in MACE between limus and paclitaxel DCBs (relative risk, 1.22 [95% CI, 0.86–1.73]). There were no significant differences in MACE between limus or paclitaxel DCB and second-generation or newer drug-eluting stents. Plain old balloon angioplasty had an increased risk of MACE compared with others. These results were consistent across subgroup analyses for in-stent restenosis, small-vessel CAD, and other de novo CAD. CONCLUSIONS: No significant differences were observed in MACE or its components between limus and paclitaxel DCBs, albeit with limited statistical power. Furthermore, DCB and second-generation or newer drug-eluting stents yielded similar outcomes though power was limited, especially for other de novo CAD. REGISTRATION: URL: https://www.crd.york.ac.uk/PROSPERO/ ; Unique identifier: CRD420250654276.

BACKGROUND: The dissemination of novel procedures should attempt to strike a balance between access and procedure quality. This study aimed to evaluate the temporal trends and geographic dispersion of mitral transcatheter edge-to-edge repair (M-TEER) sites and to examine the associations of site volume and site-to-population density with patient outcomes. METHODS: We used the Medicare administrative databases in the United States to identify sites performing M-TEER in patients aged 65 to 99 years from 2017 to 2020 and examined the annualized volume and site-to-population density (per million beneficiaries in each corresponding hospital referral region). A hierarchical Cox regression analysis accounting for site-level clustering was performed to assess the association of site volume and density with 30-day and 1-year all-cause mortality. RESULTS: We identified 456 sites performing M-TEER in 16 810 patients (median [interquartile range] age, 81 [75–86] years; female, 47%). The case number of M-TEER increased by 54% from 3125 in 2017 to 4820 in 2020, while sites performing M-TEER increased by 71% from 252 in 2017 to 432 in 2020, corresponding to a decline in the median patient-to-site distances from 37.1 kilometers (interquartile range, 14.4–105.0) to 28.6 kilometers (interquartile range, 12.8–74.9). Higher site volume (every 10 cases/y) was associated with lower 30-day (adjusted hazard ratio, 0.94 [95% CI, 0.91–0.99]) and 1 year (adjusted hazard ratio, 0.98 [95% CI, 0.96–1.00]) mortality, while there was insufficient evidence to determine the association between higher site density (every 1 site/million-beneficiaries) and 30-day (adjusted hazard ratio, 1.00 [95% CI, 0.99–1.02]) and 1-year (adjusted hazard ratio, 1.00 [95% CI, 0.99–1.01]) mortality. CONCLUSIONS: Although sites performing M-TEER have been rapidly expanding, we did not find associations between higher regional site density and patient mortality. Continuous careful planning in disseminating M-TEER while ensuring adequate procedure volume per site may optimize patient outcomes.

Background: Stroke is a recognized complication following transcatheter aortic valve replacement (TAVR). Although women have historically had a higher rate of bleeding and vascular complications after TAVR, contemporary data on sex differences in post‐TAVR stroke and stroke severity are lacking. Disabling strokes significantly affect quality of life and outcomes, underscoring the need to explore sex‐specific variations in post‐TAVR stroke risk. Methods: In this retrospective cohort study, we included all patients who underwent TAVR in the National Inpatient Sample from 2016 to 2021. Stroke and stroke severity were ascertained using validated claims‐based algorithms. Disabling strokes were defined as those resulting in death or discharge to a nonhome location. We used multivariable logistic regression to evaluate the association between sex and stroke while adjusting for covariates, including cerebral embolic protection use, and accounting for survey weights. Results: Among our weighted sample of 379 410 patients (43.9% female), women demonstrated higher overall in‐hospital stroke incidence compared with men (2.31% versus 1.69%; adjusted odds ratio [aOR], 1.208 [95% CI, 1.082–1.350]). This difference was driven primarily by disabling strokes, which were more common in women (1.61% versus 1.01%; aOR, 1.327 [95% CI, 1.158–1.520]). Conversely, the incidence of nondisabling stroke was not statistically different between sexes (0.70% versus 0.67%;( aOR, 1.013 [95% CI, 0.844–1.215]). Conclusions: Among patients undergoing TAVR in contemporary practice, women had a higher rate of any stroke and disabling strokes compared with men. These findings emphasize the need for tailored strategies to mitigate stroke risk and improve outcomes for female TAVR patients.