title: Hemodynamic outcomes of transcatheter aortic valve replacement and medical management in severe, inoperable aortic stenosis: a longitudinal echocardiographic study of cohort B of the PARTNER trial.
abstract: BACKGROUND
  Inoperable aortic stenosis may be treated with either transcatheter aortic valve replacement (TAVR) or medical management (MM) with or without balloon aortic valvuloplasty (BAV). The aim of this study was to compare the long-term echocardiographic findings among TAVR, MM, and BAV in patients with severe, inoperable aortic stenosis.
  
  
  METHODS
  A total of 358 inoperable patients in the Placement of Aortic Transcatheter Valves trial were randomized to MM or TAVR. Echocardiograms obtained at baseline, 30 days, and 1, 2, and 3 years were analyzed by a central core laboratory.
  
  
  RESULTS
  At baseline, TAVR and MM were similar, with more frequent Society of Thoracic Surgeons score > 10 (51.7% vs 65.0%, P = .03) and larger end-systolic volumes (54.5 ± 29.3 vs 69.1 ± 48.0 mL, P = .03) in MM. By 30 days after TAVR, mean aortic valve gradient had decreased (from 43.8 ± 14.7 to 10.0 ± 4.3 mm Hg, P < .001), ejection fraction had increased (from 53.2 ± 12.4% to 56.7 ± 10.0%, P < .001), and left ventricular (LV) mass index had decreased (from 144.7 ± 36.1 to 140.0 ± 37.9 gm/m(2), P < .05). After 1 year, aortic valve gradients and area were unchanged, while LV mass index had decreased by another 16 gm/m(2) (to 124 gm/m(2)). By 30 days after BAV, mean aortic valve gradient had decreased from 43.4 ± 15.0 to 31.9 ± 11.1 mm Hg, while ejection fraction and LV mass index were unchanged; gradient reverted to baseline at 1 year. No changes in gradients or mass were seen in MM patients.
  
  
  CONCLUSIONS
  TAVR results in immediate and sustained relief in pressure overload and improved LV systolic function, with continued regression of hypertrophy over 3 years. Poor clinical results with BAV are explained by the modest and transient reductions in pressure overload with BAV, which were not accompanied by improved LV function or remodeling. TAVR is the preferred treatment in eligible inoperable patients (ClinicalTrials.gov identifier NCT00530894).
authors.affiliation: Duke Clinical Research Institute and Duke University Medical Center, Durham, North Carolina. Electronic address: pamela.douglas@duke.edu.
authors.forename: Pamela S
authors.initials: PS
authors.lastname: Douglas
authors.affiliation: Columbia University Medical Center/New York Presbyterian Hospital, New York, New York.
authors.forename: Rebecca T
authors.initials: RT
authors.lastname: Hahn
authors.affiliation: Department of Medicine, Laval University, Quebec, Quebec, Canada.
authors.forename: Philippe
authors.initials: P
authors.lastname: Pibarot
authors.affiliation: Medstar Health Research Institute and Georgetown University School of Medicine, Washington, District of Columbia.
authors.forename: Neil J
authors.initials: NJ
authors.lastname: Weissman
authors.affiliation: Cleveland Clinic Foundation, Cleveland, Ohio.
authors.forename: William J
authors.initials: WJ
authors.lastname: Stewart
authors.affiliation: Cardiovascular Research Foundation, New York, New York.
authors.forename: Ke
authors.initials: K
authors.lastname: Xu
authors.affiliation: Medstar Washington Hospital Center, Washington, District of Columbia.
authors.forename: Zuyue
authors.initials: Z
authors.lastname: Wang
authors.affiliation: Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Stamatios
authors.initials: S
authors.lastname: Lerakis
authors.affiliation: Cedars-Sinai Medical Center, Los Angeles, California.
authors.forename: Robert
authors.initials: R
authors.lastname: Siegel
authors.affiliation: St Paul's Hospital, Vancouver, British Columbia, Canada.
authors.forename: Christopher
authors.initials: C
authors.lastname: Thompson
authors.affiliation: The Heart Hospital Baylor, Scott and White Health, Plano, Texas.
authors.forename: Deepika
authors.initials: D
authors.lastname: Gopal
authors.affiliation: Temple Heart and Vascular Center, Philadelphia, Pennsylvania.
authors.forename: Martin G
authors.initials: MG
authors.lastname: Keane
authors.affiliation: Cleveland Clinic Foundation, Cleveland, Ohio.
authors.forename: Lars G
authors.initials: LG
authors.lastname: Svensson
authors.affiliation: Cleveland Clinic Foundation, Cleveland, Ohio.
authors.forename: E Murat
authors.initials: EM
authors.lastname: Tuzcu
authors.affiliation: Columbia University Medical Center/New York Presbyterian Hospital, New York, New York.
authors.forename: Craig R
authors.initials: CR
authors.lastname: Smith
authors.affiliation: Columbia University Medical Center/New York Presbyterian Hospital, New York, New York.
authors.forename: Martin B
authors.initials: MB
authors.lastname: Leon
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000401:mortality / Q000601:surgery*; D006328:Cardiac Catheterization / Q000379:methods; D015331:Cohort Studies; D015150:Echocardiography, Doppler / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006439:Hemodynamics / Q000502:physiology*; D006801:Humans; D053208:Kaplan-Meier Estimate; D008137:Longitudinal Studies; D008297:Male; D018579:Patient Selection; D018570:Risk Assessment; D012720:Severity of Illness Index; D018709:Statistics, Nonparametric; D015996:Survival Rate; D065467:Transcatheter Aortic Valve Replacement / Q000379:methods* / Q000401:mortality; D016896:Treatment Outcome
keywords: Aortic stenosis; Echocardiography; Transcatheter aortic valve replacement