Surgical aortic valve replacements increasingly use bioprosthesis implants rather than mechanical valves.¹ Structural valve deterioration can result in leaflet degeneration and failure, as evidenced by valve stenosis, regurgitation, or a combination of both.^2-4 Owing to a considerable shift toward bioprosthesis implantation, it is expected that patients will increasingly present with degenerated bioprostheses. Treatment of patients with failed bioprostheses is a clinical challenge. Although reoperation is considered the standard of care, these patients are frequently elderly, and repeat cardiac surgery carries significant morbidity and mortality risks.^5,6

Aims The role of aspirin in patients with coronary artery disease (CAD) is well established, yet patients happen to discontinue aspirin according to physician’s advice or unsupervised. We thus undertook a systematic review to appraise the hazards inherent to aspirin withdrawal or non-compliance in subjects at risk for or with CAD.

Background—: Transcatheter aortic valve-in-valve implantation is an emerging therapeutic alternative for patients with a failed surgical bioprosthesis and may obviate the need for reoperation. We evaluated the clinical results of this technique using a large, worldwide registry. Methods and Results—: The Global Valve-in-Valve Registry included 202 patients with degenerated bioprosthetic valves (aged 77.7±10.4 years; 52.5% men) from 38 cardiac centers. Bioprosthesis mode of failure was stenosis (n=85; 42%), regurgitation (n=68; 34%), or combined stenosis and regurgitation (n=49; 24%). Implanted devices included CoreValve (n=124) and Edwards SAPIEN (n=78). Procedural success was achieved in 93.1% of cases. Adverse procedural outcomes included initial device malposition in 15.3% of cases and ostial coronary obstruction in 3.5%. After the procedure, valve maximum/mean gradients were 28.4±14.1/15.9±8.6 mm Hg, and 95% of patients had ≤+1 degree of aortic regurgitation. At 30-day follow-up, all-cause mortality was 8.4%, and 84.1% of patients were at New York Heart Association functional class I/II. One-year follow-up was obtained in 87 patients, with 85.8% survival of treated patients. Conclusions—: The valve-in-valve procedure is clinically effective in the vast majority of patients with degenerated bioprosthetic valves. Safety and efficacy concerns include device malposition, ostial coronary obstruction, and high gradients after the procedure.

Transcatheter aortic valve replacement (TAVR) is being increasingly performed in patients with bicuspid aortic valve stenosis (AS). This study sought to compare the procedural and clinical outcomes in patients with bicuspid versus tricuspid AS from the Bicuspid AS TAVR multicenter registry. Outcomes of 561 patients with bicuspid AS and 4,546 patients with tricuspid AS were compared after propensity score matching, assembling 546 pairs of patients with similar baseline characteristics. Procedural and clinical outcomes were recorded according to Valve Academic Research Consortium-2 criteria. Compared with patients with tricuspid AS, patients with bicuspid AS had more frequent conversion to surgery (2.0% vs. 0.2%; p = 0.006) and a significantly lower device success rate (85.3% vs. 91.4%; p = 0.002). Early-generation devices were implanted in 320 patients with bicuspid and 321 patients with tricuspid AS, whereas new-generation devices were implanted in 226 and 225 patients with bicuspid and tricuspid AS, respectively. Within the group receiving early-generation devices, bicuspid AS had more frequent aortic root injury (4.5% vs. 0.0%; p = 0.015) when receiving the balloon-expanding device, and moderate-to-severe paravalvular leak (19.4% vs. 10.5%; p = 0.02) when receiving the self-expanding device. Among patients with new-generation devices, however, procedural results were comparable across different prostheses. The cumulative all-cause mortality rates at 2 years were comparable between bicuspid and tricuspid AS (17.2% vs. 19.4%; p = 0.28). Compared with tricuspid AS, TAVR in bicuspid AS was associated with a similar prognosis, but lower device success rate. Procedural differences were observed in patients treated with the early-generation devices, whereas no differences were observed with the new-generation devices.

Infective endocarditis following surgical valve replacement occurs in 1% to 6% of patients and is associated with high morbidity and mortality.¹ Transcatheter aortic valve replacement (TAVR) has emerged as a therapeutic option for patients with aortic stenosis who are considered to be at high or prohibitive surgical risk.² The rate of infective endocarditis within the year following TAVR has been reported to be 1.5%, ranging from 0.5% to 3.1%,^3,4 similar to infective endocarditis rates after surgical valve replacement.^5,6 Greater exposure to health care procedures, older age, and a considerable amount of foreign material (eg, stent struts) of the transcatheter valve prostheses may have contributed to increase the risk of infective endocarditis in such patients. To date, data on infective endocarditis after TAVR have been limited to case reports and relatively small series with limited follow-up,^3,4,7-10 demonstrating in-hospital complication and mortality rates as high as 87% and 47%, respectively. Valve explantation rates in such patients remain relatively low (<10%). It is therefore relevant to further investigate the factors associated with and the clinical characteristics and outcomes of infective endocarditis after TAVR.