Background: Unfractionated heparin (UFH) is routinely administered during transcatheter aortic valve replacement (TAVR) to prevent thromboembolic complications. However, there are no clear evidence-based guidelines defining optimal heparin dosing or target activated clotting time (ACT) values. This study aimed to evaluate the association between intraprocedural UFH dosing, ACT values, and peri-procedural stroke risk in the overall population of patients undergoing TAVR, with a prespecified stratified analysis according to body mass index (BMI ≥ 30 vs. <30 kg/m²). Methods: This analysis enrolled consecutive individuals with severe aortic stenosis (AS) who were treated with TAVR using either balloon-expandable or self-expanding valves. The primary outcome was the occurrence of stroke during the periprocedural period in the overall population and according to BMI (<30 vs. ≥30 kg/m²). Secondary endpoints included periprocedural parameters, clinical outcomes (in-hospital and 1-year mortality), and safety outcomes. Subgroup analysis was performed to assess stroke risk according to ACT values. Patients with atrial fibrillation or receiving chronic oral anticoagulation were excluded. Results: A total of 1045 patients underwent TAVR between 2022 and 2024, including 827 with BMI < 30 and 218 with BMI ≥ 30. The study population had a mean age of 82 ± 6 years, and 56% of patients were male. In the overall study population, the mean heparin dose was 47 U/kg and the mean ACT value was 218 s. Patients with lower BMI received higher heparin doses (50 vs. 40 U/kg, p < 0.01) and had higher ACT values (221 vs. 208 s, p < 0.01). Protamine use was low and similar between groups. Periprocedural stroke rates were low overall (1.1%) and comparable between study groups (1.2% vs. 0.9%, p = 0.71). One-year mortality was also similar (3% vs. 4%, p = 0.53), with no significant differences in other safety outcomes. Subgroup analysis by ACT (≤250 vs. >250 s) showed no difference in stroke rates (1% vs. 1.5%, p = 0.60). Conclusions: In this single-center cohort, differences in heparin dosing and ACT values were not associated with differences in peri-procedural stroke or overall procedural outcomes. However, given the low number of stroke events, these findings should be interpreted cautiously. Prospective randomized studies are needed to define optimal anticoagulation strategies during TAVR.

Background: Aortic valve calcium score (AVCS) is associated with an increased risk of paravalvular leak (PVL) after Transcatheter aortic valve replacement (TAVR). We aimed to evaluate the association between AVCS burden and procedural outcomes, particularly PVL, and to determine whether valve platform performance differs according to calcium burden. Methods: This study included patients with severe aortic stenosis undergoing TAVR with balloon-expandable (Sapien platform) or self-expanding (Evolut and Navitor platforms) valves. The primary endpoint was the rate of any and moderate or greater PVLs according to AVCS burden (<3000 vs. ≥3000 AU). Valve platform comparisons were performed within each calcium stratum, and additional analyses evaluated PVLs in contemporary-generation valves. Results: A total of 4483 patients were included, of whom 1134 had an AVCS ≥ 3000 AU, and 3349 had an AVCS < 3000 AU. Any type of PVL occurred more frequently in the AVCS ≥ 3000 group (59% vs. 54%; p = 0.010), as did moderate or greater PVLs (5% vs. 3%; p = 0.011). In multivariable analysis, both SEV implantation and AVCS ≥ 3000 AU were independent predictors of moderate or greater PVL, while the interaction between AVCS burden and valve platform was not significant. When restricted to contemporary-generation valves, PVL rates were lower overall but remained higher in patients with an AVCS ≥ 3000 AU (4.4% vs. 2.4%; p = 0.001), with smaller differences between valve platforms. Conclusions: A higher AVCS is associated with increased PVLs after TAVR. BEVs showed lower rates of moderate or greater PVLs than SEVs, although no statistically significant interaction between AVCS burden and valve platform was observed. With contemporary-generation valves, overall PVL rates were reduced, and platform differences were attenuated.

Background: Transcatheter aortic valve implantation (TAVI) has become an established therapy for severe aortic stenosis and is increasingly performed in younger and lower-risk patients. Coronary access following TAVI may be technically challenging, particularly with long stent supra-annular self-expandable platforms. We aimed to evaluate the procedural characteristics and clinical outcomes of percutaneous coronary intervention (PCI) after TAVI, comparing patients treated with balloon-expandable valves (BEVs) and self-expandable valves (SEVs) at our center. Methods: In this retrospective single-center study, we included consecutive patients who underwent TAVI with BEVs (Edwards Sapien 3 and sapien 3 Ultra platforms) or SEVs (Medtronic Evolut R, Evolut Pro, Evolut Pro+, Evolut Fx and Abbot Navitor platforms) between 2016 and 2024 and subsequently underwent PCI in the index procedure post valve implantation, or returned for PCI due to chronic coronary syndrome (CCS) or acute coronary syndrome (ACS). Simple diagnostic coronary angiography without PCI was not considered in this analysis. The primary outcome was PCI success and procedural characteristics according to valve platform. A prespecified subgroup analysis was performed according to clinical presentation (CCS vs. ACS). Clinical outcomes were analysed in the whole population. Results: A total of 73 patients underwent PCI after TAVI, including 34 with balloon-expandable (Sapien) and 39 with self-expandable (33 Evolut and 6 Navitor) valves. The mean age was 81 ± 6 years, and 64% were male. The median time from TAVI to PCI was 470 days. LAD PCI was numerically more frequent in the BEV group (59% vs. 41%, p = 0.129), whereas LCX PCI was more common in the SEV group (54% vs. 29%, p = 0.035). PCI success was high overall (95%) and did not differ significantly between BEV and SEV platforms (97% vs. 92%, p = 0.374). Final TIMI 3 flow was achieved in 99% of cases. Intraprocedural coronary complications were infrequent (5%) and did not differ significantly between platforms. At 1 year, overall mortality was 8%, with no significant difference between BEV and SEV platforms. In a subgroup analysis, PCI success was high in CCS and ACS presentations (97% vs. 91%, p = 0.218), with a trend of higher 1-year mortality in ACS compared with CCS (15% vs. 3%, p = 0.061). Conclusions: PCI after TAVI is highly feasible, with excellent angiographic success and low complication rates. Procedural and clinical outcomes were comparable between BEV and SEV platforms.