Transcatheter Aortic Valve Replacement Beyond Severe Aortic Stenosis

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Severe aortic valve disease undergoing TAVR (n=1548). Intervention: High atherogenic index of plasma (AIP) trajectory vs. Low atherogenic index of plasma (AIP) trajectory. Primary outcome: Major adverse cardiovascular and cerebrovascular events (MACCEs) (HR 1.09, 95% CI 0.74-1.61, p=0.663).

Q: What does this research mean for the field?

Transcatheter aortic valve replacement is feasible and expanding beyond symptomatic severe aortic stenosis to broader indications—including bicuspid valves, asymptomatic or moderate disease, and native aortic regurgitation—with promising early- to midterm outcomes despite durability challenges. Novelty: ClaimNovelty.SYNTHESIS. Consensus alignment: ConsensusAlignment.NEUTRAL.

Frans Beerkens; Gilbert H.L. Tang; Annapoorna Subhash Kini; Stamatios Lerakis; George Dangas; Roxana Mehran; Sahil Khera; Martin Goldman; Valentı́n Fuster; Deepak L. Bhatt; John G. Webb; Samin Kumar Sharma

doi:10.1016/j.jacc.2024.11.051

March 1, 2025Journal of the American College of CardiologyOpen Access

Transcatheter Aortic Valve Replacement Beyond Severe Aortic Stenosis

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Key result

High atherogenic index of plasma trajectories show no association with post-TAVR MACCEs.

HR 1.09
95% CI 0.74-1.61
P=0.663
n=1,548

Figures

Why the study?

The expansion of TAVR indications beyond symptomatic severe AS to broader patient populations including asymptomatic severe, moderate AS, and native aortic regurgitation requires summarizing current evidence and challenges.

Does longitudinal Atherogenic Index of Plasma (AIP) trajectory pattern predict major adverse cardiovascular and cerebrovascular events or mortality in patients undergoing transcatheter aortic valve replacement?

Key Points

To review contemporary evidence evaluating the expansion of transcatheter aortic valve replacement indications beyond symptomatic severe aortic stenosis.
Narrative review of clinical evidence examining transcatheter aortic valve replacement in non-traditional patient populations.
Evaluated indications including bicuspid aortic valve, small aortic annuli, low-flow low-gradient aortic stenosis, and younger patients.
Examined early intervention for asymptomatic severe and moderate aortic stenosis, native aortic regurgitation, and valve-in-valve procedures.
Transcatheter aortic valve replacement has expanded into anatomically feasible bicuspid aortic valves, small annuli, low-flow low-gradient stenosis, and younger cohorts.
Earlier valve intervention is being evaluated in asymptomatic severe and moderate aortic stenosis to prevent irreversible cardiac remodeling.
Dedicated transcatheter devices for native aortic regurgitation and valve-in-valve procedures have demonstrated encouraging early-to-midterm outcomes despite ongoing durability questions.

Study Design

Type

Cohort (n=1,548)

Multicenter

No

Structured PICO

Does longitudinal Atherogenic Index of Plasma (AIP) trajectory pattern predict major adverse cardiovascular and cerebrovascular events or mortality in patients undergoing transcatheter aortic valve replacement?

P

Population

1,548 patients with severe aortic valve disease undergoing TAVR at a single center in China, followed long-term to evaluate the prognostic value of longitudinal atherogenic index of plasma (AIP) trajectories.

E

Exposure

Classification into three longitudinal Atherogenic Index of Plasma (AIP) trajectory groups derived from serial measurements up to follow-up (Traj1: persistently low AIP, Traj2: stable intermediate AIP, Traj3: relatively high AIP with a gradual decreasing trend).

C

Comparator

Comparison among the three distinct AIP trajectory groups (with Traj1 serving as the reference group in models).

O

Outcome

Composite of major adverse cardiovascular and cerebrovascular events (MACCEs: cardiovascular death, myocardial infarction, stroke, hospitalization for heart failure, or bioprosthetic valve failure) and all-cause mortality.composite

Main Result

Hazard Ratio: 1.09 (95% CI 0.74–1.61)

p-value: p=0.663

Limitations

Retrospective single-center design
Selection bias due to the requirement for longitudinal AIP measurements
Limited number of long-term events reducing statistical power
Temporal overlap between trajectory ascertainment and outcome occurrence
Lack of detailed data on lipid-lowering therapies and adherence
Detailed longitudinal medication data (e.g., lipid-lowering agents) were not systematically captured
Informative missingness cannot be excluded regarding echocardiographic data
Exploratory and hypothesis-generating secondary findings due to multiple comparisons
Small numbers of early disabling stroke and 1-year non-cardiovascular mortality events

Implication

Distinct longitudinal Atherogenic Index of Plasma (AIP) trajectories reflect varying metabolic phenotypes in patients after TAVR but do not show a statistically significant association with long-term major adverse cardiovascular outcomes or structural echocardiographic recovery.

Abstract

Transcatheter aortic valve replacement (TAVR) has become the preferred treatment option in appropriate patients with symptomatic severe aortic stenosis (AS). A number of advancements have since expanded the eligible population to bicuspid aortic valve with feasible anatomy; small aortic annuli; low-flow, low-gradient AS; and younger patients. Focus has also shifted beyond the symptomatic severe patients to asymptomatic severe and moderate AS, as early valve replacement may prevent irreversible cardiac remodeling. Dedicated devices to treat native aortic regurgitation have shown encouraging short-term outcomes. While the expansion of TAVR to younger patients has raised questions about valve durability and feasibility of reintervention, valve-in-valve TAVR has thus far shown encouraging midterm results. In this review, we summarize the evidence in these contemporary TAVR populations, exploring both the promise and challenge of broadening the patient pool for this minimally invasive procedure.

Discussion

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Cite This Study

Beerkens et al. (2025) conducted a cohort in Severe aortic valve disease undergoing TAVR (n=1,548). High atherogenic index of plasma (AIP) trajectory vs. Low atherogenic index of plasma (AIP) trajectory was evaluated on Major adverse cardiovascular and cerebrovascular events (MACCEs) (HR 1.09, 95% CI 0.74-1.61, p=0.663). High longitudinal atherogenic index of plasma trajectories were not significantly associated with an increased risk of MACCEs compared to low trajectories (HR 1.09, p=0.663) following TAVR.

synapsesocial.com/papers/6ad2b5284c9c4fbb13a7edf6 https://doi.org/10.1016/j.jacc.2024.11.051

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Transcatheter Aortic Valve Replacement Beyond Severe Aortic Stenosis

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Transcatheter Aortic Valve Replacement Beyond Severe Aortic Stenosis

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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