ImportanceIn patients with severe aortic valve stenosis at intermediate surgical risk, transcatheter aortic valve replacement (TAVR) with a self-expanding supra-annular valve was noninferior to surgery for all-cause mortality or disabling stroke at 2 years. Comparisons of longer-term clinical and hemodynamic outcomes in these patients are limited.ObjectiveTo report prespecified secondary 5-year outcomes from the Symptomatic Aortic Stenosis in Intermediate Risk Subjects Who Need Aortic Valve Replacement (SURTAVI) randomized clinical trial.Design, Setting, and ParticipantsSURTAVI is a prospective randomized, unblinded clinical trial. Randomization was stratified by investigational site and need for revascularization determined by the local heart teams. Patients with severe aortic valve stenosis deemed to be at intermediate risk of 30-day surgical mortality were enrolled at 87 centers from June 19, 2012, to June 30, 2016, in Europe and North America. Analysis took place between August and October 2021.InterventionPatients were randomized to TAVR with a self-expanding, supra-annular transcatheter or a surgical bioprosthesis.Main Outcomes and MeasuresThe prespecified secondary end points of death or disabling stroke and other adverse events and hemodynamic findings at 5 years. An independent clinical event committee adjudicated all serious adverse events and an independent echocardiographic core laboratory evaluated all echocardiograms at 5 years.ResultsA total of 1660 individuals underwent an attempted TAVR (n = 864) or surgical (n = 796) procedure. The mean (SD) age was 79.8 (6.2) years, 724 (43.6%) were female, and the mean (SD) Society of Thoracic Surgery Predicted Risk of Mortality score was 4.5% (1.6%). At 5 years, the rates of death or disabling stroke were similar (TAVR, 31.3% vs surgery, 30.8%; hazard ratio, 1.02 [95% CI, 0.85-1.22]; P = .85). Transprosthetic gradients remained lower (mean [SD], 8.6 [5.5] mm Hg vs 11.2 [6.0] mm Hg; P < .001) and aortic valve areas were higher (mean [SD], 2.2 [0.7] cm2 vs 1.8 [0.6] cm2; P < .001) with TAVR vs surgery. More patients had moderate/severe paravalvular leak with TAVR than surgery (11 [3.0%] vs 2 [0.7%]; risk difference, 2.37% [95% CI, 0.17%- 4.85%]; P = .05). New pacemaker implantation rates were higher for TAVR than surgery at 5 years (289 [39.1%] vs 94 [15.1%]; hazard ratio, 3.30 [95% CI, 2.61-4.17]; log-rank P < .001), as were valve reintervention rates (27 [3.5%] vs 11 [1.9%]; hazard ratio, 2.21 [95% CI, 1.10-4.45]; log-rank P = .02), although between 2 and 5 years only 6 patients who underwent TAVR and 7 who underwent surgery required a reintervention.Conclusions and RelevanceAmong intermediate-risk patients with symptomatic severe aortic stenosis, major clinical outcomes at 5 years were similar for TAVR and surgery. TAVR was associated with superior hemodynamic valve performance but also with more paravalvular leak and valve reinterventions.

Objectives To determine the role of the es-ENT1 nucleoside transporter in post-MI reperfusion injury-mediated ventricular fibrillation (VFib) and regional dysfunction. We used erythro-9 (2-hydroxy-3-nonyl)-adenine (EHNA) and p-nitrobenzylthioinosine (NBMPR) to inhibit both adenosine deamination and transport in a canine model of off pump acute MI. Methods Anesthetized adult dogs (n= 37), instrumented to monitor systolic segmental shortening (SS %) and wall thickening (WT %) using sonomicrometry, underwent 90 minutes of LAD coronary artery occlusion and 120 minutes reperfusion. Myocardial coronary blood flow, ATP pool, infarct size and the incidents of ventricular fibrillation and cardioversions were also measured. Animals received an intravenous infusion of the vehicle (Control) or 100μM of EHNA and 25 μM NBMPR before ischemia (preconditioning, PreC group) or just before reperfusion (postconditioning, PostC group). Results In the control group, ATP depletion was associated with accumulation of more inosine than adenosine during ischemia and washed out during reperfusion. Myocardial adenosine and inosine were the major nucleosides in the PreC- and Post-C groups during ischemia and remained detectable during reperfusion, respectively. In both groups, recovery of systolic SS% and WT%, and reduction in the incidence of VFib (p<0.05 vs. Control group) coincided with retention of myocardial nucleosides. Infarct sizes in the three groups were not significantly different, independent of myocardial blood flow during ischemia. Conclusion PreC-or PostC with EHNA/NBMPR significantly reduced the incidence of ventricular fibrillation and cardioversions and attenuated regional contractile dysfunction mediated by post-MI reperfusion injury and that es-ENT1 plays a major role in these events.

No abstract

No abstract

No abstract