**4. Evolving controversies**

## **4.1 Stroke**

There is a common misconception that trans-catheter therapies are inherently associated with fewer strokes. This is an observation that has not been demonstrated in many of the high-profile studies. Furthermore, there are growing concerns that the neurologic events that patients experience after trans-catheter therapies occur after the index hospitalization in which the procedure is performed. For example, one study exploring a Medicare database of over 44,000 patients suggested an 86% greater risk of ischemic stroke and a six-fold increase risk of hemorrhagic stroke after trans-catheter therapies when compared to conventional surgery, with many of the events occurring in subsequent readmissions to the hospital within the first year [19]. In fact, the 90-day readmission rate for neurologic events after TAVR was substantially higher than many other cardiac and non-cardiac procedures, including left ventricular assist device placement, cardiac catheterization, surgical aortic valve replacement, and coronary artery bypass procedures [20]. Clearly, the risk of neurologic events after catheter-based valvular interventions requires further objective review.

Such concerns have resulted in a substantial increase in the development and utilization of cerebral protection devices during TAVR. Despite the inherent appeal and considerable cost associated with these protection devices, definitive data demonstrating a clinical improvement and reduction in neurologic events is still lacking [21, 22]. Nevertheless, this is an area of tremendous research and development [23, 24].

### **4.2 Pacemaker rates**

There is no doubt, as demonstrated in almost every major study of TAVR, that this procedure is associated with a much greater risk for needing a permanent pacemaker when compared to conventional surgery. While conduction abnormalities are not uncommon after valve surgery, there is growing concern that the need for a pacemaker after TAVR is neither trivial nor benign. Some large-scale studies suggest a four-fold increase in the need for permanent pacemaker after TAVR [25]. While the long-term consequences of needing a pacemaker are still unclear, especially since the short and long-term natural history of conduction problems after valve replacement is variable, there is evidence to suggest that the need for a pacemaker is associated with worse long-term survival in these patients [26]. Considering the growing emphasis on early discharge and the concern that some of the conduction abnormalities might be physiologically significant and not present until after the index hospitalization, the consequences of such events is still unclear [27].

### **4.3 Paravalvular leaks**

Unlike surgical valve replacement in which the existing stenotic calcified valve is physically removed, TAVR inserts and expands against the existing valve. This fundamental difference in the two procedures can explain why TAVR is still associated with a significantly higher rate of paravalvular leaks – especially in those with eccentric valve pathology or bicuspid valves [28]. Again, the long-term significance of paravalvular leaks is incompletely defined, but without a doubt, those patients with at least moderate leaks have a much worse survival at 2 years than those with mild or less leaks. The PARTNER 2 study, as previously discussed

**7**

*Introductory Chapter: The Evolution of Complex Valve Pathology - The Surgeon's Perspective*

above, demonstrated a 34% risk of mortality in patients with moderate to severe paravalvular leaks, when compared to the 13-14% risk in those with none, trace, or

Durability and cost remain a considerable concern regarding catheter-based therapies. Although costs vary significantly depending on the intrinsic structure of a health-care system, conflicting evidence regarding the short- and long-term costs of different types of therapy for valvular disease exists. Without a doubt, a surgical valve is substantially less expensive than a catheter-based valve, but the overall costs of the hospitalization and short-term rehabilitation needs might be more. However, factoring in the needs for pacemakers, stroke management, and concomitant coronary disease, there is growing concern surrounding the real-world costs for catheter-based therapies – especially as an increasing number of patients with advanced comorbidities, age, and poor functional status are being treated prior to

Especially with patients who are older and have multiple comorbidities, the incidence of coronary artery disease further challenges clinical decision-making. Again, despite the appeal of catheter-based solutions to treat both obstructive coronary disease and aortic valve pathology, definitive data directing one therapeutic option over another is lacking. In fact, many of the initial studies exploring the outcomes of one approach over another specifically excluded concomitant coronary procedures or those patients with significant obstructive disease. Nevertheless, criticism of some of the more recent low risk trials is that the surgical patients had a much higher intrinsic risk profile because of the need for concomitant coronary revascularization. In addition, structural characteristics of artificial valves also raises concerns regarding difficulties in coronary access in patients with previous valve replacements (both surgical and TAVR) and further suggests the importance of complete revascularization at the time of definitive valve therapies. As mentioned, many studies specifically excluded patients with combined aortic stenosis and coronary artery disease, and current guidelines tend to favor surgery considering the limitations of the data [32, 33]. Preliminary data also suggests that patients undergoing coronary stenting prior to TAVR may have worse outcomes and increased need for re-interventions due to major adverse cardiac and cerebrovascu-

The area of aortic valve disease that probably is the most supportive of transcatheter therapies is in patients that have had previous valve replacement, either with a previous surgical valve or a trans-catheter valve. Many patients underwent surgical replacement with a biologic valve, despite established guidelines and a potential survival advantage advocating the use of a mechanical valve under the promise that their next intervention would be a trans-catheter valve [36, 37]. While the appeal of this approach is undeniable and logical, the practical applications are still under considerable study. Conflicting data regarding the best approach for the management of a failing biologic valve is substantial. Even though repeat surgery is not without risks, many experienced centers can offer re-operative surgery with a risk profile similar to first-time valve replacement. Furthermore, there are concerns

*DOI: http://dx.doi.org/10.5772/intechopen.95049*

mild leaks [29]

dying [30, 31].

lar events [34, 35].

**4.6 Repeat interventions**

**4.5 Coronary artery interventions**

**4.4 Durability and cost**

*Introductory Chapter: The Evolution of Complex Valve Pathology - The Surgeon's Perspective DOI: http://dx.doi.org/10.5772/intechopen.95049*

above, demonstrated a 34% risk of mortality in patients with moderate to severe paravalvular leaks, when compared to the 13-14% risk in those with none, trace, or mild leaks [29]
